1.A nurse is caring for a client who has 0.9% sodium chloride IV solution infusing through a peripheral IV catheter. Which of the following findings
QuestionAnswered step-by-step1. A nurse is caring for a client who has 0.9% sodium chlorideIV solution infusing through a peripheral IV catheter. Which of the following findings should the nurse expect if the client has an infiltration?Warmth along the vein Palpable cord along the vein Leakage at the insertion site Redness around the insertion site2. nurse is contributing to the development of an in-service training about child maltreatment for a group of pediatric nurses. Which of the following findings should the nurse identify as a risk factor for child maltreatment? The infant has otitis media The infant is younger than 1 year of age. The infant was born large for gestational age. The infant’s guardians are both over the age of 30.3. 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 Hypertension Bradycardia Decreased body temperature4. A nurse is reinforcing teaching with a female client who is taking phenytoin. Which of the following statements should the nurse include in the teaching? You can safely take this medication if you become pregnant. You should expect to have blood work every 6 months while taking this medication You might experience swollen gum while taking this medication You can skip a dose of the mutation if you are nauseated5. A nurse is reviewing electronic health record (EHR) documentation with assistive personnel (AP). The nurse should reinforce that the AP is permitted to document in which of the following sections of the EHR? Nurse’s notes Plan of care Discharge teaching Graphic record6. 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? “Discontinue the medication. I will ask your provider for another antibiotic.” “That reaction means your dose is too high. Cut the pill in half.” “Continue to take the medication Calf pain is a minor reaction that will resolve itself.” “This is an allergic reaction. Take the medication with an antihistamine.”7. A nurse is contributing to the plan of care for a group of clients. Which of the following tasks should the nurse delegate to an assistive personnel? Perform basic life support (CPR) for a client who has become unresponsive. Administer a client’s nighttime dose of milk of magnesia. Educate a client about the use of an incentive spirometer. Obtain the diet history from a client who has heart failure.8. nurse is preparing to administer an antibiotic to a client who has pneumonia. After confirming that the client’s assigned identification number matches the medication administration record, the nurse should use which of the following as a second identifier? Medical diagnosis Date of admission Facility room number Home telephone number9. A nurse is caring for a client who is semi-conscious and has been receiving hydromorphone for postoperative pain. The client has a respiratory rate of 3 min. Which of the following medications should the nurse anticipate administering? Naloxone Methadone Clonidine Varenicline10. A nurse is preparing to transport a client’s body to the morgue. Which of the following actions should the nurse take? Move the client’s body to the hallway after postmortem care has been completed. Maintain the client’s identification bracelet on their wrist. Keep the client’s IV tubing in place. Place the client’s dentures in a cup and keep it with their other belongings.11. A nurse in a provider’s office is collecting data from a client who has psoriasis. Which of the following statements by the client should the nurse report to the provider? “I do not use fabric softener when I wash my clothing.” “I try not to look at the scales on my body.” “I limit my time spent out in the sunlight.” “I remove old medication on my skin before applying a new dose.”12. A nurse is collecting data from a client who is 5 hours postoperative following a transurethral resection of the prostate. Which of the following findings should the nurse report to the provider? Pink-tinged urine Hgb 14 g/dL Absence of bladder spasms Decreased urinary output13. A nurse is applying a belt restraint to a client who has become physically aggressive. Which of the following actions should the nurse take? Apply the restraint under the client’s clothes. Ensure the restraint is placed across the client’s chest: Place the client in a sitting position. Tie the restraint to the railing of the client’s bed.14. A nurse is contributing to the plan of care for a client who has urinary incontinence. Which of the following interventions should the nurse include in the plan? Keep the head of the client’s bed elevated to 45 Limit periods of sitting in a chair to 4 hr. Use a no-rinse perineal cleanser after incontinence. Avoid the use of draw sheets for repositioning15. A nurse is reviewing the plan of care for a group of clients. The nurse should identify that which of the following clients is at risk for impaired elimination? A client who has a BUN level of 14 mg/dL A client who is taking a diuretic A client who has hypertension A client who ambulates independently16. A nurse is collecting data from a client who is breastfeeding and reports a sudden onset of chills and a tender, red area on the right breast. The nurse