1. A nurse is performing an abd assessment on a client. Identify the sequence of actions the nurse should take
2. A nurse is providing teaching to a client who at 26 weeks of gestation and is to have an oral glucose tol
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1. A nurse is performing an abd assessment on a client. Identify the sequence of actions the nurse should take
2. A nurse is providing teaching to a client who at 26 weeks of gestation and is to have an oral glucose tolerance test. Which of the following actions should the nurse instruct the client to take before the test?
3. A nurse is teaching a client who is at 26 weeks of gestation about common prenatal discomfort. Which of the following statements by the client indicates an understanding of the teaching?
4. A nurse is preparing a sterile field to perform a sterile dressing change. Which of the following interventions should the nurse use to maintain surgical aseptic technique?
5. A nurse is providing discharge teaching for the parents of a preschool-age child who has a new prescription for amoxicillin/clavulanate suspension. Which of the following instructions should the nurse include in the teaching?
6. A nurse is creating a plan of care for a child who has acute leukemia and an absolute neutrophil count of 400. Which of the following interventions should the nurse include in the plan?
7. A nurse is assessing a client whose partner recently died. The client states, “I don’t know what to do without my partner. Life is just not worth living.” Which of the following responses should the nurse make?
8. A nurse is assessing a newborn following a vaginal delivery. Which of the following findings should the nurse report to the report to the provider?
9. A nurse is assessing a client who has COPD. Which of the following findings should the nurse expect?
10. A nurse in an emergency department is caring for a child who has a fever and fluid-filled vesicles on the trunk and extremities. Which of the following interventions should the nurse identify as the priority?
11. A nurse is assigning task roles for a group clients in a community mental health clinic. Which of the following tasks should the nurse assign to the member of the group functioning as the orienteer?
12. A nurse is assessing a client who is taking propranolol. Which of the following findings should indicate to the nurse that this client is experiencing an adverse reaction to propranolol?
13. A nurse is providing information to a client immediately before his scheduled Romberg test. Which of the following statements should the nurse make?
14. A nurse is providing teaching to a client who has peripheral arterial disease. Which of the following client actions indicates an understanding of the teaching?
15. A nurse is caring for a client who is 2 days postpartum. Which of the following behaviors should indicate to the nurse that the client is bonding with her newborn?
16. A nurse is providing discharge instructions about newborn care to a client who is 2 days postpartum. Which of the following statements indicates to the nurse that the client understands the teaching?
17. A nurse is preparing to administer a blood transfusion to a client. Which of the following procedures should the nurse follow to ensure proper client identification?
18. A nurse is preparing to transfer a client who has had a stroke to rehab facility. The client’s family tells the nurse that they are concerned about the level of care the client will receive. Which of the following actions should the nurse take?
19. A charge nurse is providing an educational session about infection control for a group of staff nurses. Which of the following statements by one of the staff nurses indicates an understanding of isolation precautions?
20. A nurse at an urgent care clinic is assessing a client who reports impaired vision in one eye. Which of the following reports by the client should indicate to the nurse that the client has a detached retina?
21. A nurse is caring for a child who has sickle cell anemia and is having a vaso-occulsive crisis. Which of the following interventions should the nurse implement first?
22. A nurse is caring for a client who is receiving continuous bladder irrigation following a transurethral resection of the prostate. The client reports bladder spasms and the nurse observes a decreased urinary output. Which of the following actions should the nurse take?
23. A nurse is preparing to administer an IM injection to a client who is obese. Which of the following actions should the nurse plan to take?
24. A nurse in a provider’s office is caring for an 18-month old toddler who has a blood lead level of 3mcg/dL. Which of the following actions should the nurse take?
25. A nurse is assessing for correct placement of a client’s NG feeding tube prior to administering a bolus feeding. Which of the following actions should the nurse take?
26. A nurse on a med-surg unit is assessing a client who has had a stroke. For which of the following findings should the nurse initiate a referral for occupational therapy?
27. A nurse is caring for an older adult who is experiencing chronic anorexia and is receiving enteral tube feedings. Which of the following lab values indicates that the client needs additional nutrients added to the feeding?
28. A nurse is assessing a client who has bipolar disorder. Which of the following alterations in speech is the client using?
29. A nurse is caring for a client who has hypotonic dehydration and is receiving an oral rehydration solution. Which of the following lab results indicates that the treatment regimen is effective?
