1.A nurse is assisting the provider with a lumbar puncture for a client who has manifestations of meningitis. Into which of the following positions
QuestionAnswered step-by-step1. A nurse is assisting the provider with a lumbar puncture fora client who has manifestations of meningitis. Into which of the following positions should the nurse assist the client? · Trendelenburg with her body in Sims position· Head flexed to the chest and her knees pulled up to the abdomen· Prone with her arms at her side and her legs extended· Arms raised above her head with her legs elevated on pillows 2. A nurse is reinforcing teaching about disease management with a client who has GERD. Which of the following statements should the nurse make? · “You should only drink 2 cups of coffee per day.”· “You should eat three large meals and two snacks per day.”· “You should elevate the head of the bed while sleeping.”· “You should lay down for 1 hour following a meal.” 3. A nurse is reinforcing teaching about car seat safety with a parent of a newborn. Which of the following statements by the parent indicates an understanding of the teaching? · “I should position the car seat’s retainer clip at the level of my baby’s belly button.· “I should keep my baby rear-facing in the car seat until she is 2 years old.”· “I should enable the airbag when my baby is in the front seat of the car.”· “I should place my baby in the car seat at a 90-degree angle. 4. A nurse is making a follow-up call to a client who has a new prescription for an ACE inhibitor to treat hypertension. The client reports lightheadedness upon standing. Which of the following statements should the nurse make? · “Sit back down for a few minutes when this occurs.”· “Restrict your daily fluid intake.”· “Discontinue this medication if this occurs again.”· Take a daily potassium supplement.” 5. A nurse is caring for a client who is 12 hr postpartum and has deep-vein thrombosis of the left leg. The client is receiving anticoagulant therapy. Which of the following actions should the nurse take? · Massage the affected extremity every 4 hr.· Initiate bed rest.· Apply an ice pack to the effected extremity for 20 min every 2 hr.· Administer aspirin for pain. 6. A nurse is caring for a client who has dehydration due to diarrhea. Which of the following findings should the nurse report to the provider? · BUN 18 mg/dL· Urine output 12 mi/hr· Urine specific gravity 1,020· Serum creatinine 1.0 mg/di 7. A nurse is collecting data from a client who uses a continuous positive airway pressure (CPAP) machine at night for sleep apnea. The nurse should identify which of the following findings an as indication of proper CPAP use? · The mask is secured over the client’s mouth and the client’s nose is uncovered.· The therapeutic dose of albuterol is being inhaled.· There is one finger width between the strap on the mask and the client’s face.· The mask fits loosely so air can escape from underneath. 8. A nurse is reinforcing teaching with a parent of a preschooler about immunizations. Which of the following statements by the parent indicates an understanding of the teaching? · “My child will need to start the human papillomavirus series when he enters kindergarten”· “I understand that immunizations will be with held if my child has lactose intolerance”· “I can make several office visits, so my child does not get so many immunizations at once.”· “It is recommended that my child receive his first flu immunization at the age of 6” 9. A charge nurse in a long-term care facility is discussing ethical theories with a group of newly licensed nurses. Which of the following statements should the charge nurse identify as an indication that a newly licensed nurse understands utilitarianism? · “I will withhold a terminal diagnosis from a client who has cancer.”· “I will respect the decision of a client who has a chronic illness to stop treatment.· “I will place a higher emphasis on human dignity than on the needs of a· “I will consider what is going to benefit the most people when making decisions” 10. A nurse is transcribing a client’s prescription for erythromycin 500 mg four times per day. Which of the following information should the nurse clarify with the provider? · Medication· Dosage· Route· Time 11. A nurse is reviewing the medication administration record of a client who takes atenolol PO and applies a nitroglycerin transdermal patch daily. For which of the following interactions should the nurse monitor this client? · Dry cough· Hypotension· Thrombocytopenia· Hyperglycemia12. A nurse is reviewing the laboratory values of a client who has COPD. Which of the following findings should the nurse report to the provider? · WBC 13.000/mm²· Potassium 3.7 mEq/L· Iron 150 mcg/dL· Hgb 20 g/dL. 13. A nurse is monitoring a client who is postoperative following a thyroidectomy. Which of the following findings should indicate to the nurse that the client is developing a thyroid storm? · Increased incisional drainage· Decreased body temperature· Hypertension· Bradycardia 14. A nurse is planning care for four clients. Which of the following tasks should the nurse ask the charge nurse to reassign to an RN? · Administering a subcutaneous insulin injection· Removing an NG tube· Collecting a sputum culture· Providing discharge teaching about home IV medication therapy 15. A nurse in a family practice office routinely reviews clients’ immunization status at their annual physical examination visits. For which of the following clients should the nurse recommend a human papillomavirus immunization? · A teenage boy· A preschool-age girl· An older adult woman· A middle adult man 16. A nurse is caring for a 2-year-old child who has Clostridium difficile. Which of the following actions should the nurse take? · Initiate contact precautions.· Pla child in a room that h HEPA filtration system.· Use an N95 respirator.· Instruct the parents to avoid bringing fresh flowers into the room. 17. A nurse is giving change-of-shift report on a group of clients. Which of the following statements should the nurse make? (Select all that apply.). · The dient in room 204 has a new prescription for IV gentamicin.· The client in room 205 has had several visitors today· The client in room 203 will undergo surgery at 0900 tomorrow.· The client in room 204 received some pain medicine earlier today.· The client in room 205 is scheduled for a dressing change at 800,” 18. A nurse overhears two assistive personnel discussing a client’s medical history in the hallway. Which of the following actions should the nurse take first? · Participate in an in-service about client confidentiality.· Tell the staff members to stop their discussion.· Report the incident to the charge nurse.· Speak to the staff members in private about client confidentiality. 19. A nurse is reinforcing teaching with a client who has GERD and a prescription for pantoprazole. Which of the following statements indicates an understanding of the teaching? · “I will need to remain upright for 1 hour after taking the medication.”· “I have to take this medication on an empty stomach.”· “I should expect to have diarrhea while taking this medication.”· “I can take antacids at the same time as this medication. 20. A nurse is assisting with preparing a client who is to have a central venous catheter inserted for the administration of total parenteral nutrition (TPN). Which of the following actions should the nurse take? · Use clean technique when changing the catheter dressing.· Prepare the client for a chest x-ray to verify catheter placement.