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Terms in this set (96)The nurse on an inpatient mental health unit is caring with the paranoid delusions who is refusing to eat. The client states that all the food and drinks have been poisoned. Which intervention by the nurse is appropriate? Provide the client food in unopened single serving packages After listening to the parents' report and seeing the ff pediatric clients, the nurse knows that which client demonstrates signs of abuse that may necessitate mandatory reporting? 5- year old whose x- ray reveals 1 new and 2 healed humerus fractures after falling from a tree. The nurse is discussing the care needs of a client in the last stage of Huntington disease with the family. When the nurse mentions arranging for delivery of a prescribed hospital bed, the client's spouse becomes visibly upset and says, "No hospital bed. I'm just not ready for it yet." What is the best response by the nurse? What upsets you about having hospital bed? The nurse administers ondansetron to a hospitalized client. Which statement would indicate to the nurse that the ondansetron was effective? The nausea is a lot better The nurse has just received report on 4 clients. Which client should the nurse see first? Client receiving IV normal saline at 250 mL/hr who is reporting puffy legs and a new cough An unaccompanied 16 year old girl comes to the emergency department with a severe abdominal pain and vomiting. The client has a temp of 102.2 F (39 C) and a pulse of 120/min and is lethargic. The client's parents are out of town, and no guardians can be reached. How should the client's care be handled? Administer care until the parents or guardians can be reached. The nurse reinforces teaching to the parents of a 12 month old who has begun weaning from breastfeeding. Which statement by the parents indicates that teaching has been effective? I can start substituting breastfeeding sessions with whole cow's milk The child with congenital heart disease who weighs 88 lbs is prescribed furosemide 1 mg/kg by mouth every 8 hours. It is available as an oral solution of 10 mg/mL. How many milliliter (mL) of furosemide should the nurse administer to the client for each dose? prescription x available data - mL/dose 4ml The nurse cares for a client with a terminal disease who has an advanced directive supporting a do not resuscitate (DNR) code status. The client stops breathing and loses a pulse. The client's adult client states, "I changed my mind. Do whatever you can to save him!" Which intervention is most appropriate at the time? Explain the client's wishes to the client's child The nurse speaks with a client with schizophrenia who begins to look away toward the door and grimace. Which statement by the nurse is most therapeutic at this time? What do you see at the door? The nurse reinforces teaching to a 15 year primigravid client at 16 weeks gestation during an initial prenatal visit. Which information would be a priority for the nurse to include? Stress the importance of consistent prenatal care. A female client is visiting the clinic for an annual well-woman examination. The client reports having had sex with women. Which question will help the nurse determine the client's risk for sexually transmitted infections? What barrier methods do you and your partner use? While the nurse is transporting a client to a new unit, the client's chest tube drainage system falls off the bed and the tube becomes dislodged from the chest wall. What is the nurse's priority action? Firmly cover the insertion site with the palm of a clean, gloved hand. The nurse cares for a client with a burn on the arm and finds that the area is red, moist, and covered in shiny, fluid-filled vesicle. Which burn stage does the nurse document? second degree A nurse in the emergency department is caring for a client should the nurse see first? Client with myasthenia gravis who has a fever and increasing difficulty swallowing. The nurse is caring for a client who has been treated for depression and suicidal ideation. Which client statement best Indicates that the client is not currently at risk for suicide? I plan to attend my granddaughter's graduation next month The nurse removes personal protective equipment (PPE) after completing a wound dressing change for a client transmission-based precautions. Which PPE should the nurse remove first. Gloves The nurse is caring for client taking escitalopram who reports no improvement of depressive feelings since starting the medication 2 months ago. What is the best response by the nurse? Let's talk more about how you have been taking this medication The client admitted to the psychiatric unit with severe anxiety is pacing rapidly in the room, crying, and hyperventilating. The client yells, "I can't believe you took my belonging! Where are you keeping them? This is so frustrating!" What is the appropriate response by the nurse? "Your belongings are locked in a safe place to ensure that they are protected while you are here." The nurse is caring for a new mother whose infant has been diagnosed with Down syndrome. The client says to the nurse, "I'm so worried. My husband is so devastated that he won't even look at the baby." What is the best response by the nurse? How are you feeling about you baby? The new nurse reinforcing teaching to a client scheduled for electroconvulsive therapy (ECT). What information given by the new nurse would cause the charge nurse to intervene? Be sure to take your vampiric acid prior to the procedure. The nurse is reinforcing self care and medication teaching for a client diagnosed with vaginal candidiasis who has been prescribed miconazole vaginal cream. Which statement by the client indicates that further teaching is needed? I will refrain from having sex until my partner is also tested for the infection A 4-year old is diagnosed with Duchenne muscular dystrophy. Which nursing teaching is most appropriate to reinforce for this child's parents? Remove