30. A nurse is preparing to mix haloperidol lactate 5mg/mL and diphenhydramine 25mg/1.5 mL to administer IM for a client who is agitated. Which of the following actions should the nurse plan to take?
31. A nurse enters a client’s room and sees smoke coming from a small fire in the trash can. Which of the following actions should the nurse take first?
32. A client is receiving IV fluids at 150 mL/hr. which of the following findings indicates that the client is experiencing fluid overload?
33. A nurse is caring for a client who is receiving hemodialysis with an AV fistula in the right arm. Which of the following interventions should the nurse include in the client’s plan of care?
34. A nurse is providing teaching about c to a client who has bipolar disorder. Which of the following statements should the nurse include in the teaching?
35. A nurse working in an emergency department is triaging four clients. Which of the following clients should the nurse recommend for treatment?
36. A nurse is creating a plan of care for a newly admitted child. Which of the following actions should the nurse include in the plan of care?
37. A nurse is assessing a client who has pulmonary edema. Which of the following findings should the nurse expect?
38. A nurse is creating a plan of care for a client who has left-sided weakness following a stroke. Which of the following interventions should the nurse include in the plan?
39. A community health nurse is providing teaching about home safety with a group of older adult clients. Which of the following statements should the nurse take?
40. A nurse is providing teaching to a client who speaks a different language than the nurse about an upcoming diagnostic procedure. Which of the following actions should the nurse take?
41. A nurse must recommend clients for discharge in order to make room for several critically injured clients from a local disaster. Which of the following clients should the nurse recommend for discharge?
42. A nurse preparing a client for a paracentesis. Which of the following actions should the nurse take?
43. A nurse is caring for a client who is in resuscitation phase of burn injury. Which of the following findings should the nurse expect?
44. During a change of shift report, a night shift nurse informs the day shift nurse that a newly admitted client was disoriented and combative during the night. Which of the following actions should the day nurse shift nurse take?
45. A nurse is preparing to administer D5W 1000mL IV to infuse over 8 hr to a client. The nurse should set the IV pump to deliver how many mL/hr
46. A nurse is reviewing the UA report of a client who has acute glomerulonephritis. Which of the following findings should the nurse expect in the client’s urine?
47. A nurse in an emergency department is caring for a client who is unconscious and requires emergency medical procedures. The nurse is unable to locate members of the client’s family to obtain consent. Which of the following actions should the nurse take?
48. A nurse is caring for a client who has COPD and becomes extremely short of breath. Which of the following interventions by the nurse requires completion of an incident report?
49. A nurse on a mental health unit is conducting a mental status exam on a newly admitted client. Which of the following components of the MSE is the priority for the nurse to assess?
50. A nurse is caring for a client who is in the fourth stage of labor who is receiving oxytocin via continuous IV infusion. Which of the following assessments is the nurse’s priority?
51. A nurse is assessing an older adult client who has pneumonia. Which of the following findings should the nurse expect?
52. A nurse educator is teaching a group of newly licensed nurses about the need to complete an incident report. Which of the following examples should the nurse include as a reportable incident and an indication for completing a report?
53. A nurse is providing client teaching about the basal body temperature method of birth control. Which of the following information should the nurse include in the teaching?
54. A nurse has received change-of-shift report on four assigned clients. For which of the following clients should the nurse intervene to prevent a potential food and medication interaction?
55. A nurse is teaching self-administration of insulin to a client who has a new prescription for a short-acting and intermediate-acting insulin. Which of the following actions by the client indicates an understanding of the teaching?
56. An antepartum nurse is caring for four clients. For which of the following clients should the nurse initiate seizure precautions?
57. A nurse is caring for a client who has GI bleeding an NG tube in place. While performing gastric lavage, which of the following actions should the nurse take?
58. A nurse is providing teaching to a school-age child who has asthma about using an albuterol metered-dose inhaler. Which of the following instructions should the nurse include?
59. A nurse has just received change-of-shift report on four clients. Which of the following clients should the nurse assess first?
60. A nurse is caring for a client who has a prescription for chlorpromazine. Which of the following findings should the nurse identify as an indication that the medication is effective?
61. A nurse on the oncology unit is administering doxorubicin to a client who has breast cancer. Which of the following actions should the nurse take?
62. A nurse is preparing to transfer a client from the ICU to the medical floor. The client was recently weaned from mechanical ventilation following a pneumonectomy. Which of the following information should the nurse include in the change-of-shift report?