· Place the client in Sims position for catheter insertion· verify the amount of TPN solution the client is receiving every 4 hr 21. A nurse is reinforcing teaching about toilet training with the guardians of a toddler who has a cognitive impairment. Which of the following instructions should the nurse include? · Give the toddler a sticker after each successful toileting attempt.· Have the toddler remain on the toilet for a minimum of 20 min.· Entourage the toddler to flush the toilet while still seated,· Wake the idler every 2 in the night to prevent tied wetting 22. A nurse is preparing a vitamin K injection to give to a newborn. The newborn’s mother questions the purpose of the medication. Which of the following responses should the nurse make? · This medication will decrease the possibility of your newborn developing jaundice.”· “This medication will decrease the risk of hemorrhage in your newborn.”· “This medication will increase the absorption of nutrients in the intestines.· “This medication will increase the immunity of your newborn.”23. A nurse is caring for a client who has end-stage kidney disease. The client has decided to stop dialysis treatment. Which of the following actions should the nurse take? · Tell the client she should discuss this decision with her family.· Support the client’s decision to stop the treatment.· Discuss alternative treatment methods with the client.· Ask the facility chaplain to visit the client. 24. A nurse is caring for a client who has schizophrenia. Which of the following behaviors of the client should the nurse identify as a negative symptom of schizophrenia? · Has a preoccupation with religious thoughts· Smells odors that don’t exist· Mimics the nurse’s movements· Initiates speech rarely 25. A nurse is reinforcing teaching about common discomforts during the first trimester with a client who is at 10 weeks of gestation. Which of the following examples should the nurse include? · Leukorrhea· Diarrhea· Burning during urination· Swelling of the face 26. A nurse is reinforcing teaching with a client who has a prescription for ferrous sulfate elixir. Which of the following statements by the client indicates an understanding of the teaching? · “I can prevent nausea if I take the medication on an empty stomach.· “I will report black stools to my doctor.”· IM can prevent constipation if I drink more milk while taking this medication.” · “I will mix the medication with a full glass of water! 27. A nurse is reinforcing teaching about hand hygiene with a newly licensed nurse. Which of the following information should the nurse include in the teaching? · Interlace the fingers while rubbing hands together.· Dry hands starting from forearm to fingers.· Apply friction to hands for 10 seconds· Use hot water to wash hands 28. A nurse in a long-term care facility is caring for a client who has methicillin-resistant Staphylococcus aureus (MRSA). Which of the following actions should the nurse take? · Remove personal protective equipment after leaving the client’s room.· Restrict the client’s visitors.· Ensure that the negative air pressure is active for the client’s room.· Wear a gown when assisting the client with personal hygiene. 29. A nurse is assisting with the care of a client who is in the latent stage of labor and has pelvic pain with contractions. Which of the following actions should the nurse take? · Tell the client to push during contractions.· Encourage the client to soak in a hot bath.· Apply fundal pressure during contractions.· Instruct the client to change positions frequently. 30. A nurse is reinforcing teaching about home safety precautions with the parents of a 3-month-old infant. Which of the following instructions should the nurse include in the teaching? · Remove bibs when the infant is going to sleep.· Start using a highchair for feedings.· Place no more than one small pillow in the crib.· Make sure the crib mattress is soft. 31. A nurse is assisting with a prenatal examination of a client who is at 8 weeks of gestation. The nurse notes that the client’s vagina and vulva are a purplish color. The nurse should document this finding as which of the following? · Ballottement· Hegar’s sign· Chadwick’s sign· Chloasma 32. A nurse is reinforcing teaching with a new mother about facility security measures. Which of the following statements by the mother indicates an understanding of the teaching? · “I will carry my baby to the nursery.· “I will have an identification and that matches the one my baby wears· ” I can take my baby to the lobby to visit family.· ” I can remove my security and to the won a family member 33. A nurse is caring for a client who adheres to kosher dietary practices. Which of the following foods should the nurse plan to offer the client? · Bacon and eggs· Chicken sandwich· Shrimp and french fries· Cheeseburger34. A nurse is applying antiembolic stockings for a client who is postoperative. Which of the following actions should the nurse take? · Have the client point his toes before inserting his foot into the stocking.· Remove the stockings once every 24 hr.· Roll the top of the stocking down so it fits snugly above the client’s calf.· Elevate the client’s legs for 5 min prior to applying the stockings. 35. A nurse is contributing to the plan of care for a client who is experiencing delirium. Which of the following interventions should the nurse recommend? · Remind the client of the day and time often.· Alternate daily caregivers.· Avoid discussing the client’s fears.· Offer the client several choices at mealtimes. 36. A nurse is caring for a client who is postoperative following abdominal surgery and has a wound evisceration. Which of the following actions should the nurse take? · Hold gentie, direct pressure on the protruding organ.· Place the client’s knees in an extended position.· Cover the wound with sterile, saline-soaked gauze.· Raise the head of the bed to a 45° angle. 37. A nurse delegates a task to an assistive personnel (AP) and the AP refuses to complete the assigned task. Which of the following actions should the nurse take? · Perform the task on behalf of the AP· Report the AP to the risk manager.· Discuss the AP’s concerns about performing the task.· Assign the task to another AP 38. A nurse is caring for a client who has a chlamydial infection and a new prescription for doxycycline. The client reports nausea and vomiting after starting the medication. Which of the following recommendations should the nurse make? · Take the medication with an antacid.· Take the medication with crackers· Take the medication and then lay down for 30 min.· Take the medication with calcium-fortified orange juice. 39. A charge nurse is observing a newly licensed nurse perform suctioning for a client who has a tracheostomy. For which of the following actions by the newly licensed nurse should the charge nurse intervene? · Auscultates breath sounds· Preoxygenates with 100% oxygen· Suctions for 30 seconds· Applies suction during catheter removal 40. A nurse is collecting data from a client whose partner died 1 year ago. Which of the following findings indicates that the client is experiencing complicated grief? · The client reports he has no interest in dating.· The client attends a grief support group twice each month.· The client keeps a framed picture of his partner on the wall.· The client develops chest pain each time he talks about his partner. 