A nurse is preparing to administer digoxin to a client who has heart failure. Which of the following findings should indicate to the nurse that the medication has been effective? - ANSWER Cardiac workload decreases
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A nurse is preparing to administer digoxin to a client who has heart failure. Which of the following findings should indicate to the nurse that the medication has been effective? - ANSWER Cardiac workload decreases
A nurse is reinforcing teaching about stress management techniques with a client who has moderate anxiety disorder. Which of the following responses by the client indicates an understanding of the teaching? - ANSWER "I will imagine myself in a calm place when I can't concentrate"
A nurse is reinforcing teaching with a client about taking warfarin to treat atrial fibrillation. Which of the following statements by the client indicates an understanding of the teaching? - ANSWER "If I forget to take a dose, I can take it later on the same day"
A charge nurse in a long-term care facility notices an assistive personnel's (AP) repeated failure to provide oral care for clients. Which of the following actions should the charge nurse take? - ANSWER Discuss this behavior with the AP while reinforcing expectations
A nurse in a long-term care facility is observing a newly licensed nurse who is providing tracheostomy care for a client. The nurse identifies proper performance when the newly licensed nurse selects which of the following solutions to clean the inner cannula? - ANSWER Hydrogen peroxide
A nurse caring for a client who took an overdose of acetaminophen. Which of the following medications should the nurse plan to administer to the client? - ANSWER Acetylcysteine
A nurse is caring for a client who is in Buck's traction. Which of the following actions should the nurse take? - ANSWER Allow the weights to hang freely
A nurse is preparing to administer metoclopramide 10mg IM. Available is metoclopramide 5mg/mL. How many mL should the nurse administer? - ANSWER 2mL
A nurse is reinforcing discharge instructions with the parent of an infant who has rotavirus. Which of the following statements by the parent indicates an understanding of the teaching? - ANSWER "I will apply diaper cream to my baby's skin during each diaper change"
A charge nurse is observing a newly licensed nurse apply sterile gloves. Which of the following actions by the newly licensed nurse demonstrates sterile technique? - ANSWER Putting a glove on their dominant hand first
A nurse is reviewing laboratory reports for a client who has an Escherichia coli infection and is receiving gentamicin. Which of the following results should the nurse report to the provider before administering the next dose? - ANSWER Creatinine 2.5mg/dL
A nurse at a long-term care facility is caring for a client who requires oral suctioning. Which of the following supplies should the nurse plan to use for this task? - ANSWER Yankauer catheter
A nurse in a long-term care facility is serving on the ethics committee, which is addressing a client care dilemma. Which of the following strategies will facilitate resolving the dilemma? (Select all that apply) - ANSWER Determine the facts related to the dilemma
Identify possible solutions
Consider the client's wishes
A nurse is talking with a client whose son died in a motor-vehicle crash 2 weeks ago. The client states, "I really thought I'd be back to my usual routines by now, but I can't think of anything else except that my son is gone." Which of the following responses should the nurse make? - ANSWER "Grieving for your son is hard work. It will take as much time as you need to come to terms with your loss."
A nurse is reinforcing teaching with a client about cancer prevention. The nurse should include that frequent consumption of which of the following foods increases the risk for developing cancer? - ANSWER Lamb
A nurse notices an assistive personnel (AP) taking a nap in the break room during meal time. The nurse also notes that the AP is drowsy while performing routine tasks. Which of the following actions should the nurse take? - ANSWER Report the observations about the AP to the unit's nurse manager
A nurse on a pediatric unit is collecting data from four newly admitted clients. Which of the following clients should the nurse identify as being at risk for urinary retention? - ANSWER A school-age child who has allergic rhinitis and is taking diphenhydramine
A nurse is caring for a client following a bronchoscopy. Which of the following actions should the nurse take first? - ANSWER Check for a gag reflex
A nurse is assisting with the admission of a client who has a latex allergy. The nurse should identify that which of the following supplies has the potential to contain latex? - ANSWER Indwelling urinary catheter
A nurse is performing postmortem care for a client prior to the arrival of the client's family for viewing of the body. Which of the following actions should the nurse take? - ANSWER Gently close the client's eyelids
A nurse is reinforcing teaching with a client regarding prescribed asthma medications. The nurse should instruct the client to use which of the following medications for treatment of an acute asthma attack? - ANSWER Albuterol
A nurse is reinforcing teaching about home care for conjunctivitis with the parent of a school-age child. Which of the following information should the nurse include? - ANSWER Separate the child's used washcloth from those of others
A nurse is preparing to administer an influenza virus immunization to a client by the intradermal route. Which of the following actions should the nurse take? - ANSWER Avoid massaging the site after injecting the vaccine
A nurse is preparing to insert an indwelling urinary catheter for a female client. Which of the following actions should the nurse take? - ANSWER Open the outer package flap of the catheterization kit away from their body
A nurse is reinforcing teaching about food selection with a client who has a moderate burn injury. Which of the following foods should the nurse recommend as being high in vitamin C? - ANSWER Tomatoes
