ATI RN COMPREHENSIVE PREDICTOR 2019 A, RN COMPREHENSIVE PREDICTOR 2019 FORM B AND C, Exams of Nursing

Download ATI RN COMPREHENSIVE PREDICTOR 2019 A, RN COMPREHENSIVE PREDICTOR 2019 FORM B AND C and more Exams Nursing in PDF only on Docsity! ATI RN COMPREHENSIVE PREDICTOR 2019 A, RN COMPREHENSIVE PREDICTOR 2019 FORM B AND C WITH CORRECT QUESTIONS AND ANSWERS LATEST UPDATE 2023-2024 GUARANTEED PASS A nurse is assessing a client who received 2 units of packed RBCs 48 hrs ago. Which of the following findings should indicate to the nurse that the therapy has been effective? hemoglobin 14.9 g/dL a nurse working in an emergency department is triaging four clients. which of the following clients should the nurse recommend for treatment first? a middle adult client who has unstable vital signs a nurse is caring for a client who has fluid volume overload. which of the following tasks should the nurse delegate to an assistive personnel? measure the client's daily weight a nurse is preparing to administer mannitol 0.2 g/kg IV bolus over 5 min as a test dose to a client who has severe oliguria. The client weighs 198 lb. what is the amount in grams the nurse should administer? 18 g a nurse is conducting a physical examination for an adolescent and is assessing the rang of motion of the legs, which of the following images indicates the adolescent is abducting the hip joint? Moving the leg away from the midline of the body (off to the side, not to the front) a nurse is caring for a client who has hyperthyroidism. which of the following findings should the nurse expect? tremors tachycardia, diaphoresis, weight loss, insomnia, exopthalmia hypothyroidism has dry corase hair, bradycardia, and periorbital edema a nurse is assessing a school age child who has bacterial meningitis. which of the following findings should the nurse expect? nuchal rigidity also weight loss a nurse is assessing a newborn's heart rate. which of the following actions should the nurse take? auscultate the apical pulse at least 1 min a nurse is preparing to assist with a thoracentesis for a client who has pleurisy. the nurse should plan to perform which of the following actions? instruct the client to avoid coughing during the procedure a nurse is the emergency department is assessing a preschooler who has a facial laceration. the nurse should identify which of the following findings as a potential indication of child sexual abuse? the child exhibits discomfort while walking a nurse is preparing to teach about dietary management to a client who has crohn's disease and an enteroenteric fistula. which of the following nutrients should the nurse instruct the client to decrease in their diet? fiber - reduce diarrhea and inflammation a nurse is caring for a client who has a prescription for a continuous passive motion CPM machine following a total knee arthroplasty. which of the following actions should the nurse take? Turn off the CPM machine during mealtime promote client comfort and dietary intake a nurse is preparing to initiate IV access for an older adult client. Which of the following sites should the nurse select when initiating the IV for this client? radial vein of the inner arm a nurse is developing a client education program about osteoporosis for older adult clients. the nurse should include which of the following variables as a risk factor for osteoporosis? sedentary lifestyle also, small framed body with a thin build, estrogen deficiency a nurse in an emergency department is caring for a child who has a fever and fluid filled vesicles on the trunk and extremities. which of the following interventions should the nurse identify as the priority? initiate transmission based precautions a nurse is caring for a client who has a clogged percutaneous gastrostomy feeding tube. which of the following actions should the nurse take first? change the position of the client a home health care nurse is developing a teaching plan for a client who has a new ileostomy. which of the following instructions should the nurse include? empty the appliance when it is one third to one half full a nurse in an outpatient mental health clinic is caring for four clients. the nurse should recognize that which of the following clients is effectively using sublimation as a defense mechanism? a client who channels their energy into a new hobby following the loss of their job a nurse is assessing for correct placement of a client's NG feeding tube prior to administering a bolus feeding. which of the following actions should the nurse take? aspirate contents from the tube and verify the pH level an antepartum nurse is caring for four clients. for which of the following clients should the nurse initiate seizure precautions? a client who is at 33 weeks of gestation and has severe gestational hypertension a nurse is providing discharge teaching to a client who is to receive home oxygen therapy. which of the following instructions should the nurse include in the teaching? wear clothing made with cotton fabrics while oxygen is in use use water soluble lubricant not petroleum based lubricant a nurse is providing teaching for a client who has a fracture of the right fibula with a short leg cast in place a new prescription for crutches. The client is non weight bearing for 6 weeks. which of the following instructions should the nurse include in the teaching? use a three point gait a nurse is preparing to transfer a client from the ICU to the medical floor. The client was recently weaned from mechanical ventilation following a pneumonectomy. which of the following information should the nurse include in the change of shift report? The time of the client's last dose of pain medication a nurse is assessing an infant who has hydrocephalus and is 6 hr postoperative following placement of a ventriculoperitoneal VP shunt. Which of the following findings should the nurse report to the provider? irritability when being held - increased intracranial pressure a nurse is caring for a client who has a prescription for chlorpromazine. which of the following findings should the nurse identify as an indication that the medication is effective? decreased hallucinations a nurse is providing teaching about lithium to a client who has bipolar disorder. which of the following statements should the nurse include in the teaching? "Notify your provider if you experience increased thirst" a nurse is caring for a client who has a fecal impaction. which of the following actions should the nurse take when digitally evacuating the stool? insert a lubricated gloved finger and advance along the rectal wall a nurse is planning to delegate client care tasks to an assistive personnel AP. which of the following tasks should the nurse plan to delegate to the AP? perform gastrostomy feedings through a client's established gastrostomy tube a nurse manager is preparing an educational session for nursing staff about how to provide cost effective care. which of the following methods should the nurse include in the teaching? delegate non nursing tasks to ancillary staff a nurse on an inpatient mental health unit is monitoring a visit between a client who has a history of aggressive behavior and the client's partner. which of the following observations should the nurse identify as an indication for potential violence? The client is pacing around the chair in which their partner is sitting a nurse is caring for a client who has signed an informed consent form to receive electroconvulsive therapy. The client states to the nurse, "I'm not sure about this now. I'm afraid it's too risky." which of the following responses should the nurse make? "You have the right to change your mind about this procedure at any time" A rural community health nurse is developing a plan to improve health care delivery for migrant farmworkers. To identify health services data for this minority group, the nurse should gather information from which of the following sources? Agency for healthcare research and quality a nurse is assessing a newborn following a vaginal delivery. which of the following findings should the nurse report to the provider? Nasal flaring A charge nurse is speaking with the partner of a client. the partner states that the client is not receiving adequate care. which of the following actions should the charge nurse take first to resolve the situation? ask the partner to list specific concerns a nurse is providing information to a client immediately before his scheduled Romberg test. which of the following statements should the nurse make? "I will be checking you once with your eyes open and once with them closed" A nurse is teaching a client who is at 20 weeks of gestation about common discomforts associated with pregnancy. which of the following statements by the client indicates an understanding of the teaching? "I will wear a supportive bra overnight" a nurse is caring for a client who is taking valproic acid for seizure control. for which of the following adverse effects should the nurse monitor and report? jaundice a nurse is providing discharge instructions about newborn care to a client who is postpartum. which of the following statements indicates to the nurse that the client understands the teaching? select all "I will cover my baby's body when I wash her hair" "I will use the bulb syringe first in her mouth then in her nose" A nurse on a mental health unit is conducting a mental status examination MSE on a newly admitted client. which of the following components of the MSE is the priority for the nurse to assess? ideas of self-harm a nurse is preparing to administer lactated ringers 1,500 mL IV to infuse at 50 mL/hr. The drop factor of the manual IV tubing is 15 gtt/mL. The nurse should set the manual IV infusion to deliver how many gtt/min? Round to nearest whole number 13 a nurse is providing teaching to a client who has a new diagnosis of type 1 diabetes mellitus. the nurse should instruct the client to monitor for which of the following findings as a manifestation of hypoglycemia? irritability a nurse is providing teaching to a client who is scheduled for electroconvulsive therapy ECT. The nurse should inform the client that which of the following findings is an adverse effect of ECT? short term memory loss a charge nurse notices that one of the nurses on the shift frequently violates unit polices by taking an extended amount of time for break. Which of the following statements should the charge nurse