2024 Exit Comprehensive Retake Exam New Latest Version Best Studying Materials, Exams of Nursing

Download 2024 Exit Comprehensive Retake Exam New Latest Version Best Studying Materials and more Exams Nursing in PDF only on Docsity! 2024 ATI Exit Comprehensive Retake Exam New Latest Version Best Studying Materials with All Questions and Answers A nurse is reinforcing teaching to the support person of the client who has early stage labor. Which of the following instructions should the nurse include regarding effleurage? ---------- Correct Answer ----------- Gently stroke her abdomen during contractions A nurse is caring for an older adult client who is postop following a total hip arthroplasty. The client is incontinence of stool and urine. Which of the following actions should the nurse take to prevent skin breakdown? ---------- Correct Answer ----------- Used a moisture barrier on the client's skin A nurse is contributing to the POC who has herpes simplex. The nurse should plan to initiate which of the following isolation precautions when caring for this client? ---------- Correct Answer ----------- Contact precautions A nurse is documenting client care in the nurses and notices that a space was left blank. Which of the following actions should the nurse take? ---------- Correct Answer ---- ------- Draw a horizontal line through the space and sign at the end of the line A nurse is collecting data from a client who has heart failure the nurse notices the client has crackles in the bases of the lungs shortness of breath and a respiratory rate of 24 bom which of the following actions should the nurse take ---------- Correct Answer -------- - Maintain the client and high Fowlers position A home health nurse is conducting a home inspection for a client who is it was for falls which of the following instruction should the nurse provide for the client ---------- Correct Answer --------- Move the clients bed to the main floor on the house A nurse in an acute mental health facility is caring for an adolescent who is exhibiting destructive behavior which of the following actions should the nurse take after applying physical restraints to the Client ---------- Correct Answer --------- Plan to remove the restraints as soon as the client is calm A nurse is caring for a client who has AIDS. Which of the following solutions should the nurse disinfect the client's overhead table following a blood spill? ---------- Correct Answer ----------- Bleach A nurse is caring for a client who has terminal cancer. Which of the following instructions should the nurse take to promote the client's autonomy? ---------- Correct Answer ----------- Allow the client to choose treatment times A nurse in a clinic is caring for a client who is at 40 weeks gestation and experiences a sudden gush of vaginal fluids. Which of the following findings is evidence of an obstetric complication? ---------- Correct Answer ----------- Appears greenish-brown in color A nurse is assisting w the care of an adolescent client immediately following a lumbar puncture. Which of the following actions should the nurse take? ---------- Correct Answer ----------- Inform the adolescent that he might experience a headache A nurse is reinforcing teaching about advance directives w a client who has end stage renal heart failure. Which of the following statements by the client indicates an understanding of the teaching? ---------- Correct Answer ----------- "I should discuss this document with my family after I sign it" A nurse is caring for a client who has a continuous bladder irrigation following a TURP . The nurse notices clots and dark red blood in the catheter collection bag. Which of the following actions should the nurse take? ---------- Correct Answer ----------- Irrigate the bladder with 20-30 ml of 0.9% sodium chloride irrigation A nurse is planning to obtain a 12-lead ECG for a client who has a history of cardiac dysrhythmias. Which of the following actions should the nurse plan to take? ---------- Correct Answer ----------- Instruct the client to remain as still as possible during the recording A nurse is reinforcing teaching w a client who has genital herpes. Which of the following info should the nurse include in the teaching? ---------- Correct Answer ----------- You should increase fluid intake to relieve dysuria A nurse is preparing to empty a postop client's closed-wound drainage system. Which of the following actions should the nurse plan to take? ---------- Correct Answer ----------- Compress the container before replacing the drainage bag A nurse is reinforcing teaching w the parents of a toddler who has a new diagnosis of asthma and a prescription of Montelukast. Which of the following instructions should the nurse include in the teaching? ---------- Correct Answer ----------- Administer the medication to the toddler each evening A nurse in an acute mental health facility is caring for a newly admitted client. Which of the following should occur during the orientation phase of the nurse-client relationship? - --------- Correct Answer ----------- Defining responsibilities A nurse is caring for a client who reports having a decrease in fetal movement following an external cephalic version 6 hr ago. The nurse identifies the fetus is in the right occiput anterior position. The nurse should place a fetal heart monitor on which of the following sites to auscultate the fhr? ---------- Correct Answer ----------- Lower left partner abuse. Which of the following is the nurse's priority action? ---------- Correct Answer ----------- Provide information about moving to a shelter A nurse in an urgent care clinic, recently using methylenedioxy-methamphetamine. Which of the following findings should the nurse expect? ---------- Correct Answer --------- -- Hallucinations A nurse is reinforcing teaching w a client who has a prescription for ferrous sulfate elixir. Which of the following statements by the client indicates an understanding of the teaching? ---------- Correct Answer ----------- I will mix the medication w water A nurse is collecting data from a client who received oxytocin 10 units IM 30 mins ago for excessive vaginal bleeding. Which of the following findings should the nurse expect? ---------- Correct Answer ----------- Boggy fundus 3 fingerbreadths above the umbilicus A nurse is attending an educational workshop about client confidentiality. Which of the following actions by the nurse indicates an understanding of the teaching? ---------- Correct Answer ----------- Changes her personal login