A nurse is caring for a client who had a partial laryngectomy and is receiving continuous enteral feedings at 65 mL/hr through a gastrostomy tube. Which of the following findings requires immediate intervention by the nu
...
A nurse is caring for a client who had a partial laryngectomy and is receiving continuous enteral feedings at 65 mL/hr through a gastrostomy tube. Which of the following findings requires immediate intervention by the nurse? - ✔✔The infusion pump for administering contimuous feeding is turned off.
A nurse is assessing a client who has a magnesium level of 4.4 mEq/L. Which of the following findings should the nurse expect? - ✔✔Hypotension
A nurse is providing dietary teaching to a client who has an increased cholesterol level. Which of the following foods should the nurse recommend? - ✔✔Egg whites
A nurse is caring for a toddler who has respiratory syncytial virus. Which of the following actions should the nurse plan to take? - ✔✔Use a designated stethoscope when caring for the toddler.
A nurse is assessing a client who has a chest tube following a thoracotomy. Which of the following findings requires intervention by the nurse? - ✔✔1 cm of water present in the water seal
A nurse is reviewing the medical history of a client who is taking garlic supplement. The nurse should identify that which of the following findings is a contraindication for taking this supplement? - ✔✔The client takes aspirin daily.
A nurse is planning to provide community education about viral hepatitis. Which of the following should the nurse plan to include in the teaching? - ✔✔series of four hepatitis vaccines is recommended to prevent viral hepatitis.
A nurse is reviewing the history and physical of a client who has right ventricular heart failure. Which of the following is an expected finding? - ✔✔Elevated pulmonary artery pressure
A home health nurse is conducting an initial home visit for a client who has terminal breast cancer. The client has two school-age children and a limited support system. Which of the following is the priority nursing action? - ✔✔Inform the client of available community resources.
A nurse is providing postoperative teaching to a client who has a newly-inserted pacemaker. Which of the following statements by the client indicates that the teaching has been effective? - ✔✔"I will use my cell phone on the ear opposite of my pacemaker."
A nurse is caring for a client who has heart failure and has started taking a loop diuretic. Which of the following findings indicates the client is experiencing an adverse effect of the medication? - ✔✔Decreased reflexes
A nurse is caring for a client who has neutropenia due to HIV. Which of the following precautions should the nurse take while caring for this client? - ✔✔Wear an N95 respirator.
A nurse manager is presenting information to the nursing staff regarding the appropriate use of client restraints. Which of the following should the nurse include? (Select all that apply.) - ✔✔The nurse should pad the bony prominences. The nurse should remove the restraints every 2 hr. The provider's prescription should include the
A nurse is providing discharge teaching about disease prevention to a client who has active tuberculosis. Which of the following should the nurse include? - ✔✔Educating the client how to cover nose and mouth with tissues when coughing
A nurse is caring for a client who reports difficulty falling asleep at night. Which of the following actions should the nurse take? - ✔✔Schedule routine care tasks during hours when the client is awake.
A nurse is preparing a client for surgery and has just administered the preoperative injection. Which of the following actions should the nurse take? - ✔✔Review deep breathing and coughing exercises.
A nurse suspects another nurse is chemically impaired during their shift. Which of the following is an appropriate action for the nurse to take? - ✔✔Report to the nurse manager.
A nurse in the recovery room is assessing a client who has a new chest tube. The nurse finds that the water seal is no longer tidaling. The nurse should identify the finding as resulting from which of the following? - ✔✔The tubing may be kinked.
A nurse delegates tasks to a licensed practical nurse (LPN) and an assistive personnel (AP). When admitting a client who is experiencing acute liver failure and who has ascites and an NG tube, which of the following tasks is most appropriate for the nurse to delegate to the LPN? - ✔✔Measure the amount of gastric drainage every 2 hr.
A nurse is assessing an adult male client who has a BMI of 20. The nurse should identify that the client's BMI falls within which of the following categories? - ✔✔Healthy weight
A nurse is assessing a client who has a long arm cast. For which of the following findings should the nurse monitor when assessing for acute compartment syndrome? - ✔✔Change in mental status
A nurse is planning care for a newly admitted client. Which of the following interventions should the nurse plan to take first? (Click on the "Exhibit" button for additional information about the client. There are three tabs that contain separate categories of data.) - ✔✔Administer pain medication to the client.
A community health nurse is performing a vision screening on a 4-month-old infant. When shining a light source into the infant's visual field, which of the following is an expected finding? - ✔✔The infant closes their eyes.
A nurse is planning discharge teaching for a client who is scheduled to receive intravenous infusions at home. Which of the following instructions should the nurse plan to include? - ✔✔Place the infusion pump cord against the baseboards.
