RN Comprehensive Online Practice 2019 A

A nurse is planning care for a client who is receiving heparin to treat a L leg DVT. Nursing intervention? Ans- elevate the leg A nurse is teaching about child safety measures. What statement indicates understanding? ...

A nurse is planning care for a client who is receiving heparin to treat a L leg DVT. Nursing intervention? Ans- elevate the leg A nurse is teaching about child safety measures. What statement indicates understanding? Ans- avoid sun exposure 10am-2pm A home health nurse is teaching about infection prevention to a cancer pt on chemo. Which statement indicates understanding? Ans- "I'll walk short distances throughout the day" A nurse is providing dietary teaching to the parents of a 6 month old. What instructions should the nurse give? Ans- introduce new foods over 5-7 days A charge nurse is planning care for a client in mechanical restraints. What interventions? Ans- provide a staff member to stay with the client continuously A community health nurse is assisting with the development of a disaster management plan. What nursing responsibility should be included in the disaster response stage? Ans- perform a rapid needs assessment A nurse manager is assisting with the orientation of a newly licensed nurse. Which of the following requires manager intervention? Ans- tells the hospital chaplain a client's diagnosis A nurse is caring for a client that is in labor at 39 weeks gestation. During the second stage of labor, the nurse observes early decelerations on the monitor. What action should the nurse take? Ans- continue observing the fetal heart rate A nurse manager is planning to make changes to the current scheduling system on the unit. To facilitate staff acceptance, what should the nurse manager do first? Ans- provide information about scheduling issues to staff A nurse is planning teaching about allowable foods for a client with uric acid-based urinary calculi formation. What foods should the nurse recommend? Ans- oranges A charge nurse is teaching a newly licensed nurse how to identify true labor. What should the nurse include in the teaching? Ans- the cervix transitions to an anterior position A nurse on a med-surg unit is caring for a client prior to a surgical procedure. Which of the following findings should indicate to the nurse that the client can sign the informed consent? Ans- the client an accurately describe the procedure A charge nurse assigns a new nurse to a client with a chest tube. The new nurse expresses concern d/t limited experience with monitoring drainage. What should the charge do to teach about chest tubes? Ans- ask the nurse about their knowledge of the procedure A nurse is teaching a client about a new prescription for estradiol. For which of the following adverse effects should the nurse tell the client to monitor and contact the provider? Ans- headaches A nurse is preparing to administer diazepam 0.3mg/kg IV bolus to a 22lb toddler who is experiencing a grand mal seizure. Available is 5mg/mL. How many mls should the nurse administer? Ans- 0.6mL A nurse is caring for a 12 hour post op on a PCA for pain control and requires a blood pressure check in 10 min. Which of the following staff members should the nurse assign to collect this information. Ansan Ap who is assisting a client to bed A nurse is creating a plan of care for a child who has acute lymphoid leukemia and an absolute neutrophil count of 400/mm3. What intervention should the nurse include in the plan? Ans- withhold the varicella vaccine A nurse is providing teaching about improving nutrition for a client who has MS. Which instructions should the nurse include? Ans- -a speech pathologist -rest before eating -thicken beverages before eating A nurse is assessing a client who has schizophrenia and is taking chlorpromazine. Which finding is the priority for the nurse to provide to the provider? Ans- temp 102.9f A client is receiving lorazepam IV for panic attacks and develops a RR of 6/min and a BP of 90/44mm Hg. What med should the nurse anticipate administering? Ans- Flumazenil A nurse is caring for an older adult client in the PACU following general anesthesia. What finding should the nurse report to the provider Ans- audible stridor A nurse is preparing a sterile field in order to insert an indwelling urinary catheter on a male client. Which technique should the nurse use to maintain aseptic technique? Ans- set the tray on the table at waist height A nurse is planning care for a client who has a deficit with cranial nerve II. Which of the following actions should the nurse plan to take? Ans- clear objects from the client walking area A nurse is providing discharge instructions to a client following a total hip arthroplasty. Which instruction should the nurse include? Ans- install a raised toilet seat at home A nurse is assessing a client who is receiving a blood transfusion. Which of the following findings should indicate to the nurse that the client is having a hemolytic transfusion reaction? Ans- low back pain A nurse is caring for a child who is experiencing a tonic-clonic seizure. What action should the nurse take? Ans- place the child in a side-lying position A nurse is administering meds to a client who has a percutaneous gastrostomy tube for enteral feedings. Which of the following actions should the nurse take to prevent the tube from clogging? Ans- flush the tube before meds A nurse is assessing a client who has macular degeneration. Which of the following findings should the nurse expect? Ans- decreased central vision A nurse is assessing a client who has schizophrenia. The nurse should identify the following alteration in speech as which of the following? Ans- clang association A nurse in a clinic receives a call from a guardian whose child has varicella. The guardian asks when the child returns to school. Which of the following responses should the nurse make? Ans- when crusts have formed on every lesion A nurse is providing discharge instructions to a client who has a new prescription for warfarin. Which client statement indicates the client understands the teaching? Ans- "I should report a change in the color of my stools" A nurse is assessing a child with CF. Which finding is priority to report to the provider? Ans- hemoptysis 275mL in 24 hours When caring for a child a nurse plans to use nonpharm interventions to enhance pain med effectiveness. Which of the following strategies incorporates visualization techniques to help decrease the child's discomfort? Ans- blowing bubbles to "blow the hurt away" An AP and a nurse are turning a patient on their R side. Which AP action requires the nurse to intervene? Ans- place a pillow A nurse on a mental health unit has a patient refusing IM lorazepam. What is the nursing action? Ansdocument the refusal A nurse has 4 patients. What should the nurse delegate to the AP for meals? Ans- alzheimers w/ aphasia A mental health nurse is conducting the first of many meetings with a client whose partner recently died. The nurse should perform which action to establish trust in the orientation phase of the nurseclient relationship? Ans- establish the termination date A nurse is caring for a client at 28 weeks gestation. The client asks what's causing her constipation. Which response should the nurse make? Ans- enlarged uterus compresses the intestines A nurse manager reviews falls occur most often between 0530 and 0730. Which action should the nurse take in root cause analysis? Ans- investigate environmental factors A nurse is caring for an immediately post op total vaginal hysterectomy. Which action should the nurse take first? Ans- vital signs A charge nurse is planning an educational session for staff nurses about working with parents whose terminally ill children are candidates for organ donation. Which information should the nurse plan to include? Ans- the family can have the child in an open casket A nurse is teaching about TPN and IV lipid emulsions with a client who has an extensive burn injury. Which of the following information should the nurse include? Ans- "You will receive fingersticks for blood glucose testing" A nurse is caring for a client with a closed femur fracture and has had a fiberglass leg cylinder cast for 24 hours. Which of the following assessment findings should the nurse identify as the priority? Ans- the client's heel is red and tender A home health nurse is providing teaching to a client that has hep A.Which of the following instructions should the nurse include? Ans- use hydrogen peroxide to clean kitchen surfaces Intermittent Urinary Catheterization Ans- 'straight cath'