password at random times A nurse is assisting w d/c planning for a group of clients. Which of the following clients should the nurse recommend a home health referral? ---------- Correct Answer ----------- An older adult client who has heart failure and lives alone A nurse is reinforcing teaching w a female client who is taking phenytoin. Which of the following instructions should the nurse include in the teaching? ---------- Correct Answer ----------- You might experience swollen gums while taking this medication A nurse is preparing to administer paroxetine 15 mg/PO oral suspension to a client who has a depressive disorder. The amount available is 10 mg/5mL. How many mL should the nurse administer (Round to nearest tenth) ---------- Correct Answer ----------- 7.5 mL A nurse is reinforcing teaching w a client who is at 38 week's gestation and it to undergo a contraction stress test. Which of the following statements by the client indicates an understanding of the teaching? ---------- Correct Answer ----------- I am having this test because my baby was not reactive during a nonstress test A nurse is discussing health practices with a mother of a toddler who is from a different cultural background than the nurse. Which of the following statements by the mother indicates that she practices cupping? ---------- Correct Answer ----------- I sometimes place a bottle containing team against the child's skin A nurse is reinforcing teaching w a client who has primary open-angle glaucoma and has a prescription for timolol eye drops. Which of the following statements by the client indicates an understanding of the teaching? ---------- Correct Answer ----------- I should check heart rate while taking this medication A nurse is collecting data from a preschooler who has severe dehydration. Which of the following findings should the nurse expect? ---------- Correct Answer ----------- Weight loss 10% A nurse is contributing to the POC for an older adult client. Which of the following physiological changes should the nurse consider when administering medication? ------- --- Correct Answer ----------- Decreased kidney function 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 idt should the nurse make a referral? ---------- Correct Answer ----------- Advanced practice nurse A nurse is collecting data from a client who just received his first dose of sulfasalazine to treat ulcerative colitis. Which of the following findings should the nurse identify as an indication of an allergy reaction to this medication? ---------- Correct Answer ----------- Dyspnea A nurse is collecting nutritional data from a group of adult clients. For which of the following clients should the nurse recommend an interpersonal care conference w a dietitian? ---------- Correct Answer ----------- A client who has a bmi of 32 A charge nurse is reinforcing teaching w a newly licensed nurse about infection control measures. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching? ---------- Correct Answer ----------- Soiled dressings should be places in a biohazard trash receptacle A nurse is preparing to administer Vitamin K to give to a newborn. The newborn's mother questions the purpose of this medication. Which of the following responses should the nurse make? ---------- Correct Answer ----------- This medication will decrease the risk of hemorrhage in your newborn A nurse is collecting data from a client who has dka. Which of the following findings should the nurse report to the provider? ---------- Correct Answer ----------- Fruity breath odor A nurse is caring for a client who has a vacuum-assisted closure system to treat a pressure ulcer. Which of the following actions should the nurse take? ---------- Correct Answer ----------- Use an adhesive remover to remove tape before applying dressing A nurse is caring for a client who has a recent diagnosis of a terminal illness. The nurse should identify which of the following as an indication of hopelessness? ---------- Correct Answer ----------- The client has a decreased level of energy A nurse is preparing to collect data on a preschooler. Which of the following behaviors by the child indicates that he is ready to cooperate? (SATA-3) ---------- Correct Answer -- --------- 1. Allows the nurse to touch him on the arm 2. Answers questions asked by the nurse 3. Makes eye contact with the nurse A nurse on a mental health unit is planning care for a group of clients. Which of the following clients should the nurse see first? ---------- Correct Answer ----------- A client who has schizo and is having command hallucinations 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? ---------- Correct Answer ----------- "Let me show how to swaddle and cuddle him, then try." A nurse is using a glucometer to measure a client's capillary blood glucose level. Which of the following actions should the nurse take? ---------- Correct Answer ----------- Keep the finger in dependent position A nurse is reviewing the home medications with a client who recently had a transient ischemic attacks and is to begin taking clopidogrel. The nurse should instruct the client that which of the following otc meds interact adversely w clopidogrel? ---------- Correct Answer ----------- Naproxen A nurse is collecting data from a client who has a long leg cast that was applied 2 days ago. The client's foot is pale w a weak pedal pulse and the client reports foot numbness. Which of the following actions should the nurse take first? ---------- Correct Answer ------- ---- Check for pain w passive movement of the affected extremity A nurse in a providers office is reinforcing teaching about cigarette smoking w a client. Which of the following adverse effects should the nurse include in the teaching? ---------- Correct Answer ----------- Somnolence A nurse is contributing to the development of an in-service program for mental health nursing staff. The nurse should include that the staff can medicate a client against his will, without a court hearing in which of the following situations? ---------- Correct Answer ----------- A client who is attempting to hurt himself or others A nurse is reinforcing teaching with a client who has a new prescription for digoxin. Which of the following instructions should the nurse include in the teaching? ---------- Correct Answer ----------- "Monitor for muscle weakness while taking the medication" A charge nurse is discussing confidentiality requirements w a newly licensed nurse when sharing a client's medical info. Which of the following individuals