throw rugs from the home The nurse checks a client's blood pressure using an automatic, noninvasive machine. The nurse notes that the machine inflates for an unusually long amount of time, and the client reports intense pain in the arm with the cuff. The device suddenly stops inflation and displays an error message. Which action by the nurse is appropriate? Send the machine for maintenance and repeat the measurement manually The nurse is reinforcing teaching to the caregiver of a client with a new prescription for risperidone. Which statement indicates that the caregiver needs further instruction? It is normal for a client to become shaky and restless when agitated The nurse is reviewing a client's preoperative questionnaire, which indicates a religious preference with spiritual needs concerning surgery scheduled later today. Which action is most appropriate at this time? Follow up with the client regarding the nature of the spiritual needs or religious practices. The new nurse, caring for a 3-month-old client who is sedated in the intensive care unit ff surgery, needs to prevent skin breakdown. Which action performed by the new nurse would cause the charge nurse to intervene? Placing a donut pillow under the head An elderly client with diabetes comes to the clinic in winter reporting numbness of the feet. After removing the client's shoes and socks, the nurse notes that the feet are ice cold to the touch and appear waxy and pale. What is the appropriate nursing action? Soak the client's lower legs in a warm water bath The home health nurse visits a client with inflammatory bowel disease who recently underwent a total colectomy with ileostomy creation. Which statement by the client indicates that the client understands ileostomy care? I cut the appliance opening slightly larger than my stoma. The staff nurse is preparing a presentation about strategies to reduce horizontal violence. The nurse educator is reviewing the presentation beforehand. Which recommendation included in the presentation indicates a need for further teacher? Working toward diversification of staff age and gender For which client is it most important for the nurse to reinforce teaching regarding ways to prevent the spread of the condition? The client with tinea corporis The nurse assists with medication reconciliation for a client. visiting the clinic for a follow-up appointment. Which medication reported by the client requires further investigation? 200mg of celecoxib PO once daily A client is in cardiac arrest. and resuscitation efforts are in progress when the client's spouse arrives. The client's spouse insists on coming into the room. How should the nurse respond? Allow the spouse into the room and provide a chair The nurse in a psychiatric unit is approached by a aggressive client who grabs the nurse's stethoscope and attempts to strangle the nurse with it. The nurse is able to escape the client's grasp unharmed. Which action should the nurse take first? Begin escorting other clients out of the room A client comes to the emergency department after being bitten by a bat. The nurse observes 2 small, nondraining puncture wounds resembling pinpricks on the fingertip. Which action should the nurse implement first? Scrub the wound with povidone-iodine solution or soap and water The nurse on a medical-surgical unit prepares scheduled daily medications for a client and places them in a pill cup. After receiving the pill cup. the client state, "I take a whole tablet of metoprolol at home. Why did you cut this one in half?" What is the best response by the nurse? Show me which pill you're talking about so I can verify your prescriptions again A 10 year old client with autism spectrum disorder is hospitalized for a diagnostic workup. Which is the most appropriate nursing action? Giving the client a schedule of daily activities The charge nurse is educating a new nurse on IM injection technique for a 6 year old with autism spectrum disorder. Which statement by the new nurse indicates that further teaching is required? I will hold the child's hand as a soothing measure
The nurse is reinforcing client teaching about newly prescribed cyclosporine. Which client statement indicates a need for further teaching? I am going to a concert with my friends this weekend The nurse is caring for a client who reports abdominal pain and vaginal spotting. The client had a positive urine pregnancy test at home, and her lat menstrual period was 8 weeks ago. Which client report to the nurse is most concerning? Right shoulder pain in dizziness The nurse is reinforcing teaching to a client newly prescribed verapamil for chronic migraine headaches. Which statement by the client indicates the need for further teaching? I will take this medication at first sign of migraine The nurse is reviewing the medical hx for a client who has sustained a right tibia/fibula fracture from a fall. The nurse identifies which finding is most likely to hinder healing? Peripheral arterial disease The student nurse assists in caring for a client who is scheduled for electroconvulsive therapy for the treatment of depression. Which statement by the student indicates a need for further teaching? Because this client has a mental illness, the agent with medical power of attorney should sign the informed consent document. A student nurse is accompanying the charge nurse when conducting daily rounds. Which personal protective measure by the charge nurse does the student nurse question? Wears 2 pairs of gloves when emptying the urinary catheter collection bag of a client with HIV. The nurse helps a client with the end-stage renal disease and a serum potassium level of 5.2 mEq/L to plan menu choices. Which items would be best to include in the meal plan? Grilled chicken sandwich on white bread, applesauce. The nurse receives handoff of care report on four clients. Which client should see first? Client who has a urinary tract infection, temperature of 102 F and respiratory rate of 