RN Comprehensive Predictor 2019 A

A nurse in a pediatric unit is preparing to insert an IV catheter for 7-year-old. Which of the following actions should the nurse take? A. (Unable to read) B. Tell the child they will feel discomfort during the cathete ...

A nurse in a pediatric unit is preparing to insert an IV catheter for 7-year-old. Which of the following actions should the nurse take? A. (Unable to read) B. Tell the child they will feel discomfort during the catheter insertion. C. Use a mummy restraint to hold the child during the catheter insertion. D. Require the parents to leave the room during the procedure. - ANSWER B. Tell the child they will feel discomfort during the catheter insertion. A nurse is caring for a client who has arteriovenous fistula Which of the following findings should the nurse report? A. Thrill upon palpation. B. Absence of a bruit. C. Distended blood vessels D. Swishing sound upon auscultation. - ANSWER B. Absence of a bruit. A nurse is providing discharge teaching for a client who has an implantable cardioverter defibrillator which of the following statements demonstrates understanding of the teaching? A. "I will soak in the tub rather and showering" B. "I will wear loose clothing around my ICD" C. "I will stop using my microwave oven at home because of my ICD" D. "I can hold my cellphone on the same side of my body as the ICD" - ANSWER B. "I will wear loose clothing around my ICD" A nurse is caring for a client who is at 14 weeks gestation and reports feelings of ambivalence about being pregnant. Which of the following responses should the nurse make? A. "Describe your feelings to me about being pregnant" B. "You should discuss your feelings about being pregnant with your provider" C. "Have you discussed these feelings with your partner?" D. "When did you start having these feelings?" - ANSWER A. "Describe your feelings to me about being pregnant" A nurse is planning care for a client who has a prescription for a bowel- training program following a spinal cord injury. Which of the following actions should the nurse include in the plan of care? A. Encourage a maximum fluid intake of 1,500 ml per day. B. Increase the amount of refined grains in the client's diet. C. Provide the client with a cold drink prior to defecation. D. Administer a rectal suppository 30 minutes prior to scheduled defecation times. - ANSWER D. Administer a rectal suppository 30 minutes prior to scheduled defecation times. A nurse is caring for a client who is in active labor and requests pain management. Which of the following actions should the nurse take? A. Administer ondansetron. B. Place the client in a warm shower. C. Apply fundal pressure during contractions. D. Assist the client to a supine position. - ANSWER B. Place the client in a warm shower. A nurse in an emergency department is performing triage for multiple clients following a disaster in the community. To which of the following types of injuries should the nurse assign the highest priority? A. Below-the knee amputation B. Fractured tibia C. 95% full-thickness body burn D. 10cm (4in) laceration to the forearm - ANSWER A. Below-the knee amputation a nurse manager is updating protocols for the use of belt restraints. Which of the following guidelines should the nurse include? A. Remove the client's restraint every 4hr B. Document the client's condition every 15 min C. Attach the restrain to the bed's side rails D. Request a PRN restrain prescription for clients who are aggressive - ANSWER B. Document the client's condition every 15 min A nurse is teaching an in-service about nursing leadership. Which of the following information should the nurse include about an effective leader? A. Acts as an advocate for the nursing unit. B. (Unable to read) for the unit C. Priorities staff request over client needs. D. Provides routine client care and documentation. - ANSWER A. Acts as an advocate for the nursing unit. A nurse is reviewing the laboratory findings of a client who has and reports that she has been following her care. The nurse should identify which of the following findings indicates a need to revise the client's plan of care. A. Serum sodium 144 mEq/ B. (Unable to read) C. Hba1c 10 % D. Random serum glucose 190 mg/dl. - ANSWER C. Hba1c 10 % A nurse in a provider's office is reviewing the laboratory results of a group of clients. The nurse should identify that which of the following sexually transmitted infections is a nationally notifiable infectious disease that should be reported to the state health department? A. Chlamydia B. Human papillomavirus C. Candidiasis D. Herps simplex virus - ANSWER A. Chlamydia A nurse is teaching a newly licensed nurse