63. A school nurse is notified of an emergency in which several children were injured following the collapse of playground equipment. Upon arrival at the playground, which of the following actions should the nurse take first?
64. A nurse is caring for a client who has cancer and is deciding between two treatment plans. The client asks the nurse for assistance in deciding. Which of the following responses should the nurse make?
65. A nurse on an inpatient mental health unit is monitoring a visit between a client who has a history of aggressive behavior and the client’s partner. Which of the following observations should the nurse identify as an indication for potential violence?
66. A nurse is caring for a client who has a mag level of 2.5 mEq/L. Which of the following interventions should the nurse plan to take?
67. A nurse in a pediatric clinic is assessing the reflexes of an infant who is 1 week old. Which of the following images demonstrates the correct procedure to elicit the palmer grasp reflex?
68. A nurse preceptor is evaluating the performance of a newly licensed nurse. Which of the following actions by the newly licensed nurse requires intervention by the preceptor?
69. A nurse manager is preparing to teach a group of newly licensed nurse about effective time management. Which of the following steps of the time management process should the nurse manager include as the priority?
70. A home health nurse is evaluating a school aged child who has cystic fibrosis. The nurse should initiate a request for a high-frequency chest compression vest in response to which of the following parent statements?
71. A nurse is caring for a school-aged child who is taking valproic acid. The nurse should expect the provider to order which of the following diagnostic tests?
72. A nurse is assessing a client following a vaginal delivery and notes heavy lochia and boggy fundus. Which of the following medications should the nurse expect to administer?
73. A nurse is caring for a client who is receiving positive end expiratory pressure (PEEP) via mech vent. The nurse should monitor the client for which of the following adverse effects of PEEP?
74. A nurse is providing teaching for a client about his right to confidentiality. Which of the following statements should the nurse make?
75. A nurse in the emergency department is assessing a preschooler who has a facial laceration. The nurse should identify which of the following findings as a potential indication of sexual abuse?
76. A nurse in a mental health clinic is assessing a client who has a history of seeking counseling for relationship problems. The client shows the nurse multiple superficial self-inflicted lacerations on her forearms. The nurse should identify these behaviors as characteristics of which of the following personality disorders?
77. A nurse is caring for a client who has deep-vein thrombosis. Which of the following actions should the nurse take?
78. A nurse in an emergency department is assessing a school-age child who was brought in by her parents and has scald burns to both hands and wrists. The nurse suspects physical abuse. Which of the following actions should the nurse take?
79. A nurse on a pediatric unit has received change-of-shift report for four children. Which of the following children should the nurse assess first?
80. A nurse is caring for a client who has acute blood loss from a trauma. The child refuses a blood transfusion that might potentially save his life. Which of the following actions should the nurse take first?
81. A nurse is caring for a client who has a prescription for a CPM machine following a total knee arthroplasty. Which of the following actions should the nurse make?
82. A nurse is providing teaching to a client who has a new diagnosis of type 1 DM. the nurse should instruct the client to monitor for which of the following findings as a manifestation of hypoglycemia?
83. A nurse is providing discharge teaching about disease management for a client who has a new diagnosis of type 1 DM. which of the following activities is the nurse’s priority?
84. A nurse is providing teaching to a client who is to undergo electroconvulsive therapy. The nurse should inform the client that which of the following findings is an adverse effect of ECT?
85. A nurse manager in a long-term care facility is having difficulty with staffing for weekend shifts and is planning to implement some changes to the scheduling procedure. Which of the following actions should the nurse manager take first?
86. A nurse is preparing to replace a client’s transdermal fentanyl patch 72 hr of use. After the nurse opens the packet containing the new pouch, the client declines to accept it. Which of the following actions should the nurse take?
87. A nurse in an emergency department is caring for a client who report N/V for the past 2 days. Which of the following findings should the nurse expect?
88. A nurse is caring for a client who asks about ginseng to improve her appetite. The nurse should identify that ginseng can decrease the effectiveness of which of the following client medications?
89. A nurse is preparing to administer mannitol 0.2g/kg IV bolus over 5 minutes as a test dose to a client who has severe oliguria. The client weighs 198 lb. What is the amount in grams the nurse should administer?
90. A nurse is caring for a client who has active TB. Which of the following actions should the nurse plan to take to prevent the transmission of the disease?