make to address this conflict? "I would like to talk to you about the unit polices regarding break time" A nurse in an emergency department is caring for a client who is at 9 weeks of gestation and reports nausea and vomiting for the past 2 days. which of the following findings should the nurse expect? urine specific gravity 1.052 a nurse is caring for an older adult client who is experiencing chronic anorexia and is receiving enteral tube feedings. which of the following laboratory values indicates that the client needs additional nutrients added to the feedings? albumin 2.8g/dL should be 3.5 to 5.0 A nurse is conducting group therapy with clients who have breast cancer. the nurse should recognize which of the following statements by a client as an example of altruism? "I told my doctor that I would like to start a support group for other women who are sick in my community" - reaching out and helping others a charge nurse is providing an educational session about infection control for a group of staff nurses. which of the following statements by one of the staff nurses indicates an understandings of isolation precautions? "A client who requires airborne precautions should be placed in a negative pressure airflow room" a nurse is preparing to administer a blood transfusion to a client. which of the following procedures should the nurse follow to ensure proper client identification? verify the client and blood product information with another licensed nurse a nurse in a mental health clinic is assessing a client who has a history of seeking counseling for relationship problems. the client shows the nurse multiple superficial self inflicted lacerations on their forearms. The nurse should identify these behaviors as characteristics of which of the following personality disorders. borderline - emotionally unstable, troubled interpersonal relationships, often engage ion harmful behaviors a nurse is caring for a client who has type 1 diabetes mellitus and reports severe ankle pain after falling off a stepstool at home. which of the following prescriptions should the nurse clarify with the provider? apply a cold pack to the clients ankle for 30 min every hour - type 1 diabetes is a contraindication for cold therapy a nurse is teaching about adverse effects with a client who is starting to take captopril. which of the following findings should the nurse identify as an adverse effect of the medication to report to the provider? cough - due to build up of bradykinin in the lungs a nurse is reviewing the ABG values of a client. The client has a pH of 7.2, psco2 of 60 mm Hg, nd HCO3- of 25 mEq/L. The nurse should identify that the client has which of the following acid base imbalances? respiratory acidosis a nurse in a providers office is assessing an adolescent who has been taking ibuprofen for 6 months to treatjuvenile idiopathic arthritis. which of the following questions should the nurse ask to assess for adverse effect of this medication? "Have you had any stomach pain or bloody stools? a nurse on a pediatric unit has received change of shift report for four children. which of the following children should the nurse assess first? a 10 year old child who is awaiting surgery for an appendectomy and experienced sudden relief from pain a nurse on an inpatient unit is caring for a client who has schizophrenia and recently started taking risperidone. which of the following actions should the nurse take? implement fall precautions for the client - orthostatic hypotension and dizziness a nurse is assessing a client who has decreased visual acuity due to cataracts. the nurse should identify that which of the following physiological changes is the cause for the client's visual loss? increased opacity of the lens a nurse is caring for a client following a vacuum assisted birth. the nurse should monitor the client for which of the following complications related to vacuum assisted birth? cervical laceration a nurse is updating the plan of care for a client who is 48 hr post operative following a laryngectomy and is unable to speak. which of the following actions should the nurse plan to take first? determine the clients reading skills a nurse is caring for a school age child who has dehydration and is receiving an oral rehydration solution. which of the following laboratory results indicates that the treatment regimen is effective serum sodium 138 mEq/L a school nurse is notified of an emergency in which several children were injured following the collapse of playground equipment. upon arrival at the playground, which of the following actions should the nurse take first? survey the scene for potential hazards to staff and children a nurse in an emergency department is caring for a client who is unconscious and requires emergency medical procedures. the nurse is unable to locate members of the clients family to obtain consent. which of the following actions should the nurse take? proceed with provision of medical care a nurse is caring for a school age child who is taking valproic acid. the nurse should expect the provider to order which of the following diagnostic tests? serum liver enzyme levels a nurse manager is preparing to teach a group of newly licensed nurses about effective time management. which of the following steps of the time management process should the nurse manager include as the priority? making a list of activities to complete a nurse is caring for a client who has pulmonary embolism. the client is receiving heparin via continuous IVinfusion at 1,200 units/hr and warfarin 5 mg PO daily. the morning laboratory values for the client are aPTT 98 seconds and INR 1.8. which of the following actions should the nurse take? withhold the heparin infusion a nurse is providing teaching to a school age child who has asthma about using albuterol metered dose inhaler. which of the following instructions should the nurse include? take the medication 15 min before playing sports a home health nurse is evaluating a school age child who has cystic fibrosis. the nurse should initiate a request for high frequency chest compression vest in response to which of the following parent statements? "my child has only a small amount of mucus after percussion therapy" a nurse is planning care for a client who is receiving chemotherapy and has neutropenia. which of the following interventions should the nurse include in the plan? avoid including raw fruits in the clients diet a nurse is caring for a client who is in the fourth stage of labor and is reviewing oxytocin via continuous IV infusion. which of the following assessments is the nurse's priority? amount of vaginal bleeding a nurse is caring for a client who is in the resuscitation phase of burn injury. which of the following findings should the nurse expect? hyponatremia hyperkalemia a nurse is teaching a client who has a new prescription for total parenteral nutrition through a central line. which of the following information should the nurse include in the teaching? "I will need to measure your weight daily" a nurse is assessing a client who has bipolar disorder. which of the following alterations in speech is the client using? flight of ideas - changing topics suddenly a home health nurse is caring for a group of older adult clients. the nurse should initiate a referral to the program of all inclusive care for the elderly PACE for which of the following clients? a client whose caregiver requests adult day care services PACE provides adult day care services along with in home assessments and supportive services a nurse at a mental health clinic is caring for four clients. the nurse should recognize that which of the following clients is using dissociation as a defense mechanism? a client who was abused as a child describes the abuse as if it happened to someone else a nurse is caring for a client who has active pulmonary tuberculosis. which of the following actions should the nurse take? assign the client to a private room with negative air pressure a nurse is providing teaching to a client who is at 24 weeks of gestation and is scheduled for a 3 hour oral glucose tolerance test. which of the following instructions should the nurse include in the teaching? a nurse is caring for a client who has deep vein thrombosis. which of the following actions should the nurse take? instruct the client to elevate the affected extremity when sitting a nurse is preparing to replace a client's transdermal fentanyl patch after 72 hr of use. after the nurse opens the packet containing the new pouch, the client declines to accept it. which of the following actions should the nurse take? ask another nurse to witness the disposal of the new patch a nurse is assessing an older adult client who has pneumonia. which of the following findings should the nurse expect? acute confusion - along with fatigue, lethargy, and anorexia a nurse is providing teaching about the basal body temperature method of birth control. which of the following information should the nurse include in the teaching? "your body temperature might decrease slightly just prior to ovulation" - decrease in body temperature of 1 degree commonly occurs immediately prior to ovulation a nurse manager in a long term care facility is having difficulty with staffing for weekend shifts and is planning to implement some changes to the scheduling procedure. which of the following actions should the nurse manager take first? form a committee of staff members to investigate current staffing issues a nurse is preparing to administer an IM injection to a client who is obese. which of the following actions should the nurse plan to take? use the ventrolateral site - it has a thick area of muscle and contains no large nerves or blood vessels a hospice nurse is consulting with a client and her family about receiving home services. which of the following statements should the nurse identify as an indication that the family understands home hospice care? "We can expect the hospice nurse to provide support for us after our mother's death" a nurse is assessing a client after administering epinephrine for an anaphylactic reaction. which of the following findings should the nurse identify as an adverse effect of this medication? report of chest pain a nurse is caring for a client who is receiving positive end expiratory pressure via mechanical ventilation. the nurse should monitor the client for which of the following adverse effects of PEEP? tension pneumothorax a nurse manager is reviewing client's rights with the nurses on the unit. the nurse manager should tell the nurses that informed consent promotes which of the following ethical principles? autonomy a nurse preceptor is evaluating the performance of a newly licensed nurse. which of the following actions by the newly licensed nurse requires intervention by the preceptor? starts a task then determines what supplies are needed a nurse manager is preparing an educational session about advocacy to a group of nurses. the nurse manager should indicate which of the following information in the teaching? advocacy is a leadership role that helps others to self actualize a nurse is admitting a client who has pneumonia. the nurse should initiate which of the following isolation precautions for the client? droplet a nurse has just received change of shift report on four clients. which of the following clients should the nurse assess first? a client who is postoperative with abdominal distention and no bowel sounds during a change of shift report, a night shift nurse informs the day shift nurse that a newly admitted client was disoriented and combative during the night. which of the following actions should the day shift nurse take? move the client to a room near the nurses station a nurse is reviewing the laboratory results of a toddler who has hemophilia A. which of the following aPTT values should the nurse expect? 