should the charge nurse identify as appropriate with whom to share client info? ---------- Correct Answer ----------- A social worker who's assigned an involuntary committed school-age client A nurse is placing a dressing over a stage 1 pressure ulcer on a client's heel. Which of the following types of wound dressing should the nurse use? ---------- Correct Answer --- -------- Transparent film A nurse is caring for an older adult client who reports pain and has a prescription for ketorolac 15 mg IM every 5 hr PRN. The client's current bp is 114/55 mm Hg. Which of the following actions should the nurse take? ---------- Correct Answer ----------- Administer the medication to the client A charge nurse in a LTC is developing a performance improvement plan for an AP. Which of the following actions should the nurse take when developing the plans? (SATA-3) ---------- Correct Answer ----------- 1. Set a specific time frame for meeting performance goals 2. Ask the nurse supervisor to review to plan 3. Include the performance standard that the AP should meet A nurse is reinforcing teaching with a client who is undergoing radiation therapy to the neck. Which of the following instructions should the nurse include in the teaching? ------- --- Correct Answer ----------- Avoid exposing the neck to the cold 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? ---------- Correct Answer ----------- Determine the client's ability to use the call light A nurse is reinforcing teaching with a client about intermittent catheterization to measure residual urine. Which of the following info should the nurse include in the teaching? ---------- Correct Answer ----------- "You will need to urinate before the procedure" A nurse is caring for a client who has terminal cancer and has declined treatment. The nurse attempts to convince the client to reconsider his decision and discusses this attempt w the charge nurse. Which of the following actions should the charge nurse take? ---------- Correct Answer ----------- Talk with the nurse about the need to support the client's decision A nurse is reinforcing teaching about breastfeeding w a client who gave birth 2 days ago. Which of the following info should the nurse include? ---------- Correct Answer ------- ---- Feed newborn 8-12 times/day every 24 hr A nurse is assisting w the admission of a school aged child. Which of the following actions should the nurse plan to take? (Exhibit) ---------- Correct Answer ----------- Initiate contact precautions for the child A nurse is contributing to the POC for a client who has ascites due to cirrhosis. Which of the following interventions should the nurse recommend to include in the plan? ---------- Correct Answer ----------- Measure the client's abdominal girth daily A nurse is reinforcing teaching w a client who has a prescription for antibiotic therapy. The client tells the nurse that he always experiences diarrhea when he takes antibiotics. Which of the following food choices should the nurse recommend to lessen the occurrence of diarrhea? ---------- Correct Answer ----------- Yogurt A nurse is assisting with the care of a client who has ICP followed a closed head injury. Which of the following actions should the nurse take? ---------- Correct Answer ----------- Elevate HOB 30 degrees A nurse is assisting with the plan of care for a client who is in the 3rd trimester of pregnancy and has ankle edema. Which of the following interventions should the nurse include in the client's plan of care? ---------- Correct Answer ----------- Apply support stockings A nurse is contributing to the POC for a client experiencing delirium. Which of the following interventions should the nurse recommend? ---------- Correct Answer ----------- Remind the client of the day and time often 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? ---- ------ Correct Answer ----------- Grapes A nurse is reinforcing dc teaching with a client who has a new diagnosis of tb. Which of the following instructions should the nurse include in the teaching? ---------- Correct Answer ----------- "You should have a sputum examination every 4 weeks" A nurse is assisting w the care of a client who is at 37 weeks gestation and is undergoing a nonstress test. Which of the following actions should the nurse take? ------ ---- Correct Answer ----------- Remind the client to press the button when she feels fetal movement A nurse is contributing to the POC for a client who has dysphagia. Which of the following interventions should the nurse include? ---------- Correct Answer ----------- Tile the client's head forward during meals A nurse is reinforcing teaching w a client who is at 18 weeks gestation and has a medical history of mild hypertension. For which of the following findings should the nurse instruct the client to monitor and report to the provider? ---------- Correct Answer -- --------- Persistent headache A nurse is talking with the partner of a client who recently died. Which of the following statements should the nurse take? ---------- Correct Answer ----------- "Tell me what I can do for you at this time" A nurse is assisting w the admission of a client who states, "The last time I was in the hospital, the nurses took forever to answer my call light" Which of the following is an appropriate response by the nurse? ---------- Correct Answer ----------- "That must have been a difficult experience for you" A nurse in a provider's office is caring for a group of clients who have communicable diseases. Which of the following infections should the nurse report to the state health department? ---------- Correct Answer ----------- Neisseria gonorrhoeae A nurse is assisting with the admission of an adolescent client who is suspected to have bacterial meningitis. Which of the following findings should the nurse expect? ---------- Correct Answer ----------- Nuchal rigidity A nurse is reviewing lab findings for 4 clients. Which of the following lab values is an expected findings for a client who has end stage renal disease? ---------- Correct Answer ----------- Creatinine 15 mg/dL 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? ---------- Correct Answer ----------- 1. Obtain an aPTT level A nurse is assisting w the care of a client who is receiving a continuous IV infusion. Which of the following indicates fluid volume excess? ---------- Correct Answer ----------- Distended neck veins A nurse is reinforcing teaching w the parents of an infant who has a Pavlik harness. Which of the following statements should the nurse