41. A nurse is collecting data from a client who is receiving magnesium sulfate via continuous IV infusion to treat preeclampsia. Which of the following findings indicates that the medication is having a therapeutic effect? · Urinary output 20 mL/hr· Positive clonus· Respiratory rate 10/min· Deep tendon reflexes 2+ 42. A nurse is completing postmortem documentation for a client. Which of the following information should the nurse include in the documentation? · Last set of the client’s vital signs· Copy of the client’s advance directives· Location of the identification tag on the client’s body· Cause of the client’s death 43. A nurse is caring for a client who has a chest tube that was inserted 4 days ago. Which of the following findings should the nurse report to the charge nurse? · Blood pressure 110/70 mm Hg· Respiratory rate 16/min· Fluctuation in the water seal chamber with respiration· 400 mL of drainage in the collection chamber within 4 hr 44. A nurse is assisting with the care of a client following electroconvulsive therapy for the treatment of a depressive disorder. Which of the following findings should the nurse expect 15 min following the procedure? · Disorientation· Tonic-clonic seizures· Sleep apnea· Paresthesias 45. A nurse is reinforcing teaching with a client who has a new diagnosis of COPD. Which of the following statements by the client indicates an understanding of the teaching? · I should practice pursed-lip breathing exercises.”· “I will consume low-protein, low-calorie foods.”· “I should do aerobic exercises once per day.”· “I will increase my fluid intake to 1.700 milliliters per day 46. A nurse is collecting data from a client who has anorexia nervosa. Which of the following findings should the nurse identify as a positive outcome of treatment? · The client resumes menstruation.· The client’s potassium level is 2.7 mEq/L· The client’s pulse rate is 44/min.· The client develops lanugo 47. A nurse is caring for a client who is 2 days postoperative following a total bilateral mastectomy. The client is tearful and looks away when her surgical dressings are removed. The nurse should place the priority on which of the following actions? · Providing the client with information on community resources that will strengthen her coping skills· Encouraging the client to write about her feelings in a journal each day· Demonstrating a nonjudgmental attitude toward the client when providing care for her surgical wounds· Identifying the client’s perception of the changes in her physical appearance 48. A nurse is contributing to the plan of care for a client who has ascites due to cirrhosis. Which of the following interventions should the nurse recommend to include in the plan? · Measure the client’s abdominal girth daily.· Restrict the client’s sodium intake to 3 g per day.· Keep the client’s daily protein intake below 0.8 g/kg.· Position the client supine with legs elevated. 49. A nurse is reinforcing teaching with the guardians of a 6-year-old child who has cystic fibrosis. Which of the following information should the nurse include in the teaching? · “Provide homeschooling for your child.”· “Do not include your child when making decisions about treatment.”· “Ensure that your child does not receive the influenza vaccine annually”· “Have your child wear a medical identification wristband 50. A nurse is assisting with staff education about hand hygiene. Which of the following instructions should the nurse include in the teaching? · Wash hands with soap and water for 20 seconds.· Wear sterile gloves when in contact with body fluid.· Use alcohol-based cleanser when hands are visibly soiled.· Artificial nails can be worn when performing direct client care. 51. A nurse is monitoring a client who has received external radiation for throat cancer. Which of the following findings should the nurse expect? · Increased appetite· Loose stools· Loss of taste· Bladder infection 52. A nurse is caring for a client who is postoperative following a total knee arthroplasty. The client reports a pain level of 6 on a scale from 0 to 10. Which of the following medications should the nurse administer? · Acetaminophen· Oxycodone· Celecoxib· Ibuprofen 53. A nurse is caring for a client who has depressive disorder. The client states. “Everyone would be better off if I were not around.” Which of the following responses should the nurse make? · “Are you thinking of hurting yourself?· “What would your family do without you?”· “Why would you think a thing like that?· “When you get better you will not feel this way. 54. A nurse is observing an assistive personnel (AP) take a client’s tympanic temperature. Which of the following actions should the nurse identify as an indication that the AP understands how to perform the procedure? · The AP pulls the pinna up and back.· The AP points the probe posteriorly.· The AP positions the client facing her.· The AP inserts the probe with a straight, forward motion. 55. A nurse is reinforcing teaching with a newly licensed nurse about client privacy. Which of the following information should the nurse include in the teaching? · Unwanted printed health information can be discarded in a trash can.· A client is restricted from accessing his own medical records.· Information regarding client health can be e-mailed if encrypted.· Members of a health care team can share a computer password. 56. A nurse is making client care assignments for an assistive personnel (AP). Which of the following tasks should the nurse assign to the AP? · Evaluate the need to suction the airway of a client who has a new tracheostomy.· Feed a client who has difficulty swallowing liquids following a stroke.· Inspect the incision of a client who is postoperative following a leg amputation.· Complete postmortem care for a client who has died. 57. A nurse is collecting data from a client who has diabetic ketoacidosis. Which of the following findings should the nurse expect? · Bounding pulse· Elevated blood pressure· Fruity breath odor· Clammy skin 58. A nurse is reinforcing teaching with a newly licensed nurse about transcribing medication prescriptions. Which of the following prescriptions should the newly licensed nurse identify is an accurate transcription? · Doxazosin 5 mg PO at bedtime· MgSO, 10 g PO daily· Lorazepam 0.5 mg PO PRN at bedtime· Heparin 5000 U subcutaneous every 8 hr 59. A home health nurse is reinforcing teaching about home safety with an older adult client who lives alone. Which of the following client statements indicates an understanding of the teaching? · “I will have my hearing tested every 2 years.”· “I will make sure that electrical wires are run under carpeting.· “I will make sure that my hot water faucets are color-coded· “I will have the heating system inspected once every 3 years. 60. A community health nurse is developing a brochure about hypertension. Which of the following actions should the nurse take? · Explain medical terminology using basic, one-syllable words.· Present information from complex to simple.· Write the information at an 8th-grade reading level.· Use a 12-point font size. 61. A nurse is collecting nutritional data from a group of adult clients. For which of the following clients should the nurse recommend an interprofessional care conference with a dietitian? · A client who has a serum albumin level of 4.5 g/dL· A client who has a sodium Intake of 1.200 mg/day· A client who has a body mass index of 32· A client who has a total fat intake of 25% of daily calories 62. A nurse is caring for a client who has a terminal illness. The client states. “I wish I would die now.” Which of the following responses should the nurse make? · “We should talk about the treatment plan your provider has suggested.· “It is common for people who have a terminal illness to feel that way.· “You wish you were no longer alive?”· “Why do you wish you weren’t alive any longer?” 