45 seconds a nurse is planning care for a client who has rheumatoid arthritis. which of the following interventions should the nurse include in the plan? increase the client's dietary iron intake - promotes tissue repair a nurse in an outpatient mental health facility is assessing a child who has autism spectrum disorder. which of the following manifestations should the nurse expect? strict adherence to routines a nurse is caring for a client who had a stroke 6 hr ago. which of the following interventions should the nurse implement to reduce the risk of increased intracranial pressure? ICP place the client in a quiet environment What is a nurses priority action when a patient is experiencing anaphylactic shock while receiving IV medications? Priority action: stop the medication infusion The nurse can also: Administer epinephrine; infuse .9% sodium chloride, and elevate the lower extremities to help maintain adequate blood pressure A nurse is caring for a group of clients in a long-term facility. One of the clients is walking in the hallway and bumping into walls and does not respond to his name. which of the following actions should the nurse take first? Accompany the client back to his room. What medication is contra indicated while taking St. John's wort? And why? Sertraline Taking concurrently puts the patient at risk for serotonin syndrome Both of these are used for Tx of depression Persistent otitis media An infection of the middle ear Passive smoking promote adherence of respiratory pathogen's to the lining of the middle ear space which prolongs inflammation and impedes drainage from the ear Exposure to cold weather does not cause otitis media Acarbose (Precose) adverse effects Sleepiness, headaches, anemia; the most common adverse effects are gastrointestinal - diarrhea, abdominal distention, cramping, flatulence presbyopia impaired vision as a result of aging Can affect one's ability to read the newspaper, the lens is unable to change shape to focus on close up objects Myelomeningocele Most severe form of spina bifida in which the spinal cord and meninges are in a cerebrospinal fluid-filled sac and protrude through the spine Neural tube defect pts are at Rx for latex allergy Most common complication of this disorder is UTI Prevention of the development of amblyopia A disorder of the eye and which unilateral central blindness occurs as a result of another problem, such as strabismus A nurse can then assess the patient for injuries perform a neurological exam and measure the patient's vital signs once an airway is established Vaginal yeast infections during pregnancy Hormonal changes of pregnancy change the acidity of the vagina, making used infections more common Clozapine (Clozaril) Atypical Antipsychotic Tx of schizophrenia Adverse effects: urinary retention, orthostatic hypotension, agranulocytosis Fever is an early indication of possible depletion of WBCs or agranulocytosis; WBC count should be checked tympanostomy tube placement placement of a tube in the tympanic membrane to relieve symptoms caused by fluid buildup Most children do not need tubes from more than one year; usually fall out on their own between 6 to 12 months after insertion Should wear air plugs to prevent contaminated or soapy water from entering the ears Hearing impairment common with otitis media and can continue after tubes are in place Thrombocytopenia precautions Thrombocytopenia is a low platelet count, common after bone marrow transplant's Patients are at increased risk for bleeding Prevention: avoid hard foods No fresh flowers because patient is in protective isolation Use of an electric shaver Do not blow nose or insert objects into nares Lactose free calcium sources One cup of collard greens provides about the same amount of calcium equivalent to 8 ounces of milk Ventriculoperitoneal shunt placement discharge teaching Patient at increased risk for infection especially 1 to 2 months after placement; parents should report fever, vomiting, seizure activity, decreases in responsiveness which all are indications of infection A minimal amount of fluid is redirected from the ventricles to the abdomen by the shunt and is absorbed readily into the peritoneum Older children should wear a helmet during physical activity to decrease risk for injury, Helmet is not necessary for infants Chronic use of oral glucocorticoids high doses by children can result in what? Slowed linear growth Children should be prescribed inhaler glucocorticoids in order to deliver the anti-inflammatory agent directly to the local target area resulting in a decrease risk of adrenal suppression (which leads to slowed linear growth) Abdominal aortic aneurysm (AAA) aorta that becomes abnormally large, ballooning outward triple A= triple the size Indications of a rupturing AAA: Sudden and increasing lower abdominal and back pain (indication that the aneurysm is extending down word and pressing on the lumbar sacral nerve roots) Indications of Shock including decreased BP and increased pulse Right sided heart failure *RIGHT= EVERYTHING ELSE BUT LUNGS Fluid backs up into heart Manifestations: S3 gallop, peripheral edema, jugular vein distention Left sided heart failure *LEFT =LUNGS Fluid backs up into lungs Manifestations: crackles in lungs, dyspnea, pulmonary edema (d/t blood cannot get out of pulmonary circulation) Nurse should expect to see oliguria during the day because of decreased blood flow to the kidneys Varenicline (Chantix) Smoking cessation Adverse effects: changes in mood, n/v, altered sense of taste, skin rash Rx factors: ↑risk depression/suicide; priority nursing action is to monitor for any mood changes Colorectal cancer primary, secondary, tertiary prevention methods Primary prevention: Smoking secession, there is an association between ling-term smoking in colorectal cancer Dietary teaching on the benefits of a diet high in cruciferous vegetables, which helps prevent the development of the disease Secondary prevention: Screening exams starting at age 50 promotes early detection of the disease Tertiary prevention: information about ostomy appliances and care, an action to minimize the effects of long-term disease or disability Patient education for EEG therapy EEG electrodes only monitor brain activity, they do not stimulate Patient should not drink any beverages that contain caffeine the day of the test, patient should not fast because hypoglycemia can affect diagnostic results Patient should shampoo their hair before the procedure and refrain from putting any styling products on it afterwards to promote adherence of the electrodes to the scalp Short term memory loss does not occur after an EEG (common after electroconclusive therapy) Doxycycline (Vibramycin, Doryx) Tetracycline antibiotic Adverse effects: photosensitivity, diarrhea, interference with color vision Avoid direct exposure to sunlight or UV light, wearing protective clothing outdoors and using sunscreen Precipitous labor Labor that lasts 3 hours or less from onset of contractions to time of delivery occurs between 20 and 37 wks gestation, uterine contractions and cervical changes Priority nursing action: Regardless of the cause of rapid delivery, uterine atony can result, causing PP hemorrhage; nurse should palpate the fundus and massage as needed to monitor and reduce risk of hemorrhage Tx SIADH Promotes excretion of water which helps correct the flute in balance and patient to have SIADH Vasopressin (ADH) Exogenous form of antidiuretic hormone secreted by the pituitary gland Stimulates water reabsorption in the kidneys Tx Diabetes Insipidus Contraindicated: pts w/ SIADH because it worsens manifestations Desmopressin acetate (DDAVP) Synthetic form of antidiuretic hormone Medicine used to treat hyposecretion of ADH Contraindicated: patients with SIADH because it worsens manifestations Chlorpropamide (Diabinese) (Used less often today) Antidiabetic agents that also has antidiuretic affects Tx of Diabetes Inipidus Contraindicated: patient with SIADH because it worsens manifestations Adverse effects: Gastrointestinal, Cutaneous reactions, Hypoglycemia, Dermatitis, eczema Skin lesions that indicate Malignant melanoma Irregularly shaped lesions w/ hues of blue, white and red tones Commonly start an exposed skin areas like the back, scale, face, neck and metastasizes readily to other areas Pharmacological treatment of chronic phantom limb pain Amitriptyline: tricyclic antidepressant Gabapentin: anti-epileptic Propranolol and other beta blockers: can reduce the persistent doll, burning sensations of chronic phantom limo pain Preoperative teaching for a patient who is to undergo LASIK eye surgery Type of we Factive laser eye surgery to correct myopia, hyperopia, astigmatism, which are most common causes of nearsightedness Overcorrection or under correction can occur so some patients will need prescription eyeglasses after the surgery Patient might receive sedation prior to the procedure and may have blurry vision, tearing, and hyper sensitivity to