include in the teaching? ---------- Correct Answer ----------- "The harness can promote hip joint development" A nurse is caring for a client who is 2 days postop. The client has a prescription for acetaminophen 300 mg w codeine 30 mg. 1 tablet every 3-4 hr PRN for pain. The nurse inadvertently administers 2 tablets to the client in which of the following locations should the nurse document this error? ---------- Correct Answer ----------- Incident report A nurse is preparing a sterile field to perform a dressing change for a client's leg wound. Which of the following actions should the nurse take? ---------- Correct Answer ----------- Place sterile objects at least 2.5 cm (1 in) from the edge of the sterile field? A nurse begins to bath a newly admitted client who reports that she has not had anything to eat that day. The nurse interrupts the bath and obtains a healthy meal for the client. The action by the nurse is an example of which of the following? ---------- Correct Answer ----------- Countertransference a nurse is assisting w the care of a client following ect therapy for the treatment of depressive disorder. which of the following findings should the nurse expect 15 mins following this procedure? ---------- Correct Answer ----------- disorientation A nurse is caring for an adolescent who has bulimia nervosa. Which of the following actions should the nurse take first? ---------- Correct Answer ----------- Observe the client during and after meals A nurse is monitoring a client who is postop. Which of the following actions should the nurse take when collecting data about the client's respirations? ---------- Correct Answer ----------- Observe the movements of the client's chest wall A nurse is preparing to give a change o shift report on a client who is 2 days postop following a total knee arthroplasty. Which of the following info about the client should the nurse include in the report? ---------- Correct Answer ----------- Time of last pain medication A nurse is reinforcing d/c teaching w a client who has bipolar disorder and a new prescription for carbamazepine. Which of the following statements by the client indicates an understanding of the teaching? ---------- Correct Answer ----------- I will plan to avoid grapefruit juice while taking this medication An AP tells the charge nurse that her assignment is too demanding. She angrily tells the nurse to reassign one of her tasks to another AP. Which of the following actions should the nurse take to resolve the conflict? ---------- Correct Answer ----------- Ask the AP to discuss the issue in a private area A nurse is reinforcing teaching w a client who has arthritis. Which of the following instructions should the nurse include in the teaching? ---------- Correct Answer ----------- Engage in low-impact aerobic exercises A nurse is caring for a female client who has an indwelling catheter w a urinary drainage bag system. Which of the following actions should the nurse take? ---------- Correct Answer ----------- Secure the tubing w adhesive tape the lower abdomen a nurse is assisting w a support group for client who have experienced intimate partner violence. the nurse should identify which of the following client statements as indicating the greatest risk for violence? ---------- Correct Answer ----------- I have decided to tell my husband I'm leaving him 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? ---------- Correct Answer ----------- hypotension a charge nurse working in a ltc facility overhears 2 aps in the nurses stations discussing a client who was just admitted. which of the following actions should the nurse take? ---- ------ Correct Answer ----------- tell the aps to stop the conversation a nurse is reinforcing teaching w a client who is scheduled for an intravenous pyelogram. which of the following statements made by the client indicates an understanding of the teaching? ---------- Correct Answer ----------- i will feel a warming sensation after the injection of the dye a nurse is assisting w the poc of a client who has end-stage amyotrophic lateral sclerosis and has developed pneumonia. which of the following actions should the nurse take? ---------- Correct Answer ----------- verify the status of the client's advanced directive a nurse is reinforcing teaching w a new mother facility safety measures. which of the following statements by the mother indicates an understanding of the teaching? ---------- Correct Answer ----------- i will have an identification band that matches the one that my baby wears a nurse is caring for a client who is 2 days postop following a total bilateral mastectomy. the client is tearful and looks away when her surgical dressings are removed. the nurse should place the priority action on which of the following actions? ---------- Correct Answer ----------- identifying the client's perception of the changes of her physical appearance a nurse is reinforcing teaching w a client who is at risk for hypertension. which of the following risk reduction strategies should the nurse include in the teaching? ---------- Correct Answer ----------- walk 30 mins 5 days per week a nurse is caring for a client who has dependent personality disorder. which of the following manifestations should the nurse expect? ---------- Correct Answer ----------- submissive a nurse is assisting w the admission of a client who has varicella zoster. which of the following interventions should the nurse plan to implement? ---------- Correct Answer ----- ------ initiate contact precautions for the client a nurse is planning to administer 4 different meds to a client via gtube. which of the following actions should the nurse take? ---------- Correct Answer ----------- allow separate meds to flow through the tube by gravity a nurse is preparing to administer medications to a client who has pneumonia and is on droplet precautions. which of the following supplies should the nurse use while caring for this client? ---------- Correct Answer ----------- surgical mask a nurse is reinforcing dietary teaching with a client who is at risk for cardiovascular disease. which of the following statements by the client indicates an understanding of the teaching? ---------- Correct Answer ----------- i have unsalted pretzels for a snack a nurse in an inpatient psychiatric unit is caring for a client who was raised in an asian culture. which of the following communication techniques by the nurse demonstrates cultural sensitivity? ---------- Correct Answer ----------- holding eye contact for brief instances