should identify that these manifestations indicate which of the following conditions? Thrush Engorgement Mastitis Blocked milk duct17. A nurse is reinforcing teaching with a client who has a urinary tract infection. Which of the following instructions should the nurse include in the teaching? Drink orange juice dally for 3 to 4 weeks. Take the prescribed antibiotic until manifestations are gone. Restrict fluid intake to 1 L per day. Wear cotton underwear.18. A charge nurse in a long-term care facility is developing a performance improvement plan for an assistive personnel (AP). Which of the following actions should the nurse take when developing the plan? (Select all that apply.) Ask the nurse supervisor to review the plan. Set a specific time frame for meeting performance goals. Include the performance standard that the AP should meet. Request clients complete an evaluation about the AP’s quality of care. Base performance goals on peer comments.19. A nurse is caring for a client who receives cyclosporine instead of cycloserine. The nurse should monitor the client for which of the following adverse effects? Hypotension Hypoglycemia Nephrotoxicity Respiratory depression20. A nurse is caring for a client who is to undergo a subtotal thyroidectomy. Which of the following items should the nurse place at the client’s bedside? Thoracotomy set Tracheostomy kit Vacuum assisted wound device Tuning fork21. A nurse is reinforcing teaching with the support person of a client who is in the first stage of labor. Which of the following instructions should the nurse include regarding effleurage? “Apply steady pressure with this tennis bail to her sacral area.” “Help her to focus on an object in the room.” “Assist her to breathe in deeply at the beginning of each contraction.” “Gently stroke her abdomen during contractions.”22. A nurse is caring for a client who is taking warfarin and has an INR of 5.5. The nurse should expect which of the following instructions from the provider? Reduce the dosage of the medication. Obtain an aPTT level. Administer protamine sulfate. Change the medication to heparin IV.23. A nurse is discussing home care concerns with the son of a client who has Alzheimer’s disease. The son states. “I am so tired all the time, but Mom needs me.” Which of the following responses should the nurse make? “Let me give you some information about respite care for your mother.” “I think you should find other family members who could help your mother.” You I think about placing your mother in a long-term care “You owe it to your mother to take care of her now that she needs you.”24. A nurse is collecting data from a client who is at risk for a pulmonary embolism following surgery. For which of the following findings should the nurse monitor? Headache Dyspnea Bradycardia Hypertension25. A nurse is caring for a client who states, “I feel we have a good relationship, and you will keep my information confidential. I want you to know I am planning to commit suicide today.” Which of the following responses should the nurse make? “I can’t keep a conversation like this to myself.” “You should think about how your family will be affected by your decision. “Why do you think suicide is the answer to your problems?” “I won’t tell anyone if you promise not to harm yourself.”26. A nurse is assisting with the plan of care for a client who is in the third trimester of pregnancy and has ankle edema. Which of the following interventions should the nurse include in the client’s plan of care? Apply support stockings. Limit fluid intake. Administer diuretics. Place on bedrest27. A nurse is assisting with the discharge plan of care for a group of children. For which of the following children should the nurse recommend a referral for speech therapy? A toddler who has a new diagnosis of cystic fibrosis A school age child who has chronic asthma An adolescent who has juvenile idiopathic arthritis An infant who is postoperative following a cleft palate repair28. A nurse is reinforcing teaching about the prevention of sexually transmitted infections with a group of clients. Which of the following client statements indicates an understanding of the teaching? “I will apply an oil-based lubricant to condoms prior to use.” “I will use a spermicide prior to intercourse.” “I will leave a diaphragm in place for 2 hours following intercourse.” “I will use polyurethane condoms during intercourse.29. A nurse is caring for a client who has a stage 2 pressure injury. For which of the following laboratory tests should the nurse anticipate a prescription? Platelet Creatinine Vitamin D Prealbumin30. A nurse is preparing to apply a thigh-length sequential compression device for a client who is postoperative. Which of the following actions should the nurse take? Measure the circumference of the client’s upper leg Turn on the mechanical unit prior to applying the sleeve Position the client’ prone to apply the device. Wrap the sleeve loosely around the client’s lower leg31. A nurse is assisting in the care of an older adult client who has COPD and is receiving albuterol treatments and 20 mg of prednisone twice daily. The client asks why the nurse is checking his blood glucose level. Which of the following responses should the nurse make? “Albuterol