light postoperatively; should not drive afterwards Should not wear soft contact lenses for 2 to 3 weeks or hard contact lenses for four weeks prior to surgery because it limits oxygenation to the cornea which can slow post-op healing Some patients will have clear vision an hour after surgery but it can take up to four weeks for complete healing in optimal vision to occur Nursing interventions for a patient receiving a transfusion of packed RBCs that is exhibiting manifestations of a hypervolemic reaction Hypervolemic rxn due to circulatory overload If the blood transfusion is to rapid for the patient size/status this will occur Priority nursing action: use a transfusion pump to regulate and maintain the transfusion at a slower rate Administration of insulin glargine (Lantus ) and NPH insulin Do not mix insulin glargine with any other insulin- use separate syringes for administering both types of insulin Lantus (insulin glargine) Long-acting T1DM, T2DM Can administer at anytime of the day, administered only once in a 24 hour period Clear solution Pharmacological treatment of residual limb pain Meperidine (Demerol) Opioid More effective for residual limb pain rather than phantom limb pain NPH (Humulin N) Intermediate-acting insulin. Tx DM2 Onset: 1-2 hours. Peak: 4-12 hours. Duration: 18-24 hours. Cloudy solution Roll the valve between the palms, do not shake before administration When administering the patient should rotate injection sites in the same anatomical area to prevent lipodystrophy Developmental skills established by 18 months old Acquired at 8 months: sitting unsupported, stranger anxiety Acquired at 9 months: drinking well from a cup Acquired at 12 mo: Presence of six teeth, ability to say two words or speak in 2-word phrases Acquired at 18 mo: closure of anterior fontanel Treatment for systemic manifestations of SLE (systemic lupus erythematosus) Corticosteroids, such as prednisone, treatment of choice for SLE because of rapid anti-inflammatory action Expected lab values for a patient w/ SLE (lupus) Pancytopenia (decreased platelets, RBCs, HCT) increased ESR systemic lupus erythematosus (SLE) Autoimmune disorder a more severe form of lupus involving the skin, joints, and often vital organs- such as heart, lungs, kidneys Inflammation of these organs Indications of thyrotoxicosis Occurs if too much levothyroxine is taken Limit Na intake to help control HTN and prevent future TIAs Increase K intake to manage HTN Increase fiber intake Limit alcohol intake to no > 2 serving for men and 1 serving for women per day What does it mean when the low-pressure alarm on a mechanical ventilator sounds? There is either a leak or the tubing has come apart or detached from the patient What equipment should be available at the bedside of a patient following a subtotal thyroidectomy? Tracheostomy Tray Laryngeal edema common post-thyroidectomy can lead to respiratory distress and airway obstruction which makes emergency intubatuon difficult and increases risk for hemorrhaging because it increases tension in incision during insertion Metropolol d/c teaching Do not stop taking abruptly because it increases patient risk for angina, HTN, MI; reduce the dosage gradually over 1 to 2 weeks Count your radio pulse daily Change positions slowly d/t Rx of orthostatic hypotension Expected findings of celiac disease Foul, fatty, frothy stools known as steatorrhea Indications of an acute intravascular hemolytic reaction for a patient who is receiving a transfusion of packed RBCs This type of transfusion reaction causes acute kidney injury (leading to oliguria and hemoglobinuria) Manifestations: oliguria and hemoglobinuria, tachypnea, fever, hypotension Indications that can make a hearing aid whistle include- Poor seal with the earmold, air infection, excessive wax in the canal, and proper fit, malfunction hyperthyroidism excessive activity of the thyroid gland Manifestations: inability to sleep, creased attention span, mild to severe hyperactivity, low-grade fever, diaphoresis, restlessness, increased systolic BP, tachycardia, dysrhythmias, increased protein, lipid, carbohydrate metabolism rate Recommendations for managing this disorder: Frequent rest. periods in a quiet environment Cool environment to decrease discomfort of heat intolerance Increase caloric intake with meals to prevent muscle weakness and wasting from increased metabolism rate Pneumothorax Air in the pleural cavity (chest cavity) Rx after blunt chest trauma Tx: chest tube insertion Addison's disease occurs when the adrenal glands do not produce enough of the hormones cortisol (glucocorticoids) or aldosterone Manifestations: severe fluid and electrolyte imbalances -> Hyponatremia, hyperkalemia Tx: (to Prevent addisonian crisis) nurse should do rapid infusion of IV fluids such as .9 percent sodium chloride and IV administration of high-dose corticosteroid such as hydrocortisone to correct deficiency Treatment for hypoparathyroidism IV Ca+ or phosphate binding drugs An 18-month-old infant has Pneumocystis carinii pneumonia. Results of enzyme-linked immunosorbent assay (ELISA) testing indicate that she is HIV positive. When planning care, the nurse should consider which of the following factors?A. The infant's mother is likely HIV positive.B. The infant's ELISA test result is probably a false positive for HIV.C. Antiretroviral medications are inappropriate for infants and children who have HIV.D. HIV-positive status is a contraindication for measles, mumps, and rubella immunizations A. The infant's mother is likely HIV positive DKA therapy Initial goal is a blood glucose level below 240 Patient should receive regular insulin via continuous IV infusion and have blood glucose monitored hourly Mantoux skin test Negative result = reddened, flat area with no induration Positive result = injection cite is raised and feels hard to the touch (induration), with redness; determines exposure to TB not Dx of active TB A nurse is assessing a client who is receiving hemodialysis for the first time. Which of the following findings indicates to the nurse that the client is developing dialysis disequilibrium syndrome (DDS)? headache caused by the rapid removal of urea during hemodialysis; CNS disorder Rx factors: elevated BUN above 175 Manifestations: headache, nausea, vomiting, decreased LOC, seizures, restlessness; when severe, patient progress to confusion, seizures, coma, death A nurse is assessing a child who has acute lymphocytic leukemia and is receiving vincristine sulfate. Which of the following findings is the nurse's priority? parethesia Tx of acute lymphocytic leukemia Greatest Rx factor for the pt: neurotoxicity (adverse effect) Early findings of neurotoxicity: parethesia (numbing of peripheral extremities) which can progress to I don't gnomic and CNS dysfunction if not treated alopecia hair loss Rx for body image alteration chronic kidney disease kidney damage or a decrease in the glomerular filtration rate lasting for 3 or more months Restrict protein intake to preserve kidney function May require calcium, vitamin D, iron supplements Cochlear implants Work by directly stimulating nerve fibers in the cochlea Diaphragm contraceptive Use spermicidal jelly to increase effectiveness Insert up to six hours before intercourse and wait at least six hours after before removing it Multiple sizes Lab value to monitor to determine effective response of warfarin therapy And INR of 3.0 indicates effective therapy Lab value to monitor to determine effective response of heparin therapy A. Administer ondansetron. B. Place the client in a warm shower. C. Apply fundal pressure during contractions. D. Assist the client to a supine position. B. Place the client in a warm shower. A nurse in an emergency department is performing triage for multiple clients following a disaster in the community. To which of the following types of injuries should the nurse assign the highest priority? A. Below-the knee amputation B. Fractured tibia C. 95% full-thickness body burn D. 10cm (4in) laceration to the forearm A. Below-the knee amputation a nurse manager is updating protocols for the use of belt restraints. Which of the following guidelines should the nurse include? A. Remove the client's restraint every 4hr B. Document the client's condition every 15 min C. Attach the restrain to the bed's side rails D. Request a PRN restrain prescription for clients who are aggressive B. Document the client's condition every 15 min A nurse is teaching an in-service about nursing leadership. Which of the following information should the nurse include about an effective leader? A. Acts as an advocate for the nursing unit. B. (Unable to read) for the unit C. Priorities staff request over client needs. D. Provides routine client care and documentation. A. Acts as an advocate for the nursing unit. A nurse is reviewing the laboratory findings of a client who has and reports that she has been following her care. The nurse should identify which of the following findings indicates a need to revise the client's plan of care. A. Serum sodium 144 mEq/ B. (Unable to read) C. Hba1c 10 % D. Random serum glucose 190 mg/dl. C. Hba1c 10 % A nurse in a provider's office is reviewing the laboratory results of a group of clients. The nurse should identify that which of the following sexually transmitted infections is a nationally notifiable infectious disease that should be reported to the state health department? A. Chlamydia B. Human papillomavirus C. Candidiasis D. Herps simplex virus A. Chlamydia A nurse is teaching a newly licensed nurse about therapeutic techniques to use when leading a group on a mental health unit. Which of the following group facilitation techniques should the nurse include in the teaching? A. Share personal opinions to help influence the group's values B. Measure the accomplishments of the group against a previous group C. Yield in situations of conflicts to maintain group harmony D. Use modeling to help the clients improve their interpersonal skills D. Use modeling to help the clients improve their interpersonal skills A nurse is planning for a client who practices Orthodox Judaism. The client tells the nurse that its Passover holiday. Which of the following action should the nurse include in the plan of care? A. Provide chicken with cream sauce. B. Avoid serving fish with fins and scales. C. Provide unleavened bread. D. Avoid serving foods containing lamb. C. Provide unleavened bread. A