63. A nurse is monitoring a client who is receiving a blood transfusion. The nurse identifies that the client has urticaria and is wheezing. Which of the following types of transfusion reactions should the nurse suspect? · Acute hemolytic· Circulatory overload· Anaphylactic· Febrile 64. A nurse is caring for an adolescent who states. “I joined the track and field team, so I won’t argue with my brothers anymore.” The nurse should identify that the client is using which of the following defense mechanisms? · Repression· Sublimation· Regression· Denial 65. A nurse is contributing to the plan of care for a client who has bipolar disorder and is experiencing acute mania. Which of the following interventions should the nurse include in the plan of care? · Check the client’s vital signs every 4 hr.· Allow the client to establish his own schedule.· Encourage the client to participate in group activities.· Provide the client with high-calorie finger foods. 66. A nurse is collecting data from a client who is receiving magnesium sulfate via continuous IV infusion for preterm labor. Which of the following findings should the nurse expect? · Hypotension· Tachycardia· Hyperthermia· Tachypnea 67. A nurse is providing preoperative care to a client who reports he has no one at home to help him after his outpatient surgery. Which of the following actions should the nurse take? · Give the client a list of home care assistants to contact· Call the provider about admitting the client to the facility overnight.· Contact the next of kin to assist the client at home.· Assist with a referral to a home health care agency. 68. A nurse is reinforcing teaching with a female client about contraception. Which of the following statements by the client indicates an understanding of the teaching? · “My partner and I will both use a condom during intercourse.”· “I will be able to remove my contraceptive sponge immediately after intercourse.”· “My partner and I will use petroleum jelly with latex condoms.”· “My partner will use condoms with spermicides. 69. A nurse is caring for a 3-year-old child who has acute bacterial conjunctivitis of the right eye and has been prescribed bacitracin ophthalmic ointment. Which of the following actions should the nurse take? · Wipe any excess medication from the inner canthus outward.· Gently massage the eyelid to facilitate absorption of the medication.· Instruct guardian to apply erythromycin ophthalmic ointment every morning for 14 days· Place an occlusive dressing on the affected eye to prevent the spread of infection. 70. A nurse is assisting with the planning of an in-service about updates in wound care for nursing staff. Which of the following sources should the nurse identify as providing the best evidence-based information? · First-hand experience with wound care products· An entry on a nursing blog addressing wound healing· A peer-reviewed journal article· Information from a wound care product vendor 71. A nurse is caring for a client who has just died. Which of the following actions should the nurse take? · Close the client’s eyes before the family views the body.· Remove the client’s dentures.· Leave noninvasive equipment on the client’s body.· Turn the lights up in the client’s room. 72. A nurse is reinforcing teaching about a low-sodium diet with a client who has hypertension. Which of the following statements by the client indicates an understanding of the instructions? · “I like to use store-bought spaghetti sauce.”· “I will put ketchup on my hot dogs.”· “I will use frozen vegetables rather than canned.· “I will eat turkey sausage for breakfast. 73. A nurse is recommending clients for discharge to allow for admission of clients following a tornado disaster. Which of the following clients should the nurse recommend for discharge? · A client who is 3 days postoperative following a hip arthroplasty and has a warm, red area on his left calf · A client who has a sodium level of 140 mEq/L after one episode of diarrhea· A client who has atrial fibrillation and an INR of 4· A client who reports chest pain after ambulating. 74. A nurse is monitoring a client who is postoperative. Which of the following actions should the nurse take when collecting data about the client’s respirations? · Inform the client when beginning to observe his respirations.· Observe the movements of the client’s chest wall.· Count the client’s respirations for 15 seconds.· Place the client in a supine position. 75. A nurse is reinforcing dietary teaching with a client who is at 12 weeks of gestation. Which of the following statements should the nurse make? · “Increase your dietary intake by 500 calories per day.”· “Eat 40 milligrams of protein-rich foods per day.”· “Consume 600 micrograms of folic acid per day.”· “Limit your caffeine intake to 700 milligrams per day,” 76. A nurse on a mental health unit is caring for a client who has anorexia nervosa. Which of the following statements by the nurse promotes the ethical principle of client autonomy? · “I will be truthful when answering questions about your treatment.”· “The nursing staff here will provide you with nonjudgmental care.· “It is your choice to share personal information during group therapy· I will only discuss your medical information with the health care team. 77. A nurse is assisting with a community health program for caregivers of clients who have Alzheimer’s disease. Which of the following information should the nurse include? · Provide a stimulating environment for the client.· Use written signs to assist the client with locating the bathroom.· Use confrontation to manage the client’s behavior.· Limit the number of choices for the client. 78. A nurse is contributing to the plan of care for a client who had prolonged exposure to cold weather and has a core body temperature of 32.5° C (90.5° F). Which of the following data is the priority for the nurse to monitor? · Heart rhythm· Urinary output· Pain sensation· Muscle strength 79. A nurse is assisting with the care of a client who has hearing loss and has questions regarding their medication. Which of the following actions should the nurse take? · Exaggerate lip movement while speaking· Ask a few questions at a time.· Sit on the client’s right side.· Choose a room that is well lit 80. A nurse is collecting a health history from the guardian of a 4-year-old child. Which of the following statements by the guardian is the priority for the nurse to address? · “My child still wets the bed at least two times per week.”· “I have noticed that my child is withdrawn since we switched day care providers.”· My child continually asks me the same questions.”· “I have a difficult time getting my child to eat green vegetables,” 81. A nurse is assisting with discharge teaching for a client who is postoperative following the repair of a detached retina. Which of the following instructions should the nurse include in the teaching? · “You should bend from the waist to pick up objects.· You can remove your eye patch during the day.”· “You can take a stool softener to prevent constipation.”· “You can apply a warm moist, compress to your forehead to reduce pain.” 82. A nurse is collecting data from a client who has acute cholecystitis. Which of the following findings should the nurse expect? · Discomfort with urination· Increased abdominal discomfort prior to meals· Pain radiating to the jaw· Pain in the right upper abdomen 83. A nurse is reviewing client confidentiality with a group of newly licensed nurses. Which of the following situations should the nurse include as an example of a breach in confidentiality? · A facility risk manager includes information from a client’s medical record in a written report· A nurse tells the chaplain that a client has a new diagnosis of cancer.