a nurse is reinforcing teaching about safe food handling w a client who is recovering from food poisoning. which of the following statements by the client indicates an understanding of the teaching? ---------- Correct Answer ----------- I will be sure to cook chicken to 180 degree fahrenheit a nurse is assisting w the d/c plan for a client who has burns on his arms and hands. which of the following referrals should the nurse recommend to improve the client's ADLs? ---------- Correct Answer ----------- occupational therapist a nurse is assisting w a prenatal exam of a client who is at 8 weeks 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? ---------- Correct Answer ----------- Chadwick's sign a nurse should recognize that a client's right of confidentiality has been breached when which of the following occur? ---------- Correct Answer ----------- a nurse tells the chaplain that her assigned client has a new diagnosis of cancer a nurse in a med surg unit is preparing to assist w the admission of clients who were injured in a tornado. which of the following clients should the nurse recommend for d/c to make room for the new admissions? ---------- Correct Answer ----------- a client who has had a radial mastectomy 36 hr ago and has a surgical drain a nurse is reviewing lab values for a client who is experiencing respiratory acidosis. which of the following ABG values should the nurse expect? ---------- Correct Answer ---- ------- pH 7.30 PaCO2 50 mm Hg a nurse is caring for a client who is receiving oxygen when a fire starts in an adjacent room (move steps in order) ---------- Correct Answer ----------- 1. move the client to a safe location 2. pull the nearest fire alarm 3. shut all the doors and windows 4. attempt to extinguish a nurse is caring for a client who's receiving morphine for pain. which of the following findings indicate that the client is experiencing an adverse effect of the medication? ----- ----- Correct Answer ----------- urinary retention - The client does not appear to have any injuries resulting from the fall. ---------- Correct Answer --------- Client stated, I lost my balance and fell when I got out of bed to go to the bathroom. A nurse is assisting with a community health program for caregivers of clients who have Alzheimer's disease. Which of the following should the nurse include? - 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. - Provider a stimulating environment for the client. ---------- Correct Answer --------- Limit the number of choices for the client. A nurse overhears two assistive personnel AP in the nurse station discussing a client who was recently admitted. Which of them should the nurse take? - Document the event in the client's progress notes. - Tell the APs to stop the conversation. - Submit an incident report to the risk manager. - Inform the client of the APS actions. ---------- Correct Answer --------- Tell the APs to stop the conversation. 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? - Assume responsibility for making the client's decisions. - Limit the client's social interactions - Maintain a verbal no harm contract with the client. - Encourage the client to be assertive. ---------- Correct Answer --------- Encourage the client to be assertive. 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 surgical dressing is 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. - Identify the client's perception of the changes in her physical appearance. - Demonstrating a nonjudgmental attitude toward the client when providing care for her surgical wounds. ---------- Correct Answer --------- Identify the client's perception of the changes in her physical appearance. A nurse working in a rehabilitation unit is administering medications to two clients who have the same name. Which of the following should the nurse use to verify the identities of each client? - The names of the clients nearest relatives - The telephone numbers of the clients. - The room numbers of the clients - The diagnoses of the clients ---------- Correct Answer --------- The telephone numbers of the clients. A nurse is reviewing the pain 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. - Insertion of a nasogastric tube. - Irrigation of a wound with antibiotic solution. ---------- Correct Answer --------- Placement of a central venous catheter. 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? - Administer aspirin if the client develops a fever. - Assign the client to a negative pressure airflow room. - Initiate contact precautions for the client. - Have visitors remain at least 0.91 m (3feet) away from the client ---------- Correct Answer --------- Initiate contact precautions for the client. A nurse is reinforcing teaching with a client who has GERD and a prescription for pantoprazole. Which of the following statement indicate understanding of the teaching? - I have to take this medication on an empty stomach. - I will need to remain upright for 1 hour after taking the medication. - I can take antacids at the same time as this medication.? - I should expect to have diarrhea while taking this medication. ---------- Correct Answer - -------- I will need to remain upright for 1 hour after taking the medication. A nurse is caring for a client who is postoperative following abdominal surgery and has a wound evisceration. Which of the following should the nurse take? - Hold gentle, direct pressure on the protruding organ. - Place the client's knees in an extended position. - Raise the head of the bed to a 45 angle. - Cover the wound with sterile, saline- soaked gauze. ---------- Correct Answer --------- Cover the wound with sterile, saline- soaked gauze. 