25/min The nurse cares for a client with depression who states, "If I tell you something, will you keep it a secret?" What statement by the nurse is correct? I cannot make that promise; I may need to share it with your therapist. What nursing intervention is most appropriate when caring for client with impairment to cranial nerve II? Verbally explain nursing interventions in detail. The nurse is walking through a mall parking lot and witnesses the collapse of a child. The child is not breathing and has a pulse of 50/min. After the nurse calls emergency services and delivers rescue breaths for 2 minutes, the child is still not breathing and is now pale with a pulse of 49/min. What is the nurse's next action Begin chest compression The nurse receives on 4 clients. Which client should the nurse see first? Client with a right-sided ischemic stroke who is confused and is repeatedly getting out of bed without assistance The clinic nurse is caring for a 76 year-old who has heart failure and is experiencing sudden weight gain and orthopnea. Which question would be the most beneficial for the nurse to ask at this time? "When are you taking each of your medication?" Four pediatric clients are brought to the emergency department at the same time. Which client should be seen first? Child with bruising behind the ears after a football injury The experienced nurse on a medical-surgical unit is supervising a new nurse who is caring for a client with constipation. Which action by the new nurse would cause the experienced nurse to intervene? Request coffee to be included with breakfast tray A nurse is performing cardiopulmonary resuscitation (CPR) on an adult at a swimming pool. A bystander brings the automated external defibrillator (AED). The nurse notes that the victim is wet, lying in a small pool of water, and wearing a transdermal medication patch on the upper right chest. What is the most appropriate action at this time? Remove the transdermal patch and wipe the chest dry before using the AED The nurse is caring for an African American client with immune thrombocytopenia. Which location are best to monitor for the presence of petechiae? Buccal mucosae and conjunctivae of the eyes The nurse accidentally administers orally dissolving mirtazapine through a client's percutaneous endoscopic gastrostomy tube instead of the prescribed sublingual route. After assessing the client for adverse reactions, what is the nurse's priority nurse? Notify the prescribing health care provider The emergency department nurse is assigned 4 clients. Which client needs to be seen first? 9. year old with recent pacemaker insertion with dizziness and purulent drainage at the incision site The nurse working in a gastrointestinal clinic is reviewing the list of walk-in clients. Which client should the nurse see first? Client reporting constipation since having a barium enema 3 days ago The nurse understands that which factor increases a client's risk of experiencing atypical symptoms of myocardial infarction? Female gender The staff nurse caring for a client with a history of drug abuse approaches the charge nurse and says, " My client constantly requests more oxycodone elixir. I gave a cup of cherry-flavored syrup and told the client it was oxycodone, because it wasn't time for another dose." Which action by the charge nurse is the priority at this time? Instruct the nurse to notify the health care provider about the lack of pain relief The nurse is performing a home visit for a child with cystic fibrosis who had a percutaneous endoscopic gastrostomy (PEG) tube placed 6 weeks ago. During inspection of the PEG tube, the nurse should correctly recognize which findings as expected? Gastrostomy tube movement of 0.2 in (0.5 cm) is noted when a client coughs The nurse is caring for a client with non-Hodgkin lymphoma who is starting chemotherapy. What findings alert the nurse that the client is developing complications of tumor lysis syndrome? Hyperkalemia and hyperuricemia The nurse is reviewing new arterial blood gas results for a client with an exacerbation of chronic obstructive pulmonary disease. The client's serum pH is 7.45. Which result noted by the nurse is a priority to report to the health care provider? PaO2 of 52 mm Hg (6.92 kPa) Four clients enter the emergency department at the same time. Which client should the nurse alert the health care provider to see first? 40 year old with a first degree burn and singed beard from a campfire The nurse who is 10 weeks pregnant recognizes that it is appropriate to accept which of the ff client assignments? Client with an infected surgical wound positive for MRSA The nurse is reinforcing teaching a group of clients about the use of complementary and alternative therapies. Which client statement indicates that further teaching is needed? Client on apixaban who states, "I think I will try acupuncture for my arthritis." The nurse is caring for a client with cellulitis of the leg. At 11:00 AM, the client reported itching and received a PRN dose of diphenhydramine. At 9:00 PM, the client reports trouble sleeping and requests another dose of diphenhydramine to help with sleep. Which action is most appropriate? Request a prescription for a sleep aid from the health care provider Place in orde- Urinary Catheter 1. Perform hand hygiene and open sterile urinary catheterization kit A client a hx of a seizure disorder has a seizure while sitting in a chair. Which nursing interventions are appropriate during the seizure activity? - Administer oxygen as needed if client becomes cyanotic The nurse is reading a client's tuberculin skin test 48 hours after placement and notes an 11-mm are of induration. The client is a recent immigrant from Nigeria and reports symptoms. Which actions would be appropriate by the nurse? -Ask the client about hx of BCG The nurse is participating in a community health presentation about prevention of tick bites and Lyme disease. Which instruction should the nurse include? - Apply a tick repellent spray before outdoor activities The charge nurse assists a student nurse preparing to apply knee -length compression stocking onto a client with chronic venous insufficiency. Which actions by the student nurse would cause the charge nurse to intervene? - Instruct client that stockings will be worn only at night The nurse on a medical-surgical unit maintain a shared social media page. Which social media posts written by nurses breach client confidentiality? - I'm going to private-message everyone a cute story about our sweet client with dementia The clinic nurse instructs a female client on how to collect a clean catch urine specimen for culture and sensitivity. Which of the ff client statements indicate that teaching has been effective? - I will be very careful not to touch the inside rim of the container