A nurse is collecting data from a client who has multiple fractures following a motor-vehicle crash. For which of the following client statements should the nurse recommend a referral to an occupational therapist? - ANSWER "I am so frustrated. I cannot even open my milk carton for breakfast"
A nurse is assisting with the admission of an adolescent who has bulimia nervosa. Which of the following manifestations should the nurse expect? - ANSWER hematemesis
A nurse is collecting data from a client who is in the diagnostic center and is scheduled to undergo a colonoscopy. Based on the information provided in the client's chart, which of the following pieces of data places this client at risk for colorectal cancer? - ANSWER BMI
A nurse is caring for a client who has an altered mental status and has become aggressive. Which of the following prescriptions should the nurse clarify with the provider prior to administration? - ANSWER Zolpidem
A nurse is reinforcing teaching with a client who has hypothyroidism and a prescription for levothyroxine. Which of the following instructions should the nurse include in the teaching? - ANSWER "You will need to take this medication for the rest of your life"
A nurse is collecting data from a client who has myasthenia gravis (MG). Which of the following images should the nurse identify as an indication that the client is experiencing ptosis? - ANSWER Abnormal drooping of the upper eyelid
A nurse is assisting with the admission of a client who has major depressive disorder. Which of the following communication techniques should the nurse use to establish a trusting relationship with the client? - ANSWER Offering general leads
A nurse is preparing to administer a client's morning medications. Which of the following actions should the nurse take to verify the client's identity? - ANSWER Scan the client's facility identification band
A nurse is collecting data from a client who has iron deficiency anemia. Which of the following findings should the nurse expect? - ANSWER Difficulty concentrating
A nurse is caring for a client who has expressive aphasia following a stroke. Which of the following methods should the nurse use when communicating with the client? - ANSWER Provide a picture board
A nurse is caring for a client who is 1 day postoperative and is unable to ambulate. Which of the following actions should the nurse take to promote the client's venous return? - ANSWER maintain a sequential compression device
A nurse is observing an assistive personnel (AP) caring for a client. For which of the following actions by the AP should the nurse intervene? - ANSWER The AP reports client information to the oncoming AP in the hallway
A nurse is reinforcing teaching with a newborn's parents about umbilical cord care. Which of the following statements by a parent indicates an understanding of the instructions? - ANSWER "I will give our baby sponge baths until the cord falls off"
A nurse is reinforcing discharge teaching with a client who has undergone vein ligation and stripping to treat varicose veins. Which of the following instructions should the nurse include in the teaching? - ANSWER Walk for 1 to 2 hr each day
A nurse is delegating the collection of a sputum specimen to an assistive personnel (AP). At which of the following times should the nurse instruct the AP to collect the specimen? - ANSWER As soon as the client awakens in the morning
A nurse at a long-term care facility is part of a team preparing a report on the quality of care at the facility. Which of the following information should the nurse recommend including in the report to demonstrate improvement in care quality? - ANSWER The facility had 12% fewer urinary tract infections over the past 6 months
A nurse is maintaining droplet precautions for a client who has meningitis. Which of the following actions should the nurse take? - ANSWER Wear a surgical mask within 3 feet of the client
A nurse is reinforcing teaching with a client who has a new diagnosis of type 2 diabetes mellitus and inquires about information concerning oral antidiabetic agents. In addition to the provider, where should the nurse refer the client for information? - ANSWER A pharmacist
Package inserts
American Diabetes Association
A nurse is collecting data from a client who has bipolar disorder and is experiencing acute mania. Which of the following findings is the nurse's priority? - ANSWER Lack of sleep
A nurse is preparing a client for surgery. The client states, "I'm sure this surgery will not help me get better." Which of the following responses should the nurse make? - ANSWER "You're saying that you are doubtful that this procedure will benefit you."
A nurse is reinforcing discharge teaching about car seat safety with the guardian of a newborn. Which of the following statements by the guardian indicates an understanding of the teaching? - ANSWER "I will secure the car seat in the car by using the seatbelt"
A nurse is reinforcing teaching with a client about the client's recent diagnosis of multiple sclerosis. The client states, "I am very upset and I want to be alone for a little while." Which of the following responses should the nurse make? - ANSWER "I see that you are feeling overwhelmed. I will come back when you are ready."
A nurse is reinforcing teaching with a client who has a new prescription for prednisone for the treatment of Addison's disease. Which of the following instructions should the nurse include in the teaching? - ANSWER "You will need to schedule a bone density test."
A nurse in a long-term care facility is contributing to the plan of care for a client who has a new ostomy. Which of the following interventions should the nurse include? - ANSWER Change the appliance two times each week
A nurse is contributing to the plan of care for a client who is receiving mechanical ventilation. Which of the following interventions should the nurse recommend? - ANSWER Position the head of the bed at a 30 degree angle
A nurse is receiving report on four clients. Which of the following clients should the nurse plan to see first? - ANSWER A client who has pneumonia and a new onset of confusion
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