A nurse is caring for a client who has just returned to the unit following a bronchoscopy. Which of the following actions by the assistive personnel requires the nurse to intervene? - ✔✔Offers oral fluids to the client
A nurse is assessing an infant who has water intoxication. Which of the following findings should the nurse expect? - ✔✔Generalized edema
A nurse is caring for a client who is in labor and receiving electronic fetal monitoring. The nurse is reviewing the monitor tracing and notes early decelerations. Which of the following should the nurse expect? - ✔✔Head compression
nurse in a pediatric unit is caring for a group of clients. For which of the following diseases should the nurse implement droplet precautions? - ✔✔Pertussis
A client asks the nurse if it is safe to take a glucosamine supplement. The nurse should assess for which of the following potential contraindications? - ✔✔Shellfish allergy
A nurse at the family planning clinic triages several clients over the phone. Which of the following clients should the nurse instruct to come to the clinic? - ✔✔A client who has started taking oral contraceptives and is experiencing bright red vaginal breakthrough bleeding
A nurse is caring for a client who has a hearing impairment. When speaking to the client, the nurse should incorporate which of the following communication methods? - ✔✔Rephrase sentences the client does not understand.
A nurse in a mental health facility is interviewing a newly admitted client. Which of the following actions should the nurse take when conducting the interview? - ✔✔Lean in slightly when speaking to the client.
A nurse is caring for a group of clients. Which of the following clients should the nurse assign to an assistive personnel? - ✔✔A client who had a stroke 2 days ago and needs help toileting
A nurse manager at a public health clinic is concerned about the rising number of sexually transmitted infections in the community. The purpose of which of the following is to generate new ideas to address the public health concern? - ✔✔A brainstorming session with nurses
A nurse is providing teaching about preventing mastitis to a client who is postpartum and breastfeeding her newborn. Which of the following instructions should the nurse include? - ✔✔"Try to have your baby empty your breasts with each feeding."
A nurse is preparing to insert an indwelling urinary catheter for a female client. Identify the sequence of actions the nurse should take. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.) - ✔✔Apply sterile gloves and place cleansing balls in antiseptic solution. Attach prefilled syringe to indwelling catheter inflation hub. Cleanse the meatus with the dominant hand in a downward motion. Lubricate the catheter and place fenestrated drape over perineum. Insert the catheter until a flow of urine begins.
A nurse is providing teaching to a client who is at 8 weeks of gestation and experiencing episodes of nausea and vomiting. Which of the following instructions should the nurse include? - ✔✔Eat a dry carbohydrate before getting out of bed.
A nurse is caring for a client who is nulliparous and in the first stage of labor. The last internal assessment revealed 100% cervical effacement with 5 cm of dilatation. At the end of the last contraction, the nurse observes a large gush of fluid coming out of the client's perineal area. Which of the following is a priority action by the nurse? - ✔✔Check the FHR.
A nurse is assessing a client who was brought to the emergency department by his adult child. The client has visible contusions on all four extremities. Which of the following actions should the nurse take? - ✔✔Report the incident to Adult Protective Services.
A nurse is caring for a client who is postpartum and has a new prescription for methylergonovine for vaginal bleeding refractory to fundal massage and oxytocin. When reviewing the client's medical history, the nurse should recognize which of the following diagnoses as a contraindication to the administration of methylergonovine? - ✔✔Hypertension
A nurse is giving discharge instructions to a client who has a new ileostomy. The nurse should recognize that the teaching has been effective when the client states, - ✔✔"My stoma will drain liquid fluid continuously."
At the start of an evening shift on a cardiac unit, a licensed practical nurse brings the nurse a list of client reports. Which of the following client reports should the nurse assess first? - ✔✔Indigestion
A nurse is caring for a client who has constricted pupils, delayed reflexes, and decreased blood pressure. The nurse should identify that these findings are potential manifestations of which of the following? - ✔✔Opioid intoxication
A nurse is reviewing the medical record of a client who has new prescription for gentamicin. The nurse should identify that concurrent use with which of the following current medications can increase the client's risk for ototoxicity? - ✔✔Furosemide
A nurse is caring for a client who is at high risk for developing diabetes insipidus (DI) following a severe head injury. Which assessment finding indicates to the nurse that the client is developing DI? - ✔✔Urine output of 250 mL/hr
A nurse is reviewing the employee health program for new employees. Which of the following diagnostic assessments should the nurse recommend for all new employees to screen for the presence of tuberculosis? - ✔✔Sputum culture
A home health nurse is teaching a guardian about administering tube feedings to their 3-month-old infant. Which of the following information should the nurse include in the teaching? - ✔✔Allow the infant to suck on a pacifier during feedings.
A nurse is assessing a client who is postoperative following abdominal surgery. The client states, "I feel like my incision ripped open." The nurse notes dehiscence of the incision. Which of the following actions should the nurse take? - ✔✔Place the client in a low-Fowler's position.
A nurse is assessing a client's internal eye structures with an ophthalmoscope. Which of the following actions should the nurse take? - ✔✔Dim the lights in the room prior to the examination.
A nurse is providing discharge teaching to a client who is postpartum and plans to breastfeed. Which of the following should the nurse recommend the client increase in their diet during lactation? - ✔✔Iron
A nurse is planning teaching for a client who is at 10 weeks of gestation and has a history of urinary tract infections (UTIS). Which of the following information should the nurse plan to include in the teaching about UTI prevention? - ✔✔Empty the bladder before and after intercourse.
[Show More]
