Comprehensive Assesment 2020B,100% CORRECT

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A nurse is caring for a client who had abdominal surgery 24hr ago. Which of the following actions is the nurse's priority? 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? " A nurse is caring for a client who has immunosuppression and a continuous IV infusion. Which of the following actions should the nurse take? A nurse is caring for a 2 month old infant who has Hirschsprung disease (HD). Which of the following areas should the nurse assess for manifestations of HD? The nurse should assess the infant's abdomen for distention and visible peristalsis, which are manifestations of HD A nurse at a mental health clinic is caring for four clients. The nurse should recognize the following clients is using dissociation as a defense mechanism? A nurse is providing teaching to a client who has a new diagnosis of type 1 diabetes mellitus. The nurse should instruct the client to monitor for which of the following findings as a manifestation of hypoglycemia? 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? 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? A nurse is caring for a client who has active tuberculosis. Which of the following actions should the nurse take? A nurse is providing teaching to a client who is at 24 weeks of gestation and is schedule for a 3 hour oral glucose tolerance test. Which of the following instructions should the nurse include in the teaching? 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? A nurse in a community center is providing an education session to a group of clients about ovarian cancer. Which of the following manifestations of ovarian cancer should the nurse include in the teaching? A nurse is caring for a client who is postoperative after receiving moderate (conscious) sedation. The client suddenly becomes restless and reports feeling lightheaded. Which of the following actions should the nurse take? A nurse is working in an emergency department is triaging four clients. Which of the following clients should the nurse recommend for treatment first? has a fracture of the right fibula with a short leg cast in place and a new prescription for crutches. The client is non-weight bearing for 6 weeks. Which of the following instructions should the nurse include in the teaching? A nurse is preparing to initiate IV access for an older adult client. Which of the following sites should the nurse select when initiating the IV for this client? 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? A nurse is caring for a newborn immediately after delivery. Which of the following interventions should the nurse implement to prevent heat loss by conduction? A nurse is caring for a client who is receiving a continuous heparin infusion. Which of the following laboratory tests should the nurse review prior to adjusting the client's heparin? A nurse administers an incorrect dose of medication to a client. The nurse recognized the error immediately and completes and incident report. Which of the following facts related to the incident should the nurse document in the client's medical record? 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? A nurse is caring for a client who has type 1 diabetes mellitus and reports severe ankle pain after falling off a step stool at home. Which of the following prescriptions should the nurse clarify with the provider? A nurse is assessing a client who has a major depressive disorder and is taking amitriptyline. Which of the following findings should the nurse identify as an adverse effect of the medication? A nurse is caring for a client who has signed an informed consent form to receive electroconvulsive therapy (ECT). The client states to the nurse "I'm not sure about this now. I'm afraid it's too risky." Which of the following responses should the nurse make? A nurse is preparing to administer mannitol 0.2 g/kg IV bolus over 5 min 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? 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? 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? A nurse is providing teaching to the guardians of a newborn about measures to prevent sudden infant death syndrome (SIDS). Which of the following guardian statements indicates an understanding of the teaching? A nurse is assessing a client following a vaginal delivery and notes heavy loch and a boggy fundus. Which of the following medications should the nurse expect to administer? A nurse on a medical-surgical unit is caring for a client who has a new diagnosis of terminal cancer. The client tells the nurse that they would like to go home to be with family and loved ones. Which of the following actions should the nurse take? A nurse is caring for a client who has a clogged percutaneous gastrostomy feeding tube. Which of the following actions should the nurse take first? 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? 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? 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 indicated an understanding of isolation precautions? 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? Clients who take phenelzine, an MAOI, should not eat foods that contain tyramine. Broccoli, yogurt, and cream cheese do not contain tyramine. A nurse is assessing an older adult client who has pneumonia. Which of the following findings should the nurse expect? An older adult client who has pneumonia will also typically have acute confusion A nurse is providing teaching about home care to the parents of a child who has autism spectrum disorder. Which of the following instructions should the nurse include? A nurse is preparing to administer lactated ringer's 1,500 mL IV to infuse at 50 mL/hr. The drop factor of the manual IV tubing is 15 gtt/mL A nurse is caring for a client following a vacuum-assisted birth. The nurse should monitor the client for which of the following complications related to vacuum-assisted birth? A nurse is assessing a client who has COPD. Which of the following findings should the nurse expect? 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? A nurse is preparing a client for a paracentesis. Which of the following actions should the nurse take? A nurse is caring for a client who has active tuberculosis (TB). Which of the following actions should the nurse plan to take to prevent the transmission of the disease? A nurse is caring for a client who has a deep-vein thrombosis. Which of the following actions should the nurse take? A nurse is assessing a client who has a chest tube. Which of the following findings should the nurse expect? A nurse on an impatient 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? A nurse is caring for four clients. Which of the following tasks should the nurse delegate to an AP? 