· A nurse discusses a client’s postoperative complications during shift report.· A social worker reads a client’s chart as a follow-up to a requested consultation 84. A nurse is caring for a client who has Clostridium difficile. When applying a cover gown, which of the following techniques should the nurse use? · Tuck the glove cuffs under the gown sleeves.· Push the gown sleeves up to the elbows· Apply the gown before the gloves· Tie the gown with the gloves on. 85. A nurse is collecting data from a 10-month-old infant during a well-child visit. Which of the following findings should the nurse identify as a manifestation of torticollis? · Feet turn inward· Neck is in a flexed position· Frenulum connected to the tip of the tongue· Asymmetry of gluteal folds 86. A nurse is collecting data from a client about risk factors for cardiovascular disease. The nurse should identify that which of the following findings is a modifiable risk factor? · Age 65· Cholesterol 240 mg/dL· Sex· Family history of cardiovascular disease 86. A nurse is reinforcing teaching with a client who has a new prescription for warfarin. The nurse should identify which of the following over-the counter medications as safe for use with warfarin? · Aspirin· Omeprazole· Ibuprofen· Docusate 87. A nurse is reinforcing teaching about palliative care to a client who has cancer. Which of the following statements should the nurse make?· “It includes restriction of nutritional support.”· “It enhances quality of life by promoting comfort”· It is for clients who have a terminal illness· “It is for clients who are given 6 months or less to live.” 88. A nurse is completing documentation in the medical record about a client who fell on the floor. Which of the following statements should the nurse include in the documentation? · An incident report has been completed and sent to risk management· “The client does not appear to have any injuries resulting from the fall.· “Client stated, “I lost my balance and fell when I got out of bed to go to the bathroom· The client fell because the assistive personnel did not place nonskid slippers on the client. 89. A nurse is reinforcing teaching with the parents of a child who has a new diagnosis of Wilms tumor. Which of the following information should the nurse include in the teaching? · “You should give your child captopril 200 mg PO daily.”· Your child will not require further treatment after removal of the tumor.· “Your child should have surgery in 7 to 10 days to remove the tutor· you should not palpate your child’s abdomen prior to surgery. 90. A nurse is assisting in the care of a client who is in active labor and is to undergo an amniotomy. Which of the following actions should the nurse take? (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.) · Position the client with a rolled towel under her hips.· Obtain a baseline reading of the FHR and contraction pattern.· Document the procedure in the electronic medical record.· Pass the sterile hook to the provider. · Check the fluid for color, odor, and consistency. 91. A nurse is caring for a client who has paranoid schizophrenia and believes that they are being followed by FBI agents who are pretending to be psychiatric staff. Which of the following responses should the nurse make? · “What makes you think the staff is following you?”· “This must be very frightening for you. Let’s talk more about it.”· “The psychiatric staff is not FBI. They are here to help you.”· “Why do you feel the staff is the FBI?” 92. A nurse is reinforcing teaching with a client who has primary open-angle glaucoma and a new prescription for timolol eye drops. Which of the following statements indicates an understanding of the teaching? · “I should take a zinc supplement while taking this medication,· “I should check my heart rate while taking this medication.”· “This medication will darken the color of my eyes.”· “This medication will dilate my eyes.” 93. A nurse is caring for a client who is taking multiple medications and asks about possible interactions. To which of the following members of the interdisciplinary team should the nurse make a referral? · Social worker· Psychologist· Patient care technician· Advanced practice nurse 94. A nurse is caring for a client who is in bed and begins experiencing a tonic-clonic seizure. Which of the following actions should the nurse take? · Measure the duration of the seizure.· Restrain the client’s arms and legs to prevent injury.· Lower the side rails of the bed when the seizure begins.· Insert an oral airway into the client’s mouth. 95. A nurse is assisting in the care of a client who is 48 hr postpartum. The client states, “My baby won’t stop crying even though I’ve changed her diaper and breastfed her.” Which of the following statements should the nurse make? · “Breastfed babies are usually fussy from swallowing too much air during feedings.”· “Your baby needs to suck on a pacifier.”· “Swaddling your baby snugly in a blanket might help soothe her.”· “Breastfed babies often need to be supplemented with formula.” 96. A nurse is reviewing the medical record of a client who is at 37 weeks of gestation and has HELLP syndrome. Which of the following laboratory findings should the nurse expect? · Platelet count 77,000/mm³· Hemoglobin 12 g/dL· BUN 20 mg/dL· WBC count 18.000/mm³ 97. A nurse is reinforcing teaching with a client who has an ankle injury and requires crutches. Which of the following instructions should the nurse provide? · “Keep your elbows flexed at a 35 angle when using the crutches.”· “Maintain your head and neck erect when walking with crutches.”· “Wash the tips of your crutches daily.· “Support your body weight by leaning on the crutches.” 98. A nurse is participating in a performance improvement program. Which of the following actions should the nurse take to evaluate the effectiveness of the program? · Define the problem.· Review the facility’s policy and procedure manual.· Identify data collection methods· Perform chart audits. 99. A nurse is caring for a client who has AIDS. Which of the following solutions should the nurse use to disinfect the client’s overbed table following a blood spill? · Isopropyl alcohol· Bleach· Chlorhexidine· Hydrogen peroxide 100. A nurse is collecting data from a client who is 8 hr postoperative following an appendectomy. Which of the following manifestations is the best indication that the client needs a PRN analgesic? · The client grimaces when changing positions.· The client’s heart rate has increased to 110/min.· The client reports pain as 7 on a scale of 0 to 10:· The client demonstrates a decreased attention span. 101. A nurse overhears two assistive personnel (AP) in the nurses’ station discussing a client who was recently admitted. Which of the following actions should the nurse take? · Tell the APs to stop the conversation.· Submit an incident report to the risk manager.· Inform the client of the APs actions.· Document the event in the client’s progress notes. 102. A nurse is administering a client’s morning oral medications. Which of the following actions should the nurse take? · Verify the medication three times with the medication administration record.· Administer time-critical medication 60 min before or after the scheduled time.· Identify the client by using one identifier before giving the medication.· Document medication administration prior to administering medication. 