nurse is caring for a client who has a pulmonary embolism. The nurse should identify the effectiveness of the treatment: A. A chest x-ray reveals increased density in all fields. B. The client reports feeling less anxious. C. Diminished breath sounds are auscultated bilaterally D. ABG results include Ph 7.48 PaO2 77 mm Hg and PaCO2 47 mm Hg. B. The client reports feeling less anxious. A nurse in an emergency department is assessing a client who reports ingesting thirty diazepam tablets and has respiratory rate of 10/min. After securing the client's airway and initiating an IV, which of the following actions should the nurse do next. A. Monitor the client's IV site for thrombophlebitis. B. Administer flumazenil to the client. C. Evaluate the client for further suicidal behavior. D. Initiate seizure precautions for the client. B. Administer flumazenil to the client. A nurse in an emergency department is caring for a client who reports cocaine use 1hr ago. Which of the following findings should the nurse expect? A. Hypotension B. Memory loss C. Slurred speech D. Elevated temperature D. Elevated temperature A nurse is assessing a newborn who has a blood glucose level of 30 mg/dl. Which of the following manifestations should the nurse expect? A. Loose stools B. Jitteriness C. Hypertonia D. Abdominal distention B. Jitteriness A nurse in a pediatric clinic is reviewing the laboratory test results of a school age child. Which of the following findings should the nurse report to the provider? A. Hgb 12.5 g/dl B. Platelets 250,000/mm3 C. Hct 40% D. WBC 14,000/mm3 D. WBC 14,000/mm3 A charge nurse is teaching a newly licensed nurse about clients designating a health care proxy in situations that require a durable power of attorney for heal care (DPSHC). Which of the following information should the charge nurse include? A. "The proxy should make health care decisions for the client regardless of the client's ability to do so." B. "The proxy can make financial decisions if the need arises." C. "The proxy can make treatment decisions if the client is under anesthesia." D. "The proxy should manage legal issues for the client." C. "The proxy can make treatment decisions if the client is under anesthesia." A nurse in the PACU is caring for a client who reports nausea. Which of the following actions should the nurse take first? A. Varicella vaccine. B. Inactivated polio vaccine. C. Tetanus diphtheria and acellular pertussis vaccine D. Rubella vaccine. E. Inactivated influenza vaccine. C. Tetanus diphtheria and acellular pertussis vaccine E. Inactivated influenza vaccine. A nurse is providing discharge teaching for a group of clients. The nurse should recommend a referral to a dietitian A. A client who has a prescription for warfarin and states "I will need to limit how much spinach I eat". B. A client who has gout and states, "I can continue to eat anchovies on my pizza." C. A client who has a prescription for spironolactone and states "I will reduce my intake of foods that contain potassium". D. A client who has (Unable to read) and states "I'll plan to take my calcium carbonate with a full glass of water". B. A client who has gout and states, "I can continue to eat anchovies on my pizza." A hospice nurse is visiting with the son of a client who has terminal cancer. The son reports sleeping very little during the past week due to caring for his mother. Which of the following responses should the nurse make? A. "I can give you information about respite care if you are interested." B. "You should consider taking a sleeping pill before bed each night" C. "It must be difficult taking care of someone who is terminally ill" D. "You are doing a great job taking care of your mother" A. "I can give you information about respite care if you are interested." A nurse is assessing a child who is being treated for bacterial pneumonia. The nurse notes an increase in the child's glucose. The nurse should identify this finding as an adverse effect of which of the following medications? A. Methylprednisolone. B. Ondansetron. C. Guaifenesin. D. Amoxicillin. A. Methylprednisolone. The nurse is providing teaching about folic acid to a client who is prima gravida. Which of the following information should the nurse include in the teaching? A. "You should take folic acid to decrease the risk of transmitting infections to your baby" B. "You should consume a maximum of 300 micrograms of folic acid every day". C. "You can increase your dietary intake of folic acid by eating cereals and citrus fruits". D."You can expect your urine to appear red-tingled while taking folic acid supplements". C. "You can increase your dietary intake of folic acid by eating cereals and citrus fruits". A community health nurse is assessing an adolescent who is pregnant. Which of the following assessments is the nurse's priority? A. Social relationship with peers. B. Plans for attending school while pregnant. C. Help obtain Medicaid D. Understanding of infant care. C. Help obtain Medicaid A nurse manager is planning to teach staff about critical pathways. Which of the following information should the nurse include? A. Critical pathways promote individualized care. B. Critical pathways decrease administrative work time. C. Critical pathways prevent unnecessary expense. D. Critical pathways incorporate provider preferences. C. Critical pathways prevent unnecessary expense. A nurse is reviewing the medical record of a client who has schizophrenia. Which of the following should the nurse report to the provider? Exhibit 1 Blood pressure: 102/56 mm Hg. Heart rate: 95/min Respiratory rate: 18/min Temperature: 37.4C (99.3F) Exhibit 2 Medication Administration Record Clozapine 150 mg PO twice daily Benztropine 0.5 mg PO twice daily as needed for tremors. Exhibit 3 Nurse's notes: Client reports feeling dizzy when changing positions, Reports weight gain of 1kg (2.2 lb.) in the past month. Also reports a sore throat for the past 3 days and dry mouth. Client ate 75% of breakfast and reports slightly nauseous. A. Dietary intake B. Heart rate. C. Sore throat. D. Blood pressure C. Sore throat. A charge nurse is educating a group of unit nurses about delegating client tasks to assistive personnel A. "The nurse is legally responsible for the actions of the AP". B. "An AP can perform tasks outside of his range if he has been trained". C. "An experienced AP can delegate to another AP". D. "An RN evaluates the client needs to determine tasks to delegate D. "An RN evaluates the client needs to determine tasks to delegate A nurse is assessing a client who is in active labor. Which of the following findings should the nurse report to the provider? A. Contractions lasting 80 seconds B. FHR baseline 170/min C. Early decelerations in the FHR C. Temperature 37.4C (99.3) B. FHR baseline 170/min A nurse working in a rehabilitation facility is developing a discharge plan for a client who has left-sided hemiplegia. Which of the following actions is the nurse's priority? A. Consult with a case manager about insurance coverage. B. Counsel caregivers about respite care options. C. Ensure that the client has a referral for physical therapy. D. Refer the client to a local stroke support group. C. Ensure that the client has a referral for physical therapy. A nurse in a mental health unit is planning room assignments for four clients. Which of the following client should be closest to the nurse's station? A. A client who has an anxiety disorder and is experiencing moderate anxiety. B. A client who has somatic symptom disorder and reports chronic pain. C. A client who has depressive disorder and reports feeling hopeless. D. A client who has bipolar disorder and impaired social interactions. C. A client who has depressive disorder and reports feeling hopeless. A nurse is preparing to measure a temperature of an infant. Which of the following action should the nurse take? A. Place the tip of the thermometer under the center of the infant's axilla. B. Pull the pinna of the infant's ear forward before inserting the probe. -down and back C. Insert the probe 3.8 cm (1.5in) into the infant's rectum. D. Insert the thermometer in front of the infant's tongue. A. Place the tip of the thermometer under the center of the infant's axilla. A nurse is planning care for a client who has bipolar disorder and is experiencing mania. Which of the following interventions should the nurse include in the plan? A. Encourage the client to spend time in the day room A nurse in a pediatric clinic is teaching a newly hired nurse about the varicella zoster. Which of the following information should the nurse include? A. Children who have varicella are contagious until vesicles are crusted. B. Children who have varicella should receive the herpes zoster vaccination. C. Children who have varicella should be placed in droplet precaution. D. Children who have varicella are contagious 4 days before the first vesicle eruption. A. Children who have varicella are contagious until vesicles are crusted. A staff nurse is observing a newly licensed nurse suction a client's tracheostomy. Which of the following requires interventionby the staff nurse? A. Waits 2 minutes between suctions. B. Encourages the client to cough during suctioning. C. Apply suctioning for 15 seconds. D. Inserts the catheter without applying suction. A. Waits 2 minutes between suctions. - A nurse is teaching at a community health fair about electrical fire prevention. Which of the following information should the nurse include in the teaching? A. Use three pronged grounded plugs. B. Cover extension cords with a rug. C. Check the tingling sensations around the cord to ensure the electricity is working. D. Remove the plug from the socket by pulling the cord. A. Use three pronged grounded plugs. A nurse is providing care for a group of clients. Which of the following client's should the nurse identify as having the highest risk for developing a pressure injury? A. A client who has a T-tube following an open cholecystectomy. B. A client who had a knee 2 days ago following a sports injury. C. A client who has dementia and is incontinent of urine and feces D. A client who has a myocardial infarction and is receiving thrombolytic therapy. C. A client who has dementia and is incontinent of urine and feces A nurse is teaching a client who has glaucoma and a new prescription for timolol eyedrops. Which of the following statements indicates an understanding of the