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? A nurse is performing an abdominal assessment on a client. Identify the sequence of actions the nurse should take. A nurse is updating the plan of care for a client who is 48 hr postoperative following a laryngectomy and is unable to speak. Which of the following actions should the nurse plan to take first? A nurse is planning care for a client who has rheumatoid arthritis. Which of the following interventions should the nurse include in the plan? Clients who have rheumatoid arthritis require food high in protein, vitamins, and iron to promote tissue repair. A nurse is caring for a client who has acute blood loss following a trauma. The client refuses a blood transfusion that might potentially save their life. Which of the following actions should the nurse take first? A nurse is caring for a group of clients. Which of the following clients should the nurse attend to first? 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 to decrease in their diet? 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 in the teaching? A nurse is assessing a newborn following a vaginal delivery. Which of the following findings should the nurse report to the provider? 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? 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? A nurse in an emergency department is caring for a client who is unconscious and requires emergency medical procedures. The nurse in unable to locate members of the client's family to obtain consent. Which of the following actions should the nurse take? 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? A nurse is providing teaching about lithium to a client who has bipolar disorder. Which of the following statements should the nurse include in the teaching? A nurse is reviewing the ABG values of a client. The client has a pH of 7.2, PaCO2 of 60, and HCO3 of 25. The nurse should identify that the client has which of the following acid-base imbalances? A nurse is providing teaching about advance directives to a middle adult client. Which of the following client responses indicates an understanding of the teaching? A charge nurse notices that one of the nurses on the shift frequently violates unit policies by taking an extended amount of time for break. Which of the following statements should the charge nurse make to address this conflict? A nurse manager is preparing to teach a group of newly licensed nurses about effective time management. Which of the following steps of the time management process should the nurse manager include as the priority? A nurse is teaching about adverse effects with a client who is starting to take captopril. Which of the following findings should the nurse identify as an adverse effect of the medication to report to the provider? A home health nurse is caring for a group of older adult clients. The nurse should indicate a referral to the Program of All-Inclusive Care for the Elderly (PACE) for which of the following clients? A nurse is assessing a client for compartment syndrome. Which of the following findings should the nurse expect? 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? A nurse in an outpatient mental health facility is assessing a child who has autism spectrum disorder. Which of the following manifestations should the nurse expect? A nurse is caring for a client who recently signed an informed consent form to donate a kidney to her sibling who has end-stage kidney disease. The donator 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? 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? 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? A nurse is reviewing the laboratory report of a client who has end-stage kidney disease and received hemodialysis 24 hr ago. Which of the following laboratory values should the nurse report to the provider? A nurse is caring for a client who has fluid volume overload. Which of the following tasks should the nurse delegate to an AP? A nurse is caring for an older adult client who is experiencing chronic anorexia and is receiving enteral tube feedings. Which of the following laboratory values indicates that the client needs additional nutrients added to the feeding? The nurse should recognize that an albumin level of less than 3.5 indicates malnutrition and a need for additional nutritional supplementation. A home health nurse is evaluating a school age 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? The nurse should verify that the pH level of the client's gastric aspirate is less than 5 to determine proper placement of a client's NG feeding tube prior to administering a bolus feeding. A nurse is reviewing the laboratory results of a toddler who has hemophilia A. Which of the following aPTT values should the nurse expect? 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? 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? A nurse is caring for a client who is in the resuscitation phase of burn injury. Which of the following findings should the nurse expect? A nurse on a mental health unit is conducting a mental status examination (MSE) on a newly admitted client. Which of the following components of the MSE is the priority for the nurse to assess? 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? 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? A nurse is caring for a client who has hyperthyroidism. Which of the following findings should the nurse expect? . 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? Epinephrine increases cardiac workload and oxygen demand, which can result in angina. 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? A nurse manager is assessing a client who has bipolar disorder. Which of the following alterations in speech is the client using? A nurse is assessing a school age child who has bacterial meningitis. Which of the following findings should the nurse expect? 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 their forearms. The nurse should identify these behaviors as characteristics of which of the following personality disorders? 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 making the decision. Which of the following responses should the nurse make? A nurse is assigning task roles for a group of 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? A nurse is caring for a client who has a pulmonary embolism. The client is receiving heparin via continuous IV infusion at 1,200 units/hr and warfarin 5 mg PO daily. The morning laboratory values for the client are aPTT 98 seconds and INR 1.8. Which of the following actions should the nurse take? 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? A nurse is admitting a client to the psychiatric unit after attempting suicide. The client states, "My family does not care whether I live or die." Which of the following responses should the nurse make? "How does this make you feel?" A nurse in an emergency department is assessing a school age child who was brought in by their parents and has scald burns to both hands and wrists. The nurse suspects physical abuse. Which of the following actions should the nurse take? 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? A nurse is caring for a client who has a magnesium level of 2.7 mEq/L. Which of the following interventions should the nurse plan to take? A rural community health nurse is developing a plan to improve health care delivery for migrant farm workers. To identify health services data for this minority group, the nurse should gather information from which of the following sources? . A nurse is planning care for a client who has rheumatoid arthritis and has moderate to severe pain in multiple joints. Which of the following actions should the nurse plan to take? 