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? - Restrict the client client's visitors. - Remove personal protective equipment after leaving the client's room. - Ensure that the negative air pressure is active for the client's room. - Wear a gown when assisting the client with personal hygiene. ---------- Correct Answer --------- Wear a gown when assisting the client with personal hygiene. A nurse is administering pancrelipase to a child who a child who has cystic fibrosis. Which of the following outcomes should the nurse expectation effect of the treatment? - Improved respiratory function. - Improved absorption of vitamin B and C. - Reduced fat in the stools. - Decrease sodium excretion. ---------- Correct Answer --------- Reduced fat in the stools. A nurse is completing postmortem documentation for a client. Which of the following information should the nurse include in the documentation? - Cause of the client's death. - Location of the identification tag on the client's baby - Copy of the client's advance directives. - Last set of the client's vital signs. ---------- Correct Answer --------- Last set of the client's vital signs. A nurse is reinforcing teaching with a newly licensed nurse about caring for a client who has a history of dysphasia. Which of the following instruction should the nurse include in the teaching? - Place oral suction equipment next to the client's bedside. - Give the client a straw to use for drinking - Provide thin liquids to help the client swallow - Use a needless syringe to instill feedings. ---------- Correct Answer --------- Place oral suction equipment next to the client's bedside. A nurse is caring for a client who has a prescription for acetaminophen 300 mg with codeine 30 mg. 1 tablet every 3 to 4 hr PRN for pain inadvertently administer 2 tablets to the client. In which of the following locations should the nurse document this client care incident? - Incident report - Nursing care plan - Controlled substance inventory record. - Provider's progress notes ---------- Correct Answer --------- Controlled substance inventory record Place a padded tongue blade in the child's mouth. ---------- Correct Answer --------- Place a pillow under the child's head. A nurse is preparing to give change of shift report on a client who is 2 day postoperative following a total knee arthroscopy. Which of the following information should the nurse include in the report? Time of the last pain medication Admission vital signs Steps required for dressing change. Preferred bath time. ---------- Correct Answer --------- Time of the last pain medication A community health nurse is assisting with the development of a pamphlet regarding choking hazards for toddlers. Which should the nurse include? Corn Potatoes Grapes Oranges ---------- Correct Answer --------- Grapes A nurse is reinforcing teaching with a # parent of a child who has ADHD and is taking methylphenidate which of the following statements by the parents indicated the medication is effective ---------- Correct Answer --------- our child is able to complete his homework on time 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 by the client indicates an understanding of the teaching ---------- Correct Answer --------- I should check my heart rate while taking this medication A nurse is assisting in the care of a client who is at 34 weeks of gestation and is experiencing lower back pain. which of the following recommendations should the nurse make? ---------- Correct Answer --------- perform pelvic rocking exercises several times per day A nurse is collecting data from a client who diabetic ketoaçidosis. Which of the following findings should the nurse expect? ---------- Correct Answer --------- fruity breath A nurse is reinforcing teaching with a client who is about to undergo electroconvulsive therapy the nurse should explain to the client that which of the following adverse reactions can occur following the procedure ---------- Correct Answer --------- temporary memory loss A nurse is caring for a client who has anorexia nervosa and who has a behavioral management plan in place. which of the following findings should the nurse identify as an indication that the plan is effective ---------- Correct Answer --------- potassium 3.5/g dl A nurse is reinforcing teaching with a client who is postpartum about keeping her newborn safe while in the facility. which of the following should the nurse include in the teaching? ---------- Correct Answer --------- Alert the staff if any of your identification bands are missing A nurse is caring for a client who is postoperative following a subtotal thyroidectomy. The nurse should place the client in which of the following positions? A. Dorsal recumbent B. Left lateral C. Semi-fowler's D. Supine ---------- Correct Answer --------- C. Semi-fowler's A nurse is reinforcing teaching about # healthy lifestyle changes with a female client who has mild hypertension, which of the following statements by the client indicates an understanding of the teaching? ---------- Correct Answer --------- I should decrease my salt intake to 2g per day A nurse is caring for a client who delivered a newborn by cesarean birth 1 day ago. The client requests nonpharmacological therapy to manage pain when changing positions. Which of the following responses should the nurse make? A. "You can apply counterpressure to your back with each position change." B. "You can splint the incision with a pillow when changing positions." C. "You should use patterned-paced breathing when changing positions." D. "You should change positions as little as possible." ---------- Correct Answer --------- B. "You can splint the incision with a pillow when changing positions." A nurse is reinforcing teaching with a client who is to have a plaster cast applied to his right arm. Which of the following information should the nurse include in the teaching? A. The client's extremity should be elevated after the cast is applied B. The client should keep the cast covered until it is dry C. The client can shower with the cast after 24 hours D. The client should use a hair dryer on a warm setting to relieve itching inside the cast ---------- Correct Answer --------- A. The client's extremity should be elevated after the cast is applied A nurse is caring for a client who is 12 hours postpartum and has deep vein thrombosis of the left leg. The client is receiving an anticoagulant. Which of the following actions should the nurse take? A. Administer aspirin for pain B. Massage the affected extremity every 4 hr C. Apply an ice pack to the affected extremity for 20 mins every 2 hr D. Initiate bed rest ---------- Correct Answer --------- C. Apply an ice pack to the affected extremity for 20 mins every 2 hr A nurse is caring for a client who has paranoid schizophrenia and believes that she is being followed by FBI agents who are pretending to be psychiatric staf. Which of the following responses should the nurse make? a. "Why do you feel the staf is the FBI?" b. "What makes you think the staf is following you?" c. "The psychiatric staff is not FBI. They are here to help you." d. "This must be very frightening for you. Let's talk more about it." ---------- Correct Answer --------- c. "The psychiatric staff is not FBI. They are here to help you." A nurse in an urgent-care facility is collecting data from a client who is scheduled for a procedure. Which