about therapeutic techniques to use when leading a group on a mental health unit. Which of the following group facilitation techniques should the nurse include in the teaching? A. Share personal opinions to help influence the group's values B. Measure the accomplishments of the group against a previous group C. Yield in situations of conflicts to maintain group harmony D. Use modeling to help the clients improve their interpersonal skills - ANSWER D. Use modeling to help the clients improve their interpersonal skills A nurse is planning for a client who practices Orthodox Judaism. The client tells the nurse that its Passover holiday. Which of the following action should the nurse include in the plan of care? A. Provide chicken with cream sauce. B. Avoid serving fish with fins and scales. C. Provide unleavened bread. D. Avoid serving foods containing lamb. - ANSWER C. Provide unleavened bread. A nurse is caring for a client who has a pulmonary embolism. The nurse should identify the effectiveness of the treatment: A. A chest x-ray reveals increased density in all fields. B. The client reports feeling less anxious. C. Diminished breath sounds are auscultated bilaterally D. ABG results include Ph 7.48 PaO2 77 mm Hg and PaCO2 47 mm Hg. - ANSWER B. The client reports feeling less anxious. A nurse in an emergency department is assessing a client who reports ingesting thirty diazepam tablets and has respiratory rate of 10/min. After securing the client's airway and initiating an IV, which of the following actions should the nurse do next. A. Monitor the client's IV site for thrombophlebitis. B. Administer flumazenil to the client. C. Evaluate the client for further suicidal behavior. D. Initiate seizure precautions for the client. - ANSWER B. Administer flumazenil to the client. A nurse in an emergency department is caring for a client who reports cocaine use 1hr ago. Which of the following findings should the nurse expect? A. Hypotension B. Memory loss C. Slurred speech D. Elevated temperature - ANSWER D. Elevated temperature A nurse is assessing a newborn who has a blood glucose level of 30 mg/dl. Which of the following manifestations should the nurse expect? A. Loose stools B. Jitteriness C. Hypertonia D. Abdominal distention - ANSWER B. Jitteriness A nurse in a pediatric clinic is reviewing the laboratory test results of a school age child. Which of the following findings should the nurse report to the provider? A. Hgb 12.5 g/dl B. Platelets 250,000/mm3 C. Hct 40% D. WBC 14,000/mm3 - ANSWER D. WBC 14,000/mm3 A charge nurse is teaching a newly licensed nurse about clients designating a health care proxy in situations that require a durable power of attorney for heal care (DPSHC). Which of the following information should the charge nurse include? A. "The proxy should make health care decisions for the client regardless of the client's ability to do so." B. "The proxy can make financial decisions if the need arises." C. "The proxy can make treatment decisions if the client is under anesthesia." D. "The proxy should manage legal issues for the client." - ANSWER C. "The proxy can make treatment decisions if the client is under anesthesia." A nurse in the PACU is caring for a client who reports nausea. Which of the following actions should the nurse take first? A. Turn the client on their side. B. Administer an analgesic C. Administer antiemetic D. Monitor the client's vital signs. - ANSWER A. Turn the client on their side. A nurse is caring for a client who has a history of depression and is experiencing a situational crisis. Which of the following actions should the nurse take first? A. Confirm the client's perception of the event B. Notify the client's support system C. Help the client identify personal strengths D. Teach the client relaxation techniques - ANSWER A. Confirm the client's perception of the event A nurse is caring for a client who has bipolar disorder and is experiencing acute mania. The nurse obtained a verbal prescription for restraints. Which of the following actions should the nurse take? A. Request a renewal of the prescription every 8 hr. B. Check the client's peripheral pulse rate every 30 min C. Obtain a prescription for restraint within 4 hr. d. Document the client's condition every 15 minutes. - ANSWER d. Document the client's condition every 15 minutes. A nurse is caring for a client who has end-stage kidney disease. The client's adult child asks the nurse about becoming a living kidney donor for her father. Which of the following condition in the child's medical history should the nurse identify as a contraindication to the procedure? A. Amputation B. Osteoarthritis C. Hypertension D. Primary glaucoma - ANSWER C. Hypertension A charge nurse on a medical-surgical unit is planning assignments for a licensed practical nurse (LPN) who has been sent from the postpartum unit due to a staffing shortage for the shift. Which of the following client should the nurse delegate to the LPN? A. A client who has an Hgb of 6.3 g/dl and a prescription for packed RBCs. B. A client who sustained a concussion and has unequal pupils. C. A client who is postoperative following a bowel resection with an NG tube set to continuous suction. D. A client who fractured his femur yesterday and is experiencing shortness of breath. - ANSWER C. A client who is postoperative following a bowel resection with an NG tube set to continuous suction. A nurse is working on a surgical unit is developing a care plan for a client who has paraplegia. The client has an area of no blanchable erythema over his ischium. Which of the following interventions should the nurse include in the care plan? A. Place the client upright on a donut-shaped cushion B. Teach the client to shift his weight every 15 min while sitting C. Turn and reposition the client every 3 hr while in bed D. Assess pressure points every - ANSWER B. Teach the client to shift his weight every 15 min while sitting A nurse is caring for a client who is dilated to 10 cm and pushing. Which of the following pain-management is a safe option for the client? E. Naloxone hydrochloride. F. Spinal anesthesia. G. Pudendal block. H. Butorphanol tartrate. - ANSWER G. Pudendal block. A nurse is caring for a client who has left homonymous hemianopsia. Which of the following is an appropriate nursing intervention? a. Teach the client to scan the right to see objects on the right side of her body. b. Place the bedside table on the right side of the bed. c. Orient the client to the food on her plate using the clock method. d. Place the wheelchair on the client's left side. - ANSWER b. Place the bedside table on the right side of the bed. A nurse is assessing a client who has major depressive disorder. Which of the following findings should the nurse identify as the suicidal? A. The client changes the subject when future plans are mentioned. B. The client talks about being in pain constantly. C. The client sleeping over 12 hr. each day. D. The client reports giving away personal items. - ANSWER D. The client reports giving away personal items. A nurse is providing teaching about immunizations to a client who is pregnant. The nurse should inform the client that she can receive which of the following immunizations during pregnancy? (Select all that apply) A. Varicella vaccine. B. Inactivated polio vaccine. C. Tetanus diphtheria and acellular pertussis vaccine D. Rubella vaccine. E. Inactivated influenza vaccine. - ANSWER C. Tetanus diphtheria and acellular pertussis vaccine E. Inactivated influenza vaccine. A nurse is providing discharge teaching for a group of clients. The nurse should recommend a referral to a dietitian A. A client who has a prescription for warfarin and states "I will need to limit how much spinach I eat". B. A client who has gout and states, "I can continue to eat anchovies on my pizza." C. A client who has a prescription for spironolactone and states "I will reduce my intake of foods that contain potassium". D. A client who has (Unable to read) and states "I'll plan to take my calcium carbonate with a full glass of water". - ANSWER B. A client who has gout and states, "I can continue to eat anchovies on my pizza." A hospice nurse is visiting with the son of a client who has terminal cancer. The son reports sleeping very little during the past week due to caring for his mother. Which of the following responses should the nurse make? A. "I can give you information about respite care if you are interested." B. "You should consider taking a sleeping pill before bed each night" C. "It must be difficult taking care of someone who is terminally ill" D. "You are doing a great job taking care of your mother" - ANSWER A. "I can give you information about respite care if you are interested." A nurse is assessing a child who is being treated for bacterial pneumonia. The nurse notes an increase in the child's glucose. The nurse should identify this finding as an adverse effect of which of the following medications? A. Methylprednisolone. B. Ondansetron. C. Guaifenesin. D. Amoxicillin. - ANSWER A. Methylprednisolone. The nurse is providing teaching about folic acid to a client who is prima gravida. Which of the following information should the nurse include in the teaching? A. "You should take folic acid to decrease the risk of transmitting infections to your baby" B. "You should consume a maximum of 300 micrograms of folic