A nurse is caring for a client 1 day postoperative craniotomy. Which nursing actions are appropriate to prevent increased intracranial pressure? - Administer stool softener The nurse is reinforcing discharge teaching for a client who is hearing impaired. Which of the ff actions should the nurse implement? - Encourage the client to repeat back teaching The practical nurse is collaborating with the registered nurse to prepare a staff inservice regarding prevention of venous thromboembolism. Which nursing interventions should be included in the inservice? - Administer scheduled anticoagulants The nurse responds to the bed alarm of a client with a severe urinary tract infection and finds the client lying on the floor and soiled with urine. Which of the ff entries by the nurse are appropriate to include when documenting the event in the client's electronic medical record? - Blood pressure 102/60 mm Hg, pulse 97/min, and SpO2 98% on room air The nurse is reinforcing education about lifestyle choices to help reduce symptoms for a client with gastroesophageal reflux disease. Which of the ff statements by the client indicate a correct understanding? - I have switched from coffee to decaffeinated herbal tea in the mornings The nurse is caring for an older adult client with advanced dementia, confusion, and a hx of falls. Which of the ff interventions are appropriate to promote client safety? - Activate the bed alarm before leaving the room The nurse caring for an adult client who is in soft wrist restraints. Which nursing action should be included in the plan of care? - Offer fluids, nutrition, and toileting every 2 hours and as needed. The nurse is caring for a 5 clients and is assisted by experienced UAP . Which tasks can the nurse safely delegate to the UAP? - Emptying a urinary drainage bag and recording output The nurse is providing postmortem care of a client who has died after a long hospitalization. The client had a do-not-resuscitate prescription in place at the time of death. Which of the ff intervention s should the nurse include during postmortem care in preparation for transfer to the funeral home? - Allow family member to assist with care A client is at 28 weeks gestation with suspected preeclampsia. Which are potential signs/symptoms related to this syndrome? - 2+ pitting edema Which client situation would be classified as an adverse event, requiring the nurse to complete an incident report? - Cerebrospinal fluid sample is sent to the laboratory labeled as a urine sample Which client statements reflects a correct understanding of genital warts and the human papillomavirus (HPV)? - I should consult my health care provider about Pap testing
at age 21 A nurse assists a student nurse in formulating a care plan for plan for a nonverbal hospice client who demonstrates restlessness and facial grimacing during repositioning. Which statements by the student nurse indicate a correct understanding of the goals of end-of-life care? -
I can observe the client's agitation as an indicator of client's pain level A pregnant client in the third trimester completes an intake form for a clinic visit. The nurse understands that which signs and symptoms warrant further investigation? - Copious amounts of watery, clear vaginal discharge The nurse is reinforcing education about good sleep hygiene to a client with chronic insomnia. Which instruction should the nurse include? - Avoid
caffeine-containing beverages for at least 4 hours before bedtime Which tasks can the charge nurse appropriately delegate to the unlicensed assistive personnel? - Apply protective skin ointment after perineal cleansing During a follow-up visit to the primary care clinic, the nurse evaluates a client's understanding about prevention of complications from varicose veins. Which client statements indicate a correct understanding? - I avoid crossing my legs when sitting The nurse is preparing to don sterile gloves before suctioning a client's tracheostomy. Place the steps of donning sterile gloves in the correct order. 1. Perform hand hygiene, and remove the outer gloves package A client is diagnosed with septic arthritis of the knee. What manifestations does the nurse expect to find? - Fever The nurse is reinforcing education with a client with Marfan Syndrome who is recovering from an aortic root repair and mechanical aortic valve replacement via sternotomy and is prescribed warfarin. Which of the ff statements by the client indicate appropriate understanding of teaching? - I will have to have my spouse lift and carry heavy objects for me for several months The nurse is reviewing home instructions with the client who just underwent cataracts surgery with intraocular lens implantation. Which of the ff clients statements indicate appropriate understanding of the teaching? - I
need to wear an eye patch at night The nurse is reinforcing education about injury prevention with the parent of a 6-month-old infant. Which statements by the parent indicate that the teaching has been effective? - I should place safety locks on the cabinets under the bathroom and kitchen sinks
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