103. A nurse is reinforcing teaching with a client who has diabetes mellitus and is taking insulin lispro and insulin glargine. Which of the following instructions should the nurse include in the teaching? · “Anticipate that the insulin glargine will peak in 3 hours.”· “Take an extra dose of insulin lispro prior to aerobic exercise.”· “Draw up the insulin lispro and insulin giargine in separate syringes· “Expect insulin glargine to be cloudy. 104. A nurse is contributing to the plan of care for a client who is pregnant and reports having trouble sleeping. Which of the following instructions should the nurse include in the plan of care? · Obtain a prescription for pramipexole.· “Lie on your left side with your top leg forward.”· “Use a transcutaneous electrical nerve stimulator.”· “Soak in a bathtub of hot water each night.” 105. A nurse working in a rehabilitation unit is administering medications to two clients who have the same name. Which of the following identifiers should the nurse use to verify the identities of each client? · The telephone numbers of the clients· The diagnoses of the clients· The names of the clients nearest relatives· The room numbers of the clients 106. A nurse is collecting data from a client who has left sided heart failure. For which of the following findings should the nurse notify the provider? · Productive cough with pink frothy sputum· Pale, clammy skin· Weight loss of 1 kg (2.2 lb) in the past 24 hr· Fatigue when ambulating 152 m (500 ft) 107. A nurse is reinforcing discharge teaching with a client who has tuberculosis. Which of the following statements by the client indicates an understanding of the teaching? · “I should throw away my used tissues in a closed plastic bag.”· “I will no longer be infectious after 30 days of treatment.· “I will need to take medication for this condition for the rest of my life.”· My family will need to wear a mask when around me at home. 108. A nurse is caring for a client who recently gave birth to her first child. The newborn is crying and the client states, “I can’t seem to do anything right. What should I do?” Which of the following responses should the nurse make? · Babies need to cry soon after they are born to develop their lungs· “I’ll take him back to the nursery, so you can get some rest· “Let me show you how to swaddle and cuddle him, then you try”· “If I turn him on his side, maybe he’ll go back to sleep. 109. A nurse is collecting data from a client who has a sodium level of 156 mEq/L. Which of the following findings should the nurse expect? · Nausea and vomiting· Hypothermia· Dysthythmias· Altered mental status 110. A nurse is assisting with developing a plan of care for a client who is immobilized. Which of the following interventions should the nurse recommend to reduce the development of pressure ulcers? · Turn the client every 3 hr.· Place a donut-shaped cushion under the client.· Place the client in a 30 lateral position.· Check the client’s skin every 4 hr. 111. A nurse is collecting data from a client who has a urinary tract infection and is taking ciprofloxacin. The client reports pain in her calf muscle. Which of the following statements should the nurse make? · “This is an allergic reaction. Take the medication with an antihistamine.· “Continue to take the medication. Calf pain is a minor reaction that will resolve itself.· “Discontinue the medication. I will ask your provider for another antibiotic”· “That reaction means your dose is too high. Cut the pill in half.112. A nurse is caring for a client who has a new prescription for a fentanyl transdermal patch. Which of the following actions should the nurse take when administering a transdermal patch? (Select all that apply.) · Apply the patch to a clean, hairless area of the client’s skin.· Dispose of old transdermal patches in a childproof container· Apply the transdermal patch to either of the client’s forearms.· Use sterile gloves to apply and remove transdermal patches.· Remove the old transdermal patch before applying a new one. 113. A nurse is assisting in providing postmortem care for a client who was a devout follower of Hinduism. Which of the following requests should the nurse anticipate from the client’s family? · To prohibit medical personnel from touching the client’s body· To bury the client’s body within 24 hr of their death· To cremate the client’s body· To stay with the client’s body for 8 hr following their death 114. A nurse is collecting data from a client who is receiving IV therapy. The nurse suspects fluid infiltration. Which of the following findings should the nurse expect at the insertion site? · Erythema · Pruritus· Blood· Edema 115. A nurse is assisting with the care of a preschooler who has manifestations that suggest epiglottitis. Which of the following actions should the nurse take? · Determine the preschooler’s oxygen saturation level.· Collect a sputum sample.· Obtain a specimen for throat culture.· Inspect the preschooler’s tonsils for edema. 116. A nurse is contributing to the plan of care for a client who has COPD. Which of the following interventions should the nurse include in the plan? · Provide the client with three large meals each day.· Place the client in an orthopneic position.· Encourage the client to cough and deep breathe once every 8 hr.· Limit fluid intake to 1.000 mL daily. 117. A nurse is reinforcing teaching with a client who is scheduled for an intravenous pyelogram. Which of the following statements by the client indicates an understanding of the teaching? · “I will feel a warming sensation after the injection of the dye.· “I should limit my fluid intake for 2 days after the procedure.”· “I do not need to sign a consent form before this procedure.· “I can have a meal up to 2 hours before the procedure.” 118. A nurse is preparing a sterile field to perform a dressing change of a client’s leg wound. Which of the following actions should the nurse take? · Place sterile objects at least 2.5 cm (1 in) from the edge of the sterile field.· Place the irrigation solution bottle cap on the sterile field.· Hold the irrigation solution bottle 5 cm (2 in) above the sterile container.· Open the outer wrapper of the sterile package toward her body. 119. A nurse is reinforcing teaching with a client who is scheduled to have a colonoscopy in 1 week. Which of the following client statements indicates an understanding of the teaching? · “This procedure will take place while I’m under general anesthesia.”· “I’ll have my friend drive me home after the procedure.”· I follow ull-liquid diet the day before the procedure.”· “I can expect rectal bleeding for a week after the procedure.” 120. A nurse is reinforcing discharge teaching with a client who has COPD and reports problems with maintaining adequate nutrition. Which of the following instructions should the nurse include? · “Perform pulmonary hygiene 1 hour before meals.”· “Lie down for 30 minutes after eating.”· “Self-administer oxygen through your nasal cannula at 6 milliliters per minute during meals.”· “Drink at least 240 milliliters of water during each meal.” 121. A nurse is verifying informed consent for a client who is preoperative for a vaginal hysterectomy. Which of the following statements should the nurse identify as an indication that the client has given informed consent? · “I should expect my periods to resume in 1 month.”· “I am thankful I am done having children.”· “I will no longer need a regular gynecological examination· “I will have a large scar on my stomach after this procedure.” 122. A nurse working on a medical-surgical unit is notified about a mass casualty event that recently took place in the community. Which of the following assignments should the nurse anticipate? · Assist in discharging stable clients to home.