teaching? A. "I will place the eye drops in the center of my eye" B. "I will place pressure on the corner of my eye after using the eye drops" C. "I should expect my tears to turn a red color after using the eye drops." D. "I should expect the eye drops to appear cloudy." B. "I will place pressure on the corner of my eye after using the eye drops" A nurse is providing teaching to a client who is 14 weeks of gestation about findings to report to the provider. Which of the following findings should the nurse include in the teaching? A. Bleeding gums B. Faintness upon rising C. Swelling of the face D. Urinary frequency C. Swelling of the face A nurse is caring for a client who has a diagnosis of stage IV metastatic cancer. Which of the following responses should the nurse make? A. "I would recommend sharing your feelings with a psychologist". B. "I can give you information about making end of life decisions". C. "You should discuss your end life decisions with your family" D. "Everyone feels this way at first. You will start feeling better soon". B. "I can give you information about making end of life decisions". A nurse is caring for a client wo has severe hypertension and is to receive nitroprusside via continuous IV infusion. Which of the following actions should the nurse plan to take? A. Keep client's calcium gluconate at the client's bedside B. Monitor blood pressure every 2 hr. C. Remove IV bag from exposure to light. D. Attach tan inline filter to the IV tubing. C. Remove IV bag from exposure to light. A nurse is caring for a client who is experiencing mild anxiety. Which of the following findings should the nurse expect? A. Feelings of dread B. Heightened perceptual field C. Rapid speech D. Purposeless activity B. Heightened perceptual field A nurse is reviewing the laboratory report of a client who has been having lithium carbonate for the past 12 months. The nurse notes a lithium level of 0.8 mEq/L. Which of the following orders from the provider should the nurse expect? A. Withhold the next dose. B. Increase the dosage. C. Discontinue the medication. D. Administer the medication D. Administer the medication A nurse is providing teaching to an older adult client about methods to promote nighttime sleep. Which of the following instructions should the nurse include? A. Stay in bed at least 1hr if unable to fall asleep B. Take 1 hr nap during the day C. Perform exercise prior to bed D. Eat a light snack before bedtime D. Eat a light snack before bedtime A nurse is caring for a client who has fibromyalgia and requests pain medication. Which of the following medications should the nurse administer? A. Pregabalin B. Lorazepam C. Colchicine D. Codeine A. Pregabalin A nurse is caring for a client following insertion of a chest tube 12 hr. ago. Which following actions should the nurse take? A. Assess the amount of drainage in the collection chamber. B. Clamp the chest tube during ambulation. C. Report continuous bubbling in the water seal chamber. D. Strip the chest tube every 4 hr. to maintain patency. C. Report continuous bubbling in the water seal chamber. A nurse is caring for a client who is receiving morphine 4 mg via IV bolus every 4 hr. PRN. The nurse should monitor for which of the following adverse effects? A. Productive cough. B. Urinary retention. C. Rhinitis D. Fever. B. Urinary retention. A nurse is interviewing the partner of a client who was admitted in the manic phase of bipolar disorder. The partner states "I don't know what to do. Everything has been happening so quickly." Which of the following by the nurse is therapeutic? A. "Can you talk about what happens with your partner at home?" A. Raise the side rails on both sides of the client's bed during repositioning. B. Reposition the client without assistive devices. C. Discuss the client's preferences for determining a reposition schedule. D. Evaluate the client's ability to help with repositioning. D. Evaluate the client's ability to help with repositioning. A nurse is orientation a newly licensed nurse who is caring for a client who is receiving mechanical ventilation and is on pressure support ventilation (PSV) mode. Which of the following statements by the newly licensed nurse indicates and understanding of PSV? A. "It keeps the alveoli open and prevents atelectasis." B. "It allows preset pressure delivered during spontaneous ventilation." C. "It guarantees minimal minute ventilator." D. "It delivers a preset ventilatory rate and tidal volume to the client B. "It allows preset pressure delivered during spontaneous ventilation." A nurse is caring for an infant who has coaction of the aorta. Which of the following should the nurse identify as an expected finding? A. Weak femoral pulses B. Frequent nosebleeds C. Upper extremity hypotension D. Increased intracranial pressure\ A. Weak femoral pulses A nurse is auscultating for crackles on a client who has pneumonia. Which of the following anterior chest wall locations should the nurse auscultate? - Auscultate Lower Lobes A nurse is assisting with the development of an informed document for participation in a research study. Which of the following information should the nurse include? A. A statement that participants can leave the study at will. B. An assignment of the participant to either the experimental or control group. C. A list of the clients participating in the study. D. A description of the framework the researchers will use to evaluate the data. A. A statement that participants can leave the study at will. A nurse is providing teaching to a client about the adverse effects of sertraline. Which of the following adverse effects should the nurse include? A. Excessive sweating B. Increased urinary frequency C. Dry cough D. Metallic taste in mouth Excessive sweating A nurse is caring for a client who has a new temporary synchronous pacemaker. Which of the following should the nurse report to the provider? A. The client's pulse oximetry level is 96%. B. (Unable to read) C. The client develops hiccups. D. The ECG shows pacing spikes after the QRS complex. C. The client develops hiccups. A nurse is preparing discharge information for a client who has type 2 diabetes mellitus. Which of the following resources should the nurse provide to the client? A. Personal blogs about managing the adverse effects of diabetes medications B. Food label recommendations from the Institute of Medicine C. Diabetes medication information from the Physicians' Desk Reference D. Food exchange lists for meal planning from the American Diabetes Association D. Food exchange lists for meal planning from the American Diabetes Association . A nurse is providing teaching about patient-controlled analgesia (PCA) to a client. Which of the following statements should the nurse include in the teaching? A. "The PCA will deliver a double dose of medication when you push the button twice." B. "You can adjust the amount of pain medication you receive by pushing on the keypad." C. "Continuous PCA infusion is designed to allow fluctuating plasma medication levels." D. "You should push the button before physical activity to allow maximum pain control." D. "You should push the button before physical activity to allow maximum pain control." A nurse is caring for a client who has diabetes mellitus and is receiving long-acting insulin for blood glucose management. The nurse should anticipate administering which of the following types of insulin? E. Glargine insulin. F. Regular insulin. G. NPH insulin. H. Insulin aspart. E. Glargine insulin. A nurse is caring for a toddler who has acute lymphocytic leukemia. In which of the following should the toddler participate? A. Looking at alphabet flashcards. B. Playing with a large plastic truck. C. Use scissors cut out paper shapes. D. Watching a cartoon in the dayroom. B. Playing with a large plastic truck. A nurse is caring for a client who is receiving intermittent feedings via a feeding pump and is experiencing dumping syndrome. Which of the following actions should the nurse take? A. Administer a refrigerated feeding. B. Increased the amount of water use to flush the tubing. C. Monitor the rate of the client's feedings. D. Instruct the client to move onto their right side. C. Monitor the rate of the client's feedings. A nurse in an emergency department is caring for a client who received a dose of penicillin and is now anxious, flushing, tachycardic and has difficulty swallowing. Which of the following actions is the nurse's priority? A. Monitor the client's ECG B. Take the client's vital signs. C. Administer oxygen D. Insert an IV line. D. Insert an IV line. A nurse is caring for a client who has Raynaud's disease. Which of the following actions should the nurse take? A. Provide information about stress management. B. Maintain a cool temperature in the client's room. C. Administer epinephrine for acute episodes. D. Give glucocorticoid steroid twice per day. A. Provide information about stress management. A nurse is reviewing the medical history of a client who has angina. Which of the following findings in the client's medical history should identify as a risk factor for angina? A. Hyperlipidemia. B. COPD C. Seizure disorder D. Hyponatremia. A. Hyperlipidemia. A nurse is caring for a client who is 12 hr. postpartum and has a third-degree perineal laceration. The client reports not having a bowel movement for 4 days. Which of the following medications should the nurse administer? 