of the ff. clinical manifestations indicates a possi- ble latex allergy? --- ------- Correct Answer --------- rhinorrhea A nurse is caring for a client who has a recent diagnosis of a terminal illness. The nurse should identify which of the following as an indication of hopelessness? -The client wants to talk about the diagnosis with nursing staff -The client has a Decreased Energy Level -The Client Makes Funeral Arrangements - The Client Requests A Second Opinion ---------- Correct Answer --------- -The client has a Decreased Energy Level A nurse is using a glucometer to measure a client's capillary blood glucose level, Which of the following actions should the nurse take? -Testa First drop of blood that forms after the Puncture - Wear Sterile Gloves - Keep the finger in Dependent Position - Select The Centrality Of The Finger ---------- Correct Answer --------- - Keep the finger in Dependent Position A nurse in a provider's office is reinforcing teaching about cigarette smoking with a client. Which of the following adverse effects should the nurse include in the teaching? o Decreased Hemoglobin o Somnolence o Bradycardia o Decreased Blood Pressure ---------- Correct Answer --------- o Somnolence 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? o Assign The Client To A Positive-airflow room o Have visitors remain at least 0.91m (3feet) away from the client o Administer Aspirin If The Client Develops A Fever o Initiate Contact Precautions For the Client ---------- Correct Answer --------- o Initiate Contact Precautions For the Client Gentamicin ---------- Correct Answer --------- - antibiotic do not mix with aminoglycoside or penicillin in same Iv - hearing loss, dizziness, ringing in the ear advance directives ---------- Correct Answer --------- A legal document designed to indicate a person's wishes regarding care in case of a terminal illness or during the dying process The nurse is reinforcing teaching about advance directives with a client who has end stage heart failure ---------- Correct Answer --------- I should discuss this document with my family after I sign it The hours sis preparing the postoperative clients closed wound drainage system which of the following actions should the nurse plan to take ---------- Correct Answer --------- Compress the container before replacing the drainage plug A nurse is transcribing a transcription from the prescription from the provider. The prescription reads Gentanmicin 2 gtt OD q4h. WOTF informatikngvshuukd the nurse clarify ---------- Correct Answer --------- Dosage COPD (chronic obstructive pulmonary disease) ---------- Correct Answer --------- Nasal cannula A nurse is reinforcing discharge instructions with a client who had a myocardial infarction. Which of the following statements indicates an understanding of the teaching ---------- Correct Answer --------- I can take a nitroglycerin pill every pill every 5 minutes up to 3 times to relieve chest pain Bucks traction's ---------- Correct Answer --------- Weights hang freely A nurse is reinforcing teaching with a client who has hypothyroidism and a prescription for levothyroxine. Which of the following instructions should the nurse include in the teaching ---------- Correct Answer --------- "You will need to take the medication for the rest of your life." A nurse is contributing to the plan of care for a client following a transurethral resection of the prostate (TURP). Which of the following interventions should the nurse include? -- -------- Correct Answer --------- Irrigate the bladder using sterile technique UTI catherezation ---------- Correct Answer --------- Wipe front to back Cotton underwear Avoid bubble baths Male: retract foreskin Dominant hand sterile A nurse is contributing to the plan of care for for a client who has a chest tube connected to a closed drainage system. Which of the following interventions should the nurse include? ---------- Correct Answer --------- Maintain the drainage system below the level of the clients chest A nurse is caring for a female client who has an indwelling urinary catheter. Which of the following actions should the nurse take? ---------- Correct Answer --------- Wipe the drainage port with an antiseptic wipe after emptying urine from bag. Restraints ---------- Correct Answer --------- - emergency prescription within an hour - remove 1 at a time - 2 fingers - rom - prescription allow only 4 hr - provider can renew prescription within a maximum of 24 hrs - remove restraints & monitor every 2 hours C Diff ---------- Correct Answer --------- - contact - watery diarrhea - brat diet A nurse is assisting with the admission of a client who is experiencing alcohol withdrawal. Which of the following medications should the nurse expect the provider to prescribe for the client? ---------- Correct Answer --------- Chlordiazepoxide rationale: The nurse should expect to administer chlordiazepoxide to decrease anxiety and the risk for seizures associated with alcohol withdrawal. Pulmonary edema ---------- Correct Answer --------- - High fowlers - monitor respiratory - Provide o2 - Check pt or inr - Dietary precaution with vitamin k - med furosemide (helps decrease pressure & fluid in the lungs) Suctioning ---------- Correct Answer --------- 10-15 seconds on rotation motion, recover 20-30secs & document Trache care ---------- Correct Answer --------- - Provide care every 8 hr as needed - Monitor respiratory distress - suction as clinical indicated A nurse is delegating the collection of a sputum specimen to an AP. At which of the following times should the nurse instruct the AP to collect the specimen ---------- Correct Answer --------- as soon as the client awakens in the morning Steps on providing postmortem care ---------- Correct Answer --------- - notify provider / Chaplin / mortuary - remove tubes or lines - clean or prepare for viewing as family desires - provide family/significant other participate - be aware of gender - identify culture values and religious beliefs - verify death certificate & facility documentation - prepare the client for transportation - ensure identification tags are present Hopeless ---------- Correct Answer --------- Lack of energy A nurse is observing an assistive personnel apply antiembolic stockings for a client. Which of the following actions by the AP demonstrates an understanding of how to perform this skill? ---------- Correct Answer --------- Applying the stocking before the client gets out of bed Knee arthroplasty interventions ---------- Correct Answer --------- - Passive