· Determine the acuity and number of casualties arriving at the facility.· Provide informational updates to members of the media· Delegate tasks to emergency health care specialists 123. A nurse in a mental health facility is caring for a client who reports palpitations and a sense of impending doom. Which of the following actions should the nurse take first? · Explain to the client that anxiety causes physical manifestations.· Minimize environmental stimuli in the client’s surroundings.· Administer an anti-anxiety medication.· Explore behaviors that have helped to reduce the client’s anxiety in the past. 124. A nurse is assisting with the admission of an older adult client who has impaired mobility and is at risk for falls. Which of the following fall precautions should the nurse plan to implement first? · Determine the client’s ability to use the call light.· Move the bedside table with the client’s personal items close to the bed.· Create a schedule with an assistive personnel to do hourly rounding for the chent· Apply rubber-soled slippers before ambulation. 125. A nurse is administering an intermittent enteral feeding through a client’s NG tube. During the instillation, the client reports abdominal cramping and nausea. Which of the following actions should the nurse take? · Lower the head of the bed to 15%.· Replace the NG tube.· Chill and readminister the formula.· Slow the rate of formula instillation. 126. A client who has type 1 diabetes mellitus asks a nurse about beginning an exercise regimen. Which of the following instructions should the nurse include? · Inject additional insulin before exercising· Eat a piece of fruit before exercising.· Exercise when insulin is at its peak action.· Avoid protein before exercising 127. A charge nurse in a long-term care facility notices the smell of alcohol on a nurse’s breath. Which of the following actions should the nurse take first? · Remove the nurse from the client care area.· Document objective findings about the situation.· Call the supervisor to ask for another nurse.· Assign clients to the remaining staff. 128. A nurse is reinforcing teaching with the family of a client who is terminally ill about the grief process. Which of the following information should the nurse include in the teaching? · The grieving process should be complete within 1 year.”· “Anticipatory grieving prolongs the grief process.”· “Anger toward the health care staff is expected.”· The stages of grief occur in sequential order.” 129. A nurse is administering pancrelipase to a child who has cystic fibrosis. Which of the following outcomes should the nurse expect as a therapeutic effect of the treatment? · Improved respiratory function· Reduced fat in the stools· Decreased sodium excretion· Improved absorption of vitamins B and C 130. A nurse at a long-term care facility is part of a risk management team that is creating a plan to lower infection rates in the facility. Which of the following instructions regarding hand hygiene should the nurse include? · Clean hands with alcohol-based hand gel for 15 seconds.· Hold the hands slightly higher than the elbows when using running water.· Wash hands under running water for at least 10 seconds.· Dry hands thoroughly from fingers to wrist 131. A nurse is reviewing the plan of care for a group of clients. The nurse should identify that informed consent is required for which of the following procedures? · Administration of an iron injection using Z-track technique· Placement of a central venous catheter· Irrigation of a wound with antibiotic solution· Insertion of a nasogastric tube 132. A nurse is caring for a client who has Graves’ disease. Which of the following findings should indicate to the nurse that the client is developing a thyroid storm? · Respiratory depression· Neck pain· Tachycardia· Hypotension 133. A nurse in an acute care facility is assisting with the development of an in-service about reducing environmental stressors to improve clients sleep. Which of the following instructions should the nurse include? · Wear shoes with rubber soles.· Conduct change of shift report near the clients rooms.· Turn on overhead lights briefly when checking IV lines· Open curtains between clients in semi private rooms. 134. A community health nurse is assisting with the development of a pamphlet regarding choking hazards for toddlers. Which of the following foods should the nurse include? · Grapes· Potatoes· Oranges· Corn 135. A home health nurse is caring for an older adult client who lives with a family caregiver and has urinary incontinence. The client states, I guess will be locked in my room again for wetting the bed.” Which of the following actions should the nurse take? · Restrict family members from visiting with the client.· Report the suspected abuse to the nurse manager.· Review the medical record to see if the client has reported abuse in the past.· Contact the client’s caregiver to discuss the client’s comment. 136. A nurse is reinforcing discharge teaching with a client who states, “I don’t feel confident driving to my follow-up appointments.” The nurse should obtain a referral for which of the following members of the health care team? · Physical therapist· Primary care provider· Social worker· Occupational therapist 137. A nurse enters the room of a school-age child and finds them on the floor experiencing a tonic-clonic seizure. Which of the following actions should the nurse take? · Place a padded tongue blade in the child’s mouth.· Place a pillow under the child’s head.· Restrain the child’s upper extremities.· Turn the child onto their back. 138. A nurse has assigned an assistive personnel (AP) to perform a gastrostomy feeding for a client who has been receiving feedings at home. Which of the following actions should the nurse take to monitor the AP’s performance of the task? · Instruct the AP to report back once the task is complete.· Request the AP to provide a return demonstration of the task.· Ask the family if the AP performed the task correctly.· Tell the AP to list the steps of the task 139. A nurse is assisting with the admission of a client who has varicella zoster. Which of the following interventions should the nurse plan to implement? · Have visitors remain at least 0.91 m (3 feet) away from the client.· Assign the client to a negative pressure airflow room.· Administer aspirin if the client develops a fever.· Initiate contact precautions for the client. 140. A nurse is obtaining a capillary blood specimen to measure a client’s blood glucose. Which of the following actions should the nurse take? · Allow the antiseptic to dry before puncturing· Massage the client’s finger away from the puncture site.· Hold the lancet at a 45° angle.· Apply sterile gloves. 141. A nurse is caring for a client who is unable to perform ADLS and wears dentures. Which of the following actions should the nurse take when providing denture care? · Place a towel in the sink when cleaning the dentures.· Use a circular motion to cleanse the biting surface of the dentures.· Store the dentures in a dry denture cup on the bedside table after cleaning.· Remove the lower dentures before the upper dentures 142. A nurse is caring for a client who is 1 day postoperative following a total hip arthroplasty and is receiving heparin subcutaneously. Which of the following adverse effects of the medication should the nurse report to the provider? · Epistaxis· Anorexia· Weight gain· Bradycardia 143. A nurse is caring for an older adult client who is postoperative following a total hip arthroplasty. The client is incontinent of stool and urine. Which of the following actions should the nurse take to prevent skin breakdown? · Use a moisture barrier on the client’s skin.