98. A nurse is admitting a client who had a stroke and exhibits facial drooping, drooling and hoarseness. Which of the following is the nurse's priority? A. Refer the client to a speech language pathologist. B. Monitor the client's prealbumin levels C. Measure the client's weight. D. Place the client on NPO status. D. Place the client on NPO status. A nurse is providing teaching to a client who has heart failure and a new prescription for furosemide. Which of the following statements should the nurse make? A. "Taking furosemide can cause your potassium levels to be high" B. "Eat foods that are high in sodium" C. "Rise slowly when getting out of bed" D. "Taking furosemide can cause you to be overhydrated" C. "Rise slowly when getting out of bed" A nurse is planning a teaching session for a client who is postoperative following a colon resection. Which of the following actions should the nurse take first? A. Providing written material for the client to read B. Plan a short instruction about coughing and deep breathing. C. Determine the client's current pain level. D. Instruct the client about dietary restrictions. C. Determine the client's current pain level. A nurse is caring for a client who has chronic pancreatitis. Which of the following dietary recommendations should the nurse make? A. Coffee with creamer. B. Lettuce with sliced avocados. C. Broiled skinless chicken breast with brown rice. D. Warm toast with margarine. C. Broiled skinless chicken breast with brown rice. A nurse is caring for a client who asks for information regarding organ donation. Which of the following should the nurse make? A. "I cannot be a witness for your consent to donate." B. "Your name cannot be removed once you are listed on the organ donor list." C. "Your desire to be an organ donor must be documented in writing." D. "You must be at least 21 years of age to become an organ donor." C. "Your desire to be an organ donor must be documented in writing." A nurse is teaching a female client about personal hygiene. Which of the client actions indicates an understanding go the teaching? A. The client takes a hot bubble bath every day. B. The client wipes back to front when toileting. C. The client washes her perineum first when bathing. D. The client brushes her teeth twice daily. D. The client brushes her teeth twice daily. A nurse is preparing to assess a 2-week-old newborn. Which of the following actions should the nurse plan to take? A. Obtain the newborn's body temperature using a tympanic thermometer. B. (Unable to read) FACES pain scale. C. Auscultate the newborn's apical pulse for 60 seconds. D. Measure the newborn's head circumference over the eyebrows and below the occipital prominence. C. Auscultate the newborn's apical pulse for 60 seconds. A nurse is caring for a client who has pneumonia and has gained 4.2 kg (9.3 lb) over the last 5 days. The client's laboratory values this morning are the following: WBC 10,000/mm3, RBC 5.2 million/mm3, platelets 250,000/mm3, BUN, and serum creatinine 2.1 mg/dL. The nurse should report these finding to which of the following members of the interdisciplinary team? A. Dietitian B. Infection control nurse C. Nephrologist D. Cardiologist C. Nephrologist A nurse is caring for an infant who is in contact isolation and received a blood transfusion. Which of the following actions is appropriate for the nurse to take to provide cost-effective care? A. Return unopened equipment to the supply center B. Leave the unused infusion pump in the room until discharge C. Stock the room with a 2-day supply of disposable diapers D. Being in formula as needed A. Return unopened equipment to the supply center A nurse is reviewing the medical record of a client who is postoperative following a total hip arthroplasty. For which of the following findings should the nurse contact the provider? A. Hear rate 100/min B. Temperature 37.8C (100F) C. Albumin level 4.0 g/dL. D. WBC count 14,000 mm3 D. WBC count 14,000 mm3 A nurse is preparing education material for a client. Which of the following techniques should the nurse use in creating material? A. Emphasize important information using bold lettering. B. Use 7th grade reading level. C. Avoid using cartoons in the teaching material. D. Use words with three or four syllables. A. Emphasize important information using bold lettering. A nurse is creating for a client who has aids. The client states, "My mouth is sore when I eat." Which of the following instructions should the nurse provide? A. "Add salt to season" B. "Ice chips" C. "Rinse your mouth with an alcohol-based mouthwash" D. "Eat foods served at hot temperatures" B. "Ice chips" A nurse is caring for a client who is at 33 weeks of gestation following an amniocentesis. The nurse should monitor the client for which of the following complications? A. Vomiting B. Hypertension C. Epigastric pain D. Contractions D. Contractions A nurse is caring for a client who is at 38 weeks gestation, is in active labor, and has ruptured membrane. Which of the following actions should the nurse take? A. Insert an indwelling urinary catheter. B. Apply fetal heart rate monitor. C. Initiate fundal massage. D. Initiate an oxytocin IV infusion. B. Apply fetal heart rate monitor. A home health nurse is preparing to make an initial visit to a family following a referral from a local provider. Identify the sequence of steps the nurse should take when conducting a home visit. (Move the steps into the box on the right. Placing them in the order of performance) B. "I take a calcium vitamin supplement daily" C. "I limit my intake of foods with potassium" D. "I constantly take my medication between 8 and 9 each evening" B. "I take a calcium vitamin supplement daily" A nurse is teaching a newly licensed nurse about ergonomic principles. Which of the following actions by a newly licensed nurse indicates an understanding of the teaching? A. Stands with feet together when lifting a client up in bed. B. Raises the client's head of bed before pulling the cline up. C. Uses a mechanical lift to move client from bed to chair. D. Places a gait belt around the client's upper chest before assisting a client to stand. C. Uses a mechanical lift to move client from bed to chair. A client is requesting information from a nurse about a nitrazine test. Which of the following statements should the nurse make? A. "Your bladder should be full prior to me performing this test B. "If this test is positive you will be required to have a non-stress test. C. "This test will determine if there is leaking amniotic fluid" D. "I will be taking a blood sample to test for changes in your hormones levels" C. "This test will determine if there is leaking amniotic fluid" A Nurse is assessing a client who has hyponatremia and is receiving IV fluid therapy. Which of the following findings indicate the client is developing a complication of therapy? A. Peripheral edema B. Increased thirst. C. Flattened neck veins. D. Hypotension A. Peripheral edema A nurse is conducting a home visit for a family who has two young children. The nurse notes several welts across the backs of the legs of one of the children. Which of the following actions should the nurse take first? A. Document clinical findings. B. Contact child protective services. C. Refer the parents to a self-help group. D. Instruct the parents about methods of discipline. B. Contact child protective services. A nurse is planning care for a client who has thrombocytopenia. Which of the following actions should the nurse include? A. Encourage the client to floss daily. B. Remove fresh flowers from the client's room. C. Provide the client what a stool softener. D. Avoid serving the client raw vegetable. C. Provide the client what a stool softener. A nurse is assessing a client who is 30 min postoperative following an arterial thrombectomy. Which of the following findings should the nurse to report? A. Chest pain B. Muscle spasms. C. Cool, moist skin. D. Incisional pain. A. Chest pain A nurse is caring for a client who has left-sided heart failure, and the provider is concerned that the client might develop (Unable to read) Which of the following actions should the nurse take? A. Maintain the client's oxygen saturation level at 89%. B. Place the client's lower extremities on two pillows. C. Recommended that the client follow a 3g sodium diet. D. Place the client in high fowler's position. D. Place the client in high fowler's position. A charge nurse is teaching a newly licensed nurse about the administration of total parenteral nutrition. Which of the following should the charge nurse include? A. "You will need to monitor the client's electrolytes daily" B. "You will need to change the IV dressing site once per week" C. "You will need to warm the solution in the microwave before administration" D. "You need to weigh the client twice per week" A. "You will need to monitor the client's electrolytes daily" A nurse is teaching a prenatal class about infection at a community center. Which of the following statements by a client indicates an understanding of the teaching? A. "I can visit my nephew who has chickenpox 5 days after the sores have crusted." B. "I can clean my cat's litter box during my pregnancy." C. "I should take antibiotics when I have a virus." D. "I should wash my hands for 10 seconds with hot after working in the garden." A. "I can visit my nephew who has chickenpox 5 days after the sores have crusted." A nurse is caring for a client who has end-stage liver cancer. Which of the following statements should the nurse make to support the client's right to autonomy? A. "You should trust that your care team has your best interest at heart" B. "I will not share any personal information without your permission C. "The health care team will do their best to keep any promise we make to you" D. "We encourage you to participate in all decisions about your treatment" D. "We encourage you to participate in all decisions about your treatment" A nurse is completing an incident report after a client fall. Which of the following competencies of Quality and Safety Education for Nurse is the use demonstrating? A. Quality improvement. B. Patient (Unable to read) C. Evidence based practice. D. Informatics. A. Quality improvement. A nurse is talking with another nurse on the unit and smells alcohol on her breath. Which of the following actions should the nurse take? A. Confront the nurse about the suspected alcohol use. B. Inform another nurse on the unit about the suspected alcohol use. C. Ask the nurse to finish administering medications and then go home. D. Notify the nursing manager about the suspected alcohol use. D. Notify the nursing manager about the suspected alcohol use. A charge nurse is teaching new staff members about factors that increase a client's risk to become violent. Which of the following risk factors should the nurse include as the best predictor of future violence? A. Previous violent behavior B. A history of being in prison C. Experiencing delusions D. Male gender A. Previous violent behavior A charge nurse is teaching a newly licensed nurse about medication administration. Which of the following information should the charge nurse include? A. Inform clients about the action of each medication prior to administration. B. (Unable to read) two times prior to administration. C. Complete an incident report if a client vomits after taking a medication. D. Avoid preparing medications for more than