motion CPN machine to promote joint mobility - Monitor for pain rotation & extremity shortening, indication of infection - Ambulate day of survey - toilet seat extender Prenatal care - edema interventions ---------- Correct Answer --------- - avoid standing for long period - Comfortable shoes and socks - Avoid anything that might make feet swell - rest your feet as much as possible - drink plenty fluids Rest and sleep ---------- Correct Answer --------- - identify sleep patterns - history & any recent changes - ask about sleep problems - establish bedtime routine A nurse is reinforcing teaching with a client who has diabetes Molite us about a 24 hour creatinine clearance test which of the following statements should the nurse include in the teaching? ---------- Correct Answer --------- You can begin collection of urine after discarding your first morning void A nurse is planning care for a 4 * client who is six hours postoperative following a right knee arthroplasty which of the following interventions should the nurse include in the clients plan of care? ---------- Correct Answer --------- Use the continuous passive motion machine intermittently A nurse is preparing to administer eyedrops to a child which of the following actions should the nurse take ? ---------- Correct Answer --------- Apply pressure to the lacrimal punctum after administering drops A nurse in an acute care setting is preparing to administer medications to a client which of the following information should the nurse obtain to identify the client ---------- Correct Answer --------- Client's telephone number A nurse is reinforcing teaching with a client who has a prescription for an antibiotic therapy the client tells the nurse that he always experiences diarrhea when he takes antibiotics which of the following food choices should the nurse recommend to lessen the occurrence of diarrhea ---------- Correct Answer --------- Yogurt A nurse is reviewing the medical record for a child who is scheduled to receive a varicella immunization which of the following findings in the clients record should the nurse recognize as a contra indication ---------- Correct Answer --------- Chemotherapy treatments A nurse in an inpatient medical health facility is reinforcing teaching with a client who signed a consent form for electro convulsive therapy which of the following statements about a client indicates an understanding of the procedure ---------- Correct Answer --------- I might have short term memory loss after the procedure A charge nurse in a long-term care facility notices the smell of alcohol on a nurses breath which of the following actions should the nurse take first ---------- Correct Answer --------- Call the supervisor to ask for another nurse A nurse is reinforcing dietary teaching with a client who's pre-pregnancy BMI was 30.5 the nurse should recognize that the client understands the teaching when she states she should expect to gain how many pounds during her pregnancy ---------- Correct Answer --------- 16 pounds A nurse is reinforcing teaching with a parent of a newborn about home safety percolation which of the following statements by the parent indicates an understanding of the teaching ---------- Correct Answer --------- I will make sure that I can fit one finger between the mattress and the side of my newborns crib A nurse is reinforcing teaching with a client who is in 16 weeks of gestation and has a prescription for fear is Sophie to treat I am deficiency anemia which of the following recommendations should the nurse week to improve the absorption of the medication ---------- Correct Answer ----- ---- Avoid drinking milk with the iron supplement A nurse is implementing a bladder training program for a client who had a stroke which of the following intervention should the nurse take ---------- Correct Answer --------- Check for residual urine after voiding A nurse is reinforcing teaching with the partner of a client who is receiving hospice care about music therapy for management which of the following statements by the partner indicates an understanding of the teaching ---------- Correct Answer --------- Music will distract my husbands awareness of the pain A nurse is assisting with the plan of care for a group of clients which of the following client should the most recommend for an interprofessional conference ---------- Correct Answer --------- A client who has a spinal cord injury A nurse is receiving change of shift report on 4 clients which of the following clients should the nurse plan to see first ---------- Correct Answer --------- A client who has a femur fracture and reports numbness of the toes A nurse in an adult daycare facility is contributing to the plan of care for a client whose family reports recent confusion and memory lOSs which of the following strategies should the nurse include in the plan ---------- Correct Answer --------- Use symbols in the communal room signage 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? ---------- Correct Answer --------- Insertion of a nasogastric tube A nurse is reinforcing teaching with a client who is about to start using an albuterol metered dose inhaler. Which of the following instructions should the nurse include in the teaching? ---------- Correct Answer --------- close your mouth around the mouthpiece A nurse in an acute care setting is assisting in collecting client information To include in a referral for a physical therapist. Which of the following information should the nurse plan to include? ---------- Correct Answer --------- physical assessment findings 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? ---------- Correct Answer --------- "Clean the teeth with a small, soft-bristled toothbrush" A nurse is caring for a client who has terminal cancer. which of the following responses by the client's school-age brother should the nurse expect? ---------- Correct Answer ----- ---- Believes that his behavior is causing his death A nurse is caring for a client who is 4 as postpartum following a cesarean birth ---------- Correct Answer --------- Foul smelling lochia. Endometritis. Painful tender breast Mastitis. Temerature Mastitis and Endometritis. Chills Mastitis. The nurse is continuing to care for the client Vital signs dav 1, 0900 Temperature (oral) 36.9 C (98.4 F) Heart rate 72/min Respiratory rate 16/min BP 162/112 mm Hg Oxygen saturation 97% on room air. ---------- Correct Answer --------- *Hemoglobin. HELLP syndrome *Alamine aminotransferase (ALT) HELLP syndrome Blood pressure Preeclampsia