· Clean the client’s skin with soap and hot water.· Massage the area around the client’s coccyx· Limit the client’s fluid intake. 144. A nurse is reinforcing teaching with a client’s family about home oxygen use via nasal cannula. Which of the following statements by a family member indicates an understanding of the teaching? · “We will need to remove the nasal cannula when he is eating· “We can use petroleum jelly to keep his nares moist.”· “We can turn the oxygen up to 10 when he has trouble breathing”· “We will frequently check the top of his ears for sores. 145. A nurse is assisting with the care of a client who is at 37 weeks of gestation and is undergoing a nonstress test. Which of the following actions should the nurse take? · Assist the client into a supine position· Tell the client the test should take about 10 min.· Remind the client to press the button when she feels fetal movement!· Explain that nonreactivity might require immediate medication administration 146. A nurse is discussing risk factors for child abuse with members of a parenting group. The nurse should identify which of the following findings as characteristic of perpetrators of child abuse? · Rigid expectations of behavior· Laissez-faire leadership style· High self-esteem· Self-blame for financial problems 147. A nurse is reinforcing discharge teaching with the caregiver of a client who has dependent personality disorder. Which of the following instructions should the nurse include in the teaching? · Encourage the client to be assertive.· Assume responsibility for making the client’s decisions.· Maintain a verbal no-harm contract with the client.· Limit the client’s social interactions.148. A nurse is reinforcing teaching with the parents of a child who has ADHD and is taking methylphenidate. Which of the following statements by the parents indicates that the medication is effective? · “Our child is able to complete his homework on time.· “Our child has increased his daily caloric intake.”· “Our child has a better grasp of reality.”· “Our child has lost some weight since his last appointment.” 149. A nurse is caring for an older adult client who wears hearing aids with detachable ear molds. Which of the following actions should the nurse take when caring for the hearing aids? · Change the battery once per month.· Disinfect the hearing aid with isopropyl alcohol.· Clean the hearing aid with a soft cloth.· Replace the ear molds once per year. 150. A nurse is preparing to ibuprofen solution 60mg orally to a 3-month-old infant who is febrile. Available is ibuprofen 50 mg/1.25 ml. How many ml should the nurse administer? (Round the answer to the nearest tenth. U se a leading zero if it applies. Do not use a trailing zero) 151. A nurse is collecting data from a client who is taking tranylcypromine and reports ingestion of tyramine-rich foods. The nurse should monitor the client for which of the following findings as an adverse effect of this medication? · Hypertension· Hyperglycemia· Hematuria· Tinnitus 152. A nurse is caring for a client who has chronic diarrhea. Which of the following findings should the nurse expect? · Hypertension· Hypokalemia· Hypermagnesemia· Respiratory acidosis 153. A nurse is caring for a client who is confused and is trying to pull out their IV catheter. After attempting other measures to prevent the client from self-harm, the nurse places wrist restraints on the client. Which of the following actions should the nurse take? · Remove the restraints from the client’s wrists every 2 hr· Fasten the restraints ties to the bed’s side rails.· Check that one finger will fit between the client’s wrists and the restraints.· Contact the provider within 48 hr to obtain a prescription for the restraints 154. A nurse is contributing to the plan of care for a client who has a potassium level of 2.9 mEq/L. Which of the following actions should the nurse plan to take? · Administer furosemide.· Monitor for Chvostek’s sign.· Apply a cardiac monitor.· Give a dose of alendronate 155. A nurse is caring for a client who has an indwelling catheter with a urinary drainage system. Which of the following actions should the nurse take? · Instruct the client to hold the drainage bag at waist height when ambulating.· Collect a sterile specimen from the urinary drainage bag.· Secure the tubing with adhesive tape to the lower abdomen.· Coil the tubing on the bed above the collection bag 156. A nurse is reinforcing teaching with a client about advance directives and a health care proxy. Which of the following client statements indicates an understanding of the teaching? · “My health care proxy designee is not able to sign a consent form on my behalf.· If I have a health care proxy, then I do not need to have a living will· “Once my health care proxy is in place, I relinquish my right to make my own decisions.· I do not need to name a relative as my designee in my health care proxy 157. A nurse is assisting with the care of a group of clients. Which of the following actions should the nurse take to manage her time effectively (Select all that apply.) · Keep track of how long it takes to complete certain tasks.· Make a priority to-do list at the beginning of the shift.· Delegate collection of vital signs to the assistive personnel on the team.· Plan a time at the end of the shift to document nursing interventions.· Complete activities with one client before moving to another client. 158. A nurse is caring for a client who delivered a newborn by cesarean birth 1 day ago. The client requests nonpharmacological interventions to manage pain when changing positions. Which of the following responses should the nurse make? · “You should use patterned-paced breathing when changing positions· “You should change positions as little as possible.· “You can splint the incision with a pillow when changing positions· “You can apply counterpressure to your back with each position change.” 159. A nurse is talking with a client who refuses a blood transfusion for religious reasons. Which of the following responses should the nurse make? · “I’m sure that everything will be all right, regardless of your decision.”· “You have a right to change your mind.”· “If I were you would contact your spiritual director.”· “Making this decision is wrong. 160. A nurse is preparing to give change-of-shift report on a client who is 2 days postoperative following a total knee arthroscopy. Which of the following information should the nurse include in the report? · Steps required for dressing change· Admission vital signs· Time of last pain medication· Preferred bath time 161. A nurse is monitoring a client’s lower extremity following the placement of a cast earlier in the day. Which of the following findings should the nurse identify as manifestations of compartment syndrome? (Select all that apply.) · Pain relieved by analgesia· Decreased skin turgor· Pale colored toes· Diminished capillary refill· Sensation of tingling 162. A nurse is caring for a client who has a prescription for NPH insulin 10 units and regular insulin 15 units subcutaneously. After injecting 10 units of air into the NPH insulin vial, which of the following actions should the nurse take next? · Verify the dosage with another nurse.· Inject 15 units of air into the regular insulin vial.· Place the cap over the needle· Withdraw 10 units of NPH insulinHealth ScienceScienceNursingNUR 0000Share Question