treatments can cause blood glucose levels to decrease.” “Older adults are at risk for developing type 1 diabetes mellitus.” “Prednisone can cause blood glucose levels to increase.” “Having COPD causes blood glucose levels to fluctuate.32. A nurse is assisting with monitoring a client who is receiving a unit of packed RBCs. Which of the following findings indicates the client is experiencing a transfusion reaction? Straw-colored urine Temperature 38.8° C (101.8 F) Blood pressure 158/92 mm Hg Apical pulse rate 58/min33. A nurse is assisting with a group therapy session and notes a client who remains silent. Which of the following actions should the nurse take? Ask other group members to limit the number of times they speak. Tell the client to leave the group if they cannot contribute. Appoint the client to lead the discussion. Allow the client extra time to think of a response.34. A nurse is caring for a client who has been given methylergonovine intramuscularly for a postpartum hemorrhage. The nurse should monitor for which of the following adverse effects? Elevated blood pressure Diarrhea Hematuria Uterine relaxation35. A nurse is reinforcing teaching with the guardian of an infant who has failure to thrive due to neglect. Which of the following instructions should nurse reinforce with the guardian to help prevent further neglect? Demonstrate effective timeout techniques for the guardian. Review strategies with the guardian to address their frustrations. Tell the guardian that they are required to see a therapist. Have the guardian attend a presentation about neglect.36. A nurse is preparing to provide tracheostomy care for a client. Which of the following actions should the nurse plan to take? Cleanse the inner cannula with isopropyl alcohol. Clean the stoma using an inward to outward circular motion. Prepare sterile supplies after removing the inner cannula. Ensure at least three finger withs of spare under tracheostomy ties37. A nurse is reinforcing teaching with a client who is starting digoxin therapy to treat heart failure. The nurse should reinforce with the client that which of the following adverse effects is a possible indication of digoxin toxicity and should be reported to the provider? Constipation Blurry vision Tinnitus Joint pain38. A nurse is caring for a client who is recovering from a thoracic spinal cord injury. The nurse should identify that the client is at risk for which of the following conditions Decreased fine motor hand movement Loss of urinary control Difficulty swallowing Inability to clear secretions39. A nurse is caring for a client who has a femur fracture with the leg in Buck’s traction. Which of the following actions should the nurse take? Remove the weights for 20 min for the client’s report of severe pain. Compare bilateral pedal pulses Position the knot of the rope at the top of the pulley. Apply 6.8 kg (15(b) of weight for use in traction.40. A nurse is reinforcing discharge teaching with a client who has undergone a vein stripping of the right leg. Which of the following instructions should the nurse include in the teaching? Wrap the leg with an elastic bandage. Keep legs in a dependent position. Maintain bed rest for 48 hr. Implement a sodium-restricted diet,41. A nurse is contributing to the plan of care for an older adult client. Which of the following physiological changes should the nurse recommend considering when administering medication? Increased liver function Decreased pulmonary function Decreased kidney function Increased metabolism42. A nurse is preparing to perform a wet-to-dry dressing change for a client who has an infected abdominal wound. Which of the following techniques should the nurse use when performing this dressing change? Remove the tape by pulling from the center of the dressing Clean the wound from the center to the outer edges. Moisten the dressing before removal. Wear sterile gloves to remove the dressing.43. A nurse is reviewing the cardiac monitor strip for a client who is recovering from an acute myocardial infarction. Which of the following findings should the nurse report to the provider immediately? Sinus tachycardia rate 104/min Two premature ventricular contractions per minute First degree heart block A new onset of atrial fibrillation44. A nurse is reinforcing teaching about preventing dental caries with the parent of a 12-month-old toddler. Which of the following instructions should the nurse provide? “Use a 5-inch strip of toothpaste on the toothbrush.” “Clean the teeth with a small, soft-bristled toothbrush.” Position the bristles of your child’s toothbrush against the teeth at a 90-degree angle “Floss between your child’s teeth before brushing”45. A nurse is preparing to perform an abdominal examination for a client who has a gastrointestinal disease. Identify the order in which the nurse should use the examination techniques. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.) Auscultation Light palpation Inspection Deep palpation46. A nurse is reinforcing teaching with a client about reducing dietary caffeine intake. The nurse should remind the client that 240 mL (8 oz) of which of the following beverages contains the least amount of caffeine? Instant coffee Hot cocoa Cola soft drink Brewed green tea47. A nurse is reinforcing teaching with the parents of a newborn about bathing. Which of the following instructions should the nurse include in the teaching? “Check the water temperature with your finger. “Set the water heater to 125.6 degrees Fahrenheit. “Cleanse the eyes from the inner canthus outward.” “Hold your baby under running water when washing his hair”48. A nurse is assisting with the care of a client who has decreased mobility and requires repositioning every 2 hr. Which of the following outcomes should the nurse expect? The client refuses to eat because they are nauseated The client was discharged to home without developing complications of immobility The client developed a rash on their back and lower extremities The client returned to the facility 2 days after being discharged due to a urinary tract infection.49. A nurse is reinforcing dietary teaching with a client who has cholecystitis. Which of the following food choices should indicate that the client understands the nurse’s instructions? Dark chocolate Skim milk Peanut butter Cream of potato soup50. A nurse is caring for a client who is receiving a continuous enteral tube feeding and develops diarrhea. Which of the following actions should the nurse take? Provide the client with low-calorie formula. Switch the client to a formula containing less protein. Increase the rate of the client’s feeding. Administer the client’s formula at room temperature.51. A nurse is providing a client with IV fluids and finds that the IV pump screen is malfunctioning. Which of the following actions should the nurse take? Replace the IV pump’s tubing Discontinue use and tag the IV pump. Clear the settings and reset the TV pump. Plug the IV pump’s cord into a different outlet.52. A nurse is collecting data from a client who has heart failure and is taking furosemide. Which of the following findings should indicate to the nurse that the medication is effective? Decreased BUN level Decreased hemoglobin level Increased urinary output Increased weight of 0.91 kg (2 lb)53. A nurse is reinforcing teaching with a client who has a cystocele. Which of the following statements by the client indicates an understanding of the teaching? “I should use a perineal tox luce odor from urinary leakage” “I will decrease my fluid intake to reduce incontinence.” “I will experience less urinary incontinence if I use artificial sweeteners “I will practice perineal exercises to decrease urinary leakage54. A nurse is performing a heelstick on a newborn to obtain blood for glucose monitoring. Which of the following actions should the nurse take? Puncture the inner lateral part of the newborn’s heel Place the newborn in the prone position during the procedure Use a 25-gouge butterfly needle Apply a warm cloth to the heel 10 min prior to the procedure55. A nurse is collecting data from a client who is 18 hours postpartum. The nurse notes that the client is in the “taking-in phase” of maternal adjustment. Which of the following manifestations should the nurse expect? Performs self-care independently Begins reconnecting with their partner Tolerates physical discomforts Is eager to review the birth experience56. A nurse in a provider’s office is collecting data from a client who has candidiasis. Which of the following findings should the nurse expect? Thick white vaginal discharge Feeling of pelvic heaviness Frothy, malodorous discharge Hard, painless chanter57. A nurse is caring for a client who is receiving chemotherapy for breast cancer and states they are upset about their hair loss. Which of the following statements should the nurse make? “You should focus on getting better “I lost my hair, too, when i went through chemotherapy.” “Before you know it hair grow back “You can use an eyebrow pencil to fill in your eyebrows58. A nurse is reinforcing teaching about bottle feeding techniques with the guardian of a newborn. Which of the following statements by the guardian indicates an understanding of the teaching?”The feeding should last 5 to 10 minutes.” “My baby might spit up a small amount of formula while feeding.” “The opening of the nipple should be enlarged” “My baby should be burped prior to feeding.”59. A nurse is collecting data from a client who has bipolar disorder. Which of the following findingsshould the nurse expect? Well-groomed appearance Flight of ideas Command hallucinations Ritualistic behavior60. 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 develops chest pain each time he talks about his partner.The client keeps a framed picture of his partner on the wall.The client attends a grief support group twice each month.61. A nurse in a clinic is caring for a client who is 40 weeks of gestation and experiences a sudden gush of vaginal fluid. Which of the following findings is evidence of an obstetric complication?Has a pH of 7Preceded by bloody mucusTurns a nitrazine strip blueAppears greenish-brown in color62. A nurse is contributing to the plan of care for a client who has dysphagia. Which of the following interventions should the nurse include?Elevate the head of the client’s bed 30Provide three large meals per day.Encourage socialization during mealtimes.Tilt the client’s head forward during meals.Health ScienceScienceNursingNURSING 000Share Question