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? A nurse is assessing a client following a colonoscopy. Which of the following findings should indicate to the nurse that the client is hemorrhaging? A nurse is caring for a client who is in the fourth stage of labor and is receiving oxytocin via continuous IV infusion. Which of the following assessment is the nurse's priority? A nurse is caring for a child who has hypotonic dehydration and is receiving an oral rehydration solution. Which of the following laboratory results indicates that the treatment regimen is effective? A nurse is assessing a newborn's heart rate. Which of the following actions should the nurse take? 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 nurse is providing information to a client immediately before his scheduled Romberg test. Which of the following statements should the nurse make? A nurse is assessing a client who is at 11 weeks of gestation and reports drinking ginger tea. Which of the following findings indicates the client's use of ginger tea is effective? A nurse is assessing an infant who has hydrocephalus and is 6 hr postoperative following placement of a ventriculoperitoneal (VP) shunt. Which of the following findings should the nurse report to the provider? Irritability is a manifestation of increased ICP, which is an indication that the VP shunt is malfunctioning. A client is receiving IV fluids at 150 mL/hr. Which of the following findings indicates that the client is experiencing fluid overload? A nurse in an emergency department is caring for a client who is at 9 weeks of gestation and reports nausea and vomiting for the past 2 days. Which of the following findings should the nurse expect? 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? 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 child sexual abuse? A nurse in a provider's office is assess an adolescent who has been taking ibuprofen for 6 months to treat juvenile idiopathic arthritis. Which of the following questions should the nurse ask to assess for an adverse effect of this medication? A nurse is teaching a client who is at 20 weeks of gestation about common discomforts associated with pregnancy. Which of the following statements by the client indicates an understanding of the teaching? 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? 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? A nurse is admitting a client who has pneumonia. The nurse should initiate which of the following isolation precautions for the client? . A nurse is conducting a physical examination for an adolescent and is assessing the range of motion of the legs. Which of the following images indicates the adolescent is abducting the hip joint? A nurse is providing discharge teaching about disease management for a client who has a new diagnosis of type 1 diabetes mellitus. Which of the following activities is the nurse's priority? A nurse is caring for client who is receiving positive end-expiratory pressure (PEEP) via mechanical ventilation. The nurse should monitor the client for which of the following adverse effects of PEEP? The nurse should monitor the client's lung sounds hourly for indications of a tension pneumothorax, such as tracheal deviation, absent breath sounds, and distended neck veins. During the 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 shift nurse take? 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? 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? A nurse is preparing to administer insulin to a client via a pen device. Which of the following actions should the nurse take? 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? A nurse in a provider's office is caring for an 18 month old toddler who has a blood lead level of 3 mcg/dL. Which of the following actions should the nurse take? 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? 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? A nurse is assessing a client who has pulmonary edema. Which of the following findings should the nurse expect? A nurse is assessing a client who received 2 units of packed RBC's 48 hr ago. Which of the following findings should indicate to the nurse that the therapy has been effective? 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? A nurse is caring for a client who had a stroke 6 hr ago. Which of the following interventions should the nurse implement to reduce the risk of increased ICP? A nurse is planning care for a client who is receiving chemotherapy and has neutropenia. Which of the following interventions should the nurse include in the plan? 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? A nurse is caring for a school age child who is taking valproic acid. The nurse should expect the provider to order which of the following diagnostic tests? A nurse is preparing to transfer a client who has had a stroke to a rehabilitation facility. The client's family tells the nurse they are concerned about the level of care the client will receive. Which of the following actions should the nurse take? A charge nurse is speaking with the partner of a client. The partner states that the client is not receiving adequate care. Which of the following actions should the charge nurse take first to resolve the situation? A nurse is caring for a client who has a prescription for a continuous passive motion (CPM) machine following a total knee arthroplasty. Which of the following actions should the nurse take? A nurse is providing discharge instructions about newborn care to a client who is postpartum. Which of the following statements indicates to the nurse that the client understands the teaching? A nurse has just received change of shift report on four clients. Which of the following clients should the nurse assess first? A nurse is preparing to replace a client's transdermal fentanyl patch after 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? A nurse is teaching a client who has a new prescription for total parenteral nutrition through a central line. Which of the following information should the nurse include in the teaching? A nurse is performing an admission assessment on a client who had a recent positive pregnancy test. The first day of her last menstrual period (LMP) was May 8. According Nägele's rule, which of the following should the nurse document as the client's estimated date of birth (EDB)? A nurse on a medical-surgical 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? A nurse is providing teaching to a client who is schedule for electroconvulsive therapy (ECT). The nurse should inform the client that which of the following findings is an adverse effect of ECT? An antepartum nurse is caring for four clients. For which of the following clients should the nurse initiate seizure precautions? [Show More]

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