acid every day". C. "You can increase your dietary intake of folic acid by eating cereals and citrus fruits". D."You can expect your urine to appear red-tingled while taking folic acid supplements". - ANSWER C. "You can increase your dietary intake of folic acid by eating cereals and citrus fruits". A community health nurse is assessing an adolescent who is pregnant. Which of the following assessments is the nurse's priority? A. Social relationship with peers. B. Plans for attending school while pregnant. C. Help obtain Medicaid D. Understanding of infant care. - ANSWER C. Help obtain Medicaid A nurse manager is planning to teach staff about critical pathways. Which of the following information should the nurse include? A. Critical pathways have unlimited timeframe for completion B. aimed to decrease health care costs. C. (Unable to read) critical pathway if variances (Unable to read) D. (Unable to read) are used to create the critical pathway. - ANSWER B. aimed to decrease health care costs. A nurse is reviewing the medical record of a client who has schizophrenia. Which of the following should the nurse report to the provider? Exhibit 1 Blood pressure: 102/56 mm Hg. Heart rate: 95/min Respiratory rate: 18/min Temperature: 37.4C (99.3F) Exhibit 2 Medication Administration Record Clozapine 150 mg PO twice daily Benztropine 0.5 mg PO twice daily as needed for tremors. Exhibit 3 Nurse's notes: Client reports feeling dizzy when changing positions, Reports weight gain of 1kg (2.2 lb.) in the past month. Also reports a sore throat for the past 3 days and dry mouth. Client ate 75% of breakfast and reports slightly nauseous. A. Dietary intake B. Heart rate. C. Sore throat. D. Blood pressure - ANSWER C. Sore throat. A charge nurse is educating a group of unit nurses about delegating client tasks to assistive personnel A. "The nurse is legally responsible for the actions of the AP". B. "An AP can perform tasks outside of his range if he has been trained". C. "An experienced AP can delegate to another AP". D. "An RN evaluates the client needs to determine tasks to delegate - ANSWER D. "An RN evaluates the client needs to determine tasks to delegate A nurse is assessing a client who is in active labor. Which of the following findings should the nurse report to the provider? A. Contractions lasting 80 seconds B. FHR baseline 170/min C. Early decelerations in the FHR C. Temperature 37.4C (99.3) - ANSWER B. FHR baseline 170/min A nurse working in a rehabilitation facility is developing a discharge plan for a client who has left-sided hemiplegia. Which of the following actions is the nurse's priority? A. Consult with a case manager about insurance coverage. B. Counsel caregivers about respite care options. C. Ensure that the client has a referral for physical therapy. D. Refer the client to a local stroke support group. - ANSWER C. Ensure that the client has a referral for physical therapy. A nurse in a mental health unit is planning room assignments for four clients. Which of the following client should be closest to the nurse's station? A. A client who has an anxiety disorder and is experiencing moderate anxiety. B. A client who has somatic symptom disorder and reports chronic pain. C. A client who has depressive disorder and reports feeling hopeless. D. A client who has bipolar disorder and impaired social interactions. - ANSWER C. A client who has depressive disorder and reports feeling hopeless. A nurse is preparing to measure a temperature of an infant. Which of the following action should the nurse take? A. Place the tip of the thermometer under the center of the infant's axilla. B. Pull the pinna of the infant's ear forward before inserting the probe. -down and back C. Insert the probe 3.8 cm (1.5in) into the infant's rectum. D. Insert the thermometer in front of the infant's tongue. - ANSWER A. Place the tip of the thermometer under the center of the infant's axilla. A nurse is planning care for a client who has bipolar disorder and is experiencing mania. Which of the following interventions should the nurse include in the plan? A. Encourage the client to spend time in the day room B. Withdraw the client's TV privileges is the does not attend group therapy C. Encourage the client to take frequent rest periods D. Place the client in seclusion when he exhibits signs of anxiety - ANSWER C. Encourage the client to take frequent rest periods A nurse is admitting medications to a group of clients. Which of the following occurrences requires the completion of an incident report? A. A client receives his antibiotics 2hr late B. A client vomits within 20min of taking his morning medications C. A client requests his statin to be administ