91. A nurse is performing an admission on a client who had a recent positive pregnancy test. The first day of her last menstrual period (LMP) May 8. According to Nagele’s rule, which of the following dates should the nurse document as the client’s estimated date of birth?
92. A nurse is caring for a client who has a new prescription for clonidine. The nurse should inform the client that which of the following findings is an adverse effect of this medication?
93. A nurse is developing a client education program about osteoporosis for older adult clients. The nurse should include which of the following variables as a risk factor for osteoporosis?
94. A nurse is preparing to assist with a thoracentesis for a client who has pleurisy. The nurse should plan to perform which of the following actions?
95. A nurse is conducting visual acuity testing using the Snellen letter chart for a school-age child who has eyeglasses. Which of the following instructions should the nurse give to the child?
96. A nurse is preparing to teach about dietary management to a client who has Crohn’s disease and an enteroenteric fistula. Which of the following nutrients should the nurse instruct the client in his diet?
97. A nurse is caring for a client who has hyperthyroidism. Which of the following findings should the nurse expect?
98. A nurse is developing a discharge plan for a school-age child who has thrombocytopenia. The nurse should instruct the child to avoid which of the following?
99. A nurse is caring for a client who is post op after receiving moderate (conscious) sedation. The client suddenly becomes restless and reports feeling lightheaded. Which of the following actions should the nurse take?
100. A nurse is talking with a client who has stage IV breast cancer. The nurse should recognize which of the following statements by the client as a constructive use of a defense mechanism?
101. A nurse is assessing a newborn’s heart rate. Which of the following actions should the nurse take?
102. following placement of a VP shunt. Which of the following findings should the nurse report to the provider?
103. A nurse is caring for a client who has fluid volume overload. Which of the following tasks should the nurse delegate to an AP?
104. A nurse is reviewing the ABG values of a client. The client has a pH of 7.20, PaCO2 of 60 mmhg and HCO3 of 25. The nurse should identify that the client has which of the following acid-base imbalances
105. A nurse is assessing a client who is at 11 weeks of gestation and reports drinking ginger tea. Which of the following findings indicate the client’s se of ginger tea is effective?
106. A nurse is caring for a newborn after delivery. Which of the following interventions should the nurse implement to prevent heat loss by conduction?
107. A nurse administers an incorrect dose of medication to a client. The nurse recognizes the error immediately and completes an incident report. Which of the following facts related to the incident should the nurse document in the client’s medical record?
108. A nurse manager is preparing an educational session about advocacy to a group of nurses. The nurse manager should include which of the following information in the teaching?
109. A nurse is caring for a client who has a pulmonary embolism. The client is receiving heparin via a continuous IV infusion at 1200 units/hr and warfarin 5 mg PO. The morning lab values for the client are aPTT 98 secs and INR 1.8. Which of the following actions should the nurse take?
110. A nurse is caring for a group of clients. Which of the following clients should the nurse attend to first?
111. A nurse in a provider’s office is assessing who has been taking ibuprofen for 6 months to treat juvenile idiopathic arthritis. Which of the following questions should the nurse ask for to assess for an adverse effect of this medication?
112. A nurse is assessing a client who has depressive disorder and is taking amitriptyline. Which of the following findings should the nurse identify as an adverse effect of the medication?
113. A nurse is providing education to the parent of a school-age child who has asthma. Which of the following statements by the parent indicates an understanding of the teaching?
114. A nurse is providing to a client who is at 24 weeks of gestation and is scheduled for a 3-hour oral glucose tolerance test. Which of the following instructions should the nurse include in the teaching?
115. A hospice nurse is consulting with a client and her family about receiving home services. Which of the following statements should the nurse identify as an indication that the family understands home hospice care?
116. A nurse is updating the plan of care for a client who is 48 post op following a laryngectomy and is unable to speak. Which of the following actions should the nurse plan to take first?
117. A nurse is assessing a client who has decreased visual acuity due to cataracts. The nurse should identify that which of the following physiological changes is the cause for the client’s visual loss?
118. A nurse is assessing a client who received 2 units of packed RBCs 48 hours ago. Which of the following findings should indicate to the nurse that the therapy is effects?
119. A nurse on med surg unit is caring for a client who has a new diagnosis of terminal cancer. The client tells the nurse that he would like to go home to be with family and loved ones. Which of the following actions should the nurse take?
