1. A nurse at a public health clinic is caring for a group of clients. Which of the following should the nurse identify as a reportable diagnosis to the CDC?
2 A nurse is planning care for a newborn who has hyperbilir
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1. A nurse at a public health clinic is caring for a group of clients. Which of the following should the nurse identify as a reportable diagnosis to the CDC?
2 A nurse is planning care for a newborn who has hyperbilirubinemia and is to receive phototherapy. Which of the following interventions should the nurse include?
3 an assistive personnel tells the nurse that several client measurements were obtained with morning vital signs. Which of the following clients should the nurse plan to assess?
4. A nurse is assessing a client who is postoperative3 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?
5 A community health nurse recognizes that the teen pregnancy rate in the community has increased. Which of the following program-planning strategies should the nurse implement first?
6 After making morning rounds, the charge nurse on a surgical unit delegates the following task to the assistive personnel, which of the following task does the nurse direct the AP to complete first?
7 A nurse is caring for a client who is receiving a localized epidural analgesia infusion. Which of the following nursing actions is appropriate?
8 A nurse is performing disaster triage following a natural disaster. Which of the following should the nurse identify as the highest priority to receive care?
9 A nurse is planning to provide community education about viral hepatitis. Which of the following should the nurse plan to include in the teaching?
10 A nurse in the emergency department caring for a client who has abdominal pain. Which of the following actions by nurse demarcates veracity?
11 A nurse is about to administer an injection to a client who states, “I don’t want that injection. The last time I got that I was sore for a week.” The nurse goes ahead and administers the injection against the client’s wishes. The nurse committed which of the following?
12 A home health nurse is assessing a client who is receiving from an acute myocardial infarction (MI). Which of the following assessment findings should the nurse report to the provider as a possible indication of left-sided heart failure?
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14 A nurse is caring for a group of clients. The nurse should request a referral for a speech language pathologist for which of the following clients?
15 A nurse is preparing to provide education about electroconvulsive therapy (ECT) for a client who has major depressive disorder. Which of the following should the nurse include in the teaching?
16 A nurse is caring for a mother who prescribed methadone during pregnancy. The nurse should assess the newborn for which of the following manifestations of neonatal abstinence syndrome
17 A nurse is caring for a client following an open colectomy. Which of the following findings places the client at risk for delayed wound healing?
18 A nurse who typically works on the postpartum unit is assigned to float to the maternal newborn unit. The nurse is very anxious about floating and uncomfortable with the assignment the charge nurse has selected. Which of the following actions is appropriate for nurse to take?
19 A client hospitalized for a bone marrow transplant is in protective isolation while undergoing total body radiation and intense chemotherapy. The client’s sibling comes visit but has obvious manifestations of an upper respiratory infection. Which of the following nursing actions is appropriate at this time?
20 A nurse is caring for a client following insertion of a subclavian nontunneled percutaneous central venous catheter (CVC). The provider writes a prescription to initiate an IV infusion ringer’s lactate at 150 mL per hr. prior to starting the infusion, which of the following actions should the nurse take?
21 A nurse is providing teaching to an adolescent client who has cystic fibrosis and has a prescription for pancrealipase. Which of the following should the nurse include in the teaching?
22 A nurse is assessing laboratory values on a client who has taken an overdose of acetaminophen. The nurse should expect which of the following laboratory values indicative of organ damage from the overdose?
23 A nurse on an orthopedic floor is completing morning assessments on several clients. Which of the following clients has the greatest risk for fat embolism syndrome (FES)?
24 A nurse is caring for a client who has end stage liver disease. The daughter of the client asks about her father’s do-not-resuscitate request. Which of the following is a therapeutic response by the nurse?
25 A nurse is providing teaching to the parent of preschooler who was newly diagnosed with a latex allergy. The nurse should discuss that a cross reaction may occur with which of the following foods?
26 A nurse is planning to admit a client who has hyperthyroidism. Which of the following rooms is appropriate for the nurse to assignment client to?
27 A nurse has just returned to the nursing unit following cardiac catheterization. In the immediate postprocedure period, which of the following is the priority nursing action?
28 A nurse is caring for an infant who is being treated for dehydration. Which of the following findings indicate the treatment is effective?
29 A nurse is reviewing medical for four clients. Which of the following represents appropriate documentation?
30 A nurse in the clinic is providing information to a client who has mastitis of the left breast. The client asks the nurse, “does this mean that I must stop nursing my baby?” which of the following is an appropriate statement by the nurse?
31 A nurse in a mental health clinic is observing clients in the day room. The nurse sits down to talk with an adolescent client who was admitted with clinical depression. After a few minutes of conversation, the adolescent asks the nurse, “why did you choose to talk to me out of this room full of kids?” which of the following responses by the nurse is therapeutic?
32 A nurse working in an inpatient mental health facility observes a client who is agitated and threatening staff members in the day room. Which of the following actions should the nurse take first?
33 A client who is precepting a nursing student is brings the following client observation to the nurse’s attention. Which of the following client should the nurse assess first?
34 A nurse is planning teaching for a client who is at 10 weeks 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?
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