A nurse is caring for a newborn whose parent asks why her baby is receiving vitamin K. The nurse should explain to the parents that the newborn should receive vitamin K to prevent which of the following? - ANSWER Bleedin
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A nurse is caring for a newborn whose parent asks why her baby is receiving vitamin K. The nurse should explain to the parents that the newborn should receive vitamin K to prevent which of the following? - ANSWER Bleeding
A charge nurse is observing a newly licensed nurse administer enteral feedings via NG tube. Which of the following actions by the newly licensed nurse indicates an understanding of the procedure? - ANSWER Keeps the head of the bed elevated to 45° for 1 hr after feedings.
A nurse is teaching a client about foods high in vitamin A. Which of the following foods should the nurse recommend as having the highest amount of vitamin A? - ANSWER 1 medium raw carrot
An RN is planning care for a group of clients and is working with a licensed practical nurse (LPN) and an assistive personnel (AP). Which of the following tasks should the RN delegate to the LPN? - ANSWER
An RN is planning care for a group of clients and is working with a licensed practical nurse (LPN) and an assistive personnel (AP). Which of the following tasks should the RN delegate to the LPN? - ANSWER Insertion of a nasogastric tube
A nurse on a medical-surgical unit is caring for a client prior to a surgical procedure. Which of the following findings should indicate to the nurse that the client has the ability to sign the informed consent? - ANSWER The client is able to accurately describe the upcoming procedure.
A nurse is caring for a client who is receiving total parenteral nutrition (TPN) solution by continuous IV infusion at 60 mL/hr. The nurse discovers the infusion pump has stopped working. Which of the following actions should the nurse take while waiting for a new infusion pump? - ANSWER Provide dextrose 10% in water solution using manual drip tubing at 60 mL/hr.
MY ANSWERThe nurse should use an infusion pump when administering TPN solution to ensure accurate dosage and should taper the infusion rate before discontinuing the solution to prevent hypoglycemia. If the nurse is unable to continue the TPN infusion by infusion pump, the nurse should use manual drip tubing to infuse dextrose 10% in water at the same rate as the TPN solution.
A nurse is assessing a client who has schizophrenia and is taking chlorpromazine. Which of the following findings is the priority for the nurse to report the provider? - ANSWER Temperature 39.4° C (103° F)
A nurse is teaching the parent of a school-age child about administering ear drops. Which of the following responses by the parent indicates an understanding of the teaching? - ANSWER "I should pull the top of her ear upward and back while instilling the medication."
A nurse is assessing a client who is experiencing autonomic dysreflexia. Which of the following findings should the nurse expect? (Select all that apply.) - ANSWER Facial flushing is correct.
Nasal congestion is correct.
Headache is correct.
A nurse is caring for a client who has a deficit with cranial nerve (CN) II. Which of the following actions should the nurse plan? - ANSWER Clear objects from the client's walking area.
A nurse is planning care for a client who has thrombocytopenia. Which of the following instructions should the nurse include in the client's plan of care? - ANSWER Avoid venipunctures when possible.
A nurse in the delivery room is caring for a newborn immediately after birth. Which of the following actions should the nurse take first? - ANSWER Dry the newborn.
A nurse is assessing a newborn who was just admitted to the nursery and is sleeping. For which of the following findings should the nurse intervene? - ANSWER Axillary temperature 36.2° C (97.2° F)
The expected reference range for the axillary temperature of a newborn is between 36.5° C and 37.5° C (97.7° F and 100° F). An axillary temperature of 36.2° C (97.2° F) or below requires the nurse to intervene to prevent cold stress.
A nurse is assessing a client who has a stage II pressure ulcer. Which of the following wound characteristics should the nurse expect? - ANSWER Partial-thickness skin loss
A nurse is caring for a toddler who has infectious gastroenteritis. Which of the following actions should the nurse take? - ANSWER Initiate oral rehydration therapy for the toddler.
A nurse is caring for a client who had a recent stoke. Prior to transferring the client to the bedside commode, which of the following actions should the nurse take first? - ANSWER Assess the client for functional limitations.
A nurse is assessing a client who has schizophrenia. The nurse should identify the following alteration in speech as which of the following? (Click on the audio button to listen to the clip. - ANSWER Clang association
A nurse is counseling a couple who have been unsuccessful at conceiving for more than a year. Which of the following statements should the nurse make to help the couple cope with prolonged infertility? - ANSWER "Would you like information regarding some support groups?"
A nurse is caring for an adolescent client who has a new diagnosis of terminal cancer. When discussing the client's prognosis with her parents, the nurse should recognize which of the following responses by the parents as an example of rationalization? - ANSWER "Maybe this is better for our child because we don't want her to suffer through chemotherapy treatments."
A nurse is caring for a client who vomits on a reusable BP cuff. Which of the following actions should the nurse take? - ANSWER Place the BP cuff in a labeled bag to send it for decontamination.
A nurse is teaching the parents of a toddler about snacks. Which of the following foods should the nurse recommend? - ANSWER Steamed carrots
A nurse is providing teaching to a client who has hepatitis A. Which of the following instructions should the nurse include? - ANSWER Use a 1:100 chlorine bleach solution to clean kitchen surfaces.
A nurse is providing teaching to a parent of a child who has a permanent tracheostomy tube. Identify the sequence of steps the parent should follow to perform tracheostomy care. (Move the steps into the box on the right, placing them in the selected order of performance. Use all the steps.) - ANSWER When teaching the parent to provide tracheostomy care, the nurse should instruct the parent to first remove the inner cannula. Next, the nurse should instruct the parent to remove the soiled dressing and then clean the stoma with sterile saline. Finally, the nurse should instruct the parent to change the tracheostomy collar.
A nurse is providing discharge instructions to a client who has a new prescription for warfarin. Which of the following client statements should the nurse identify as an indication that the client understands the teaching? - ANSWER "I should report a change in the color of my stools."
A nurse is caring for a client who is in the manic phase of bipolar disorder. Which of the following clinical manifestations should the nurse expect? - ANSWER Grandiose thoughts
A nurse is planning to teach a client who is to start a new prescription for fluoxetine. For which of the following findings should the nurse instruct the client to monitor and report to the provider? - ANSWER Tremors
Fluoxetine can cause serotonin syndrome within 2 to 72 hr after starting treatment. The client can experience tremors, agitation, confusion, anxiety, and hallucinations. The nurse should instruct the client to report these manifestations to the provider and to stop taking the medication.
A nurse in an emergency department is admitting a client who has cardiac tamponade. Which of the following assessment findings should the nurse expect? - ANSWER Pulsus paradoxus
The nurse should identify pulsus paradoxus, a finding in which the systolic BP is 10 mm Hg or greater on expiration than inspiration, as an expected finding of cardiac tamponade, along with jugular vei
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