120. A nurse is planning to delegate client care tasks to an AP. Which of the following tasks should the nurse plan to delegate to the AP?
121. A nurse is caring for a client who is taking valproic acid for seizure control. For which of the following adverse effects should the nurse monitor and report?
a. Jaundice
122. A nurse is reviewing the lab results of a toddler who has hemophilia A. which of the following aPTT values should the nurse expect?
123. A nurse is providing teaching about advanced directives to a middle adult client. Which of the following client responses indicates an understanding of the teaching?
a. I can designate my partner as my health care surrogate
124. A nurse is caring for a client who has fecal impaction. Which of the following actions should the nurse take when digitally evacuating the stool?
125. A nurse is assessing a client who has hypocalcemia. Which of the following sites should the nurse tap to elicit a positive chvostek’s sign?
126. A nurse is caring for a client who has major depressive disorder and has signed informed consent to receive ECT. The client states to the nurse, “I’m not sure about this now. Im afraid its too risky.” Which of the following responses should the nurse make?
127. A nurse is caring for a client who is receiving a continuous heparin infusion. Which of the following lab tests should the nurse review prior to adjusting the client’s heparin?
128. A nurse is caring for four clients. Which of the following tasks should the nurse delegate to an AP?
129. An RN is observing a LPN and an AP move a client up in bed. For which of the following situations should the nurse intervene?
130. A rural community health nurse is developing a plan to improve health care delivery for migrant farmworkers. To identify health services data for this minority group, the nurse should gather information from which of the following sources?
131. A nurse manager is preparing an educational session for nursing staff about how to provide cost-effective care. Which of the following methods should the nurse include?
132. A nurse is admitting a client who has pneumonia. The nurse should initiate which of the following isolation precautions for the client?
133. A nurse is providing dietary teaching to a client who has a new prescription for phenelzine. Which of the following food recommendations should the nurse make?
134. A charge nurse notices that one of the nurses on her shift frequently violates unit policies taking an extended amount of time for break. Which of the following statements should the charge nurse make to address this conflict?
135. A nurse manager is planning to use a democratic leadership style with the nurses on the unit. Which of the following actions by the nurse manager demonstrates a democratic leadership style?
136. A nurse is reviewing the lab report of a client who has end-stage kidney disease received hemodialysis 24 hr ago. Which of the following lab values should the nurse report to the provider?
a. Sodium 148
137. A nurse is caring for a newborn who has hsV. Which of the following isolation precautions should the nurse initiate?
138. A nurse is caring for a multiparous client following a vacuum-assisted birth. The nurse should assess the client for which of the following possible complications related to birth method?
139. A nurse in an outpatient mental health clinic is caring for four clients. The nurse should recognize that which of the following clients is effectively using sublimation as a defense mechanism?
140. A nurse is providing discharge teaching to a client who is to receive home oxygen therapy. Which of the following instructions should the nurse include in the teaching?
141. A nurse is assessing a client for compartment syndrome. Which of the following findings should the nurse expect?
142. A nurse at a mental health clinic is caring for four clients. The nurse should recognize that which of the following clients is using dissociation as a defense mechanism?
143. A nurse manager is reviewing clients’ rights with the nurses on the unit. The nurse manager should tell the nurses that informed consent promotes which of the following ethical principles?
144. A nurse is providing teaching to the parents of a child who has autism spectrum disorder. Which of the following instructions should the nurse include?
145. A nurse is assessing a client after administering epinephrine for an anaphylactic reaction. Which of the following findings should the nurse identify as an adverse effect of this medication?
146. nurse is caring for a client who recently signed informed consent to donate a kidney to her sibling who has end-stage kidney disease. The donor states to the nurse, “ I don’t want my brother to die, but what if I need this kidney one day?” which of the following responses should the nurse make?
147. A nurse is providing care for a client who has a colostomy. Which of the following actions should the nurse take?
148. A home health nurse is assessing a 2-week-old newborn who had a birth weight of 3.64kg (8lb) and is being breastfed. Which of the following findings indicates effective breastfeeding?
149. A nurse is providing teaching for a client who has a fracture of the right fibula with a short-leg cast in place. The client is non-weight bearing for 6 weeks. Which of the following instructions should the nurse include in the teaching?
150. A nurse on an inpatient unit is caring for a client who has schizophrenia and recently started taking risperidone. Which of the following actions should the nurse take?
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