two clients at one time. B. Administer an analgesic. C. Obtain arterial blood gas levels. D. Elevate the head of the client's bed 30 degrees. C. Obtain arterial blood gas levels. A nurse is caring for a client following a paracentesis. Which of the following findings should the nurse identify as an indication of a complication? A. Decreased hematocrit. B. Increased blood pressure. C. Tachycardia. D. Hypothermia. C. Tachycardia. A certified IV nurse is providing education about peripherally inserted catheters (PICC) to a newly licensed nurse. Which of the following statements by the newly licensed nurse indicated an understanding of the teaching? A. "Use a vein in the middle of the lower arm to insert a PICC." B. "Flush a PICC using a 3-milliliter syringe." C. "Informed consent is required prior to PICC placement." D. "Position the client's arm in adduction for PICC placement." C. "Informed consent is required prior to PICC placement." A nurse is reviewing admission prescriptions for a group of clients. Which of the following prescriptions should the nurse identify as complete? A. Furosemide 20 mg BID B. Nitroglycerin transdermal patch. C. Aspirin 1 tablet daily. D. Metoprolol 5mg IV now. D. Metoprolol 5mg IV now. A nurse is caring a child who has cystic fibrosis and requires postural drainage. Which of the following actions should the nurse take? A. Hold hand flat to perform percussion on the child B. Perform the procedure twice a day C. Administer a bronchodilator after the procedure D.Perform the procedure prior to meals B. Perform the procedure twice a day A nurse is reviewing the medical records of four clients. The nurse should identify that which of the following client findings requires follow up care? A. A client who received a Mantoux test 48hr ago and has an induration B. A client who is schedule for a colonoscopy and is taking sodium phosphate C. A client who is taking warfarin and has an INR of 1.8 D. A client who is takin bumetanide and has a potassium level of 3.6 mEq/L A. A client who received a Mantoux test 48hr ago and has an induration A nurse is caring for a client who is postpartum and request information about contraception. Which of the following instructions should the nurse include? A. "The lactation amenorrhea method is effective for your first year postpartum" B. "You can continue to use the diaphragm used before your pregnancy" C. "Place transdermal birth control patch on your upper arm" D. "I should avoid vaginal spermicides while breast feeding." C. "Place transdermal birth control patch on your upper arm" A nurse is reviewing the facility's safety protocols considering newborn abduction with the parent of a newborn. Which of the following statements indicates an understanding of the teaching? A. "Staff will apply identification band after first bath" B. "I will not publish public announcement about my baby's birth" C. "I can remove my baby's identification band as long as she is in my room" D. "I can leave my baby in my room while I walk in the hallway" B. "I will not publish public announcement about my baby's birth" A nurse is developing a plan of care for a client who has preeclampsia and is to receive magnesium sulfate via continuous IV infusion. Which of the following actions should the nurse include in the plan? A. Restrict the client's total fluid intake to 250 mL/hr B. Give the protamine if signs of magnesium sulfate toxicity occur C. Monitor the FHR via Doppler every 30min D. Measure the client's urine output every hour D. Measure the client's urine output every hour A nurse is receiving a telephone prescription from a provider for a client who requires additional medication for pain control. Which of the following entries should the nurse make in the medical record? A. "Morphine 3 mg SQ every 4 hr. PRN for pain." B. "Morphine 3 mg Subcutaneous (Unable to read) C. "Morphine 3.0 mg sub q every 4 hr. PRN for pain." D. "Morphine 3 mg SC q 4 hr. PRN for pain." B. "Morphine 3 mg Subcutaneous (Unable to read) A nurse is assessing a client who has acute kidney injury and a respiratory rate of 34/min. The client's ABG results are ph. 7.28 HCO3 18 mEq/L. (Unable to read) PaO2 90 mm Hg. Which of the following conditions should the nurse expect? A. Metabolic acidosis. B. Metabolic alkalosis. C. Respiratory acidosis. D. Respiratory alkalosis. A. Metabolic acidosis. A nurse realizes that the wrong medication has been administered to a client. Which of the following actions should the nurse take first? A. Notify the provider. B. Report the incident to the nurse manager. C. Monitor vital signs. D. Fill out an incident report. C. Monitor vital signs. A nurse received a telephone call from a parent reporting that their school-age child has a nosebleed and that they cannot stop the bleeding. Which of the following instructions should the nurse provide to the provider? A. "Have your child lie down and turn their head to their side for 10 minutes" B. "Use your thumb and forefinger to Apply continuous pressure to the lower part of his nose." C. "Place a warm wet washcloth over your child's forehead and the bridge of their nose" D. "Tell your child to blow their nose gently and then sit down and tilt your head back" B. "Use your thumb and forefinger to apply continuous pressure to the lower part of his nose." A nurse is preparing to administer an autologous blood product to a client. Which of the following actions should the nurse take to identify the client? A. Match the client's blood type with the type and cross match specimens. B. Confirm the provider's prescription matches the number on the blood component. C. Ask the client to state the blood type and the date of their last blood donation. D. Ensure that the client's identification band matches the number on the blood unit. D. Ensure that the client's identification band matches the number on the blood unit. A nurse is transcribing new medication prescriptions for a group of clients. For which of the following prescriptions should the nurse contact the provider for clarifications? A. Zolpidem 10mg PO one tablet at bedtime B. Hydrochlorothiazide 12.5 mg PO BID C. Triamcinolone acetonide 100 mcg/inhalation two puffs TID D. Lorazepam .5mg PO one tablet daily A. "Limit your child's potassium intake while she is taking this medication." B. "You can add the medication to a half-cup of your child's favorite juice." C. "Repeat the does if your child vomits within 1 hour after taking the medication." D. "Have your child drink a small glass of water after swallowing the medication." D. "Have your child drink a small glass of water after swallowing the medication." A nurse is teaching about preventing sudden infant syndrome (SIDS) to parent of a 1-month-old infant. Which of the following indicates that the parent understands how to place the infant in the crib at bedtime? B A nurse is collecting a sputum specimen from a client who has tuberculosis. Which of the following actions should the nurse take? A. Obtain the specimen immediately upon the client waking up. B. Wait 1 day to collect the specimen if the client cannot provide sputum. C. Ask the client to provide 15 to 20 ml of sputum in the container. D. Wear sterile gloves to collect specimen from the client. A. Obtain the specimen immediately upon the client waking up. A nurse is reviewing the laboratory report of a client who has a prescription for digoxin. For which of the following laboratory results should the nurse withhold the medication and notify the provider? Digoxin 0.8 ng/ml Sodium (Was out of range) BUN 15 Potassium 3.1 mEq/L. A. Obtain the specimen immediately upon the client waking up. A nurse is reviewing the laboratory report of a client who has a prescription for digoxin. For which of the following laboratory results should the nurse withhold the medication and notify the provider? a.Digoxin 0.8 ng/ml b.Sodium (Was out of range) c.BUN 15 d.Potassium 3.1 mEq/L. d.Potassium 3.1 mEq/L. A nurse is caring for a client who wears glasses. Which of the following actions should the nurse take? A. Store the glasses in a labeled case. B. Clean the glasses with hot water. C. Clean the glasses with a paper towel. D. Store the glasses on the bedside table. A. Store the glasses in a labeled case. A school nurse is teaching a parent about absent seizures. Which of the following information should the nurse include? A. "This type of seizure can be mistaken for daydreaming." B. "This type of seizure lasts 30 to 60 seconds." C. "The child usually has an aura prior to onset." D. "This type of seizure has a gradual onset." A. "This type of seizure can be mistaken for daydreaming." A nurse is planning care for a client who has cancer and is about to receive low dose brachytherapy via a vaginal implant applicator. Which of the following interventions should the nurse include in the plan of care? A. Removal of vaginal packing B. Insertion of an indwelling urinary catheter C. Ambulation four times daily D. Maintenance of NPO status until therapy is complete B. Insertion of an indwelling urinary catheter A nurse is caring for a client who has deep vein thrombosis and is receiving heparin therapy. Which of the following tests should the nurse use to monitor and regulate the dosage of the medications? A. aPTT. B. Pyro (Unsure if that's the writing) C. Platelet count. D. INR. A. aPTT. A charge nurse is preparing to lead negotiations among nursing staff due to conflict about overtime requirements. Which of the following strategies should the nurse use to promote effective negotiation? A. Identify solutions prior to negotiation B. Focus on how the conflict occurred C. Attempts to understand both sides of the issue D. Personalize the conflict C. Attempts to understand both sides of the issue A nurse manager is developing a protocol for an urgent care clinic that often cares for clients who do not speak the same language as clinical staff. Which of the following instructions should the nurse include? A. Use the client's children to provide interpretation. B. (Answer was the nurse was going to do the interpretation) C. Offer client's translation services for a nominal fee. D. Evaluate the clients' understanding at regular intervals. B. (Answer was the nurse was going to do the interpretation) A nurse is caring for a client who experienced a traumatic brain injury 72 hr. ago. Which of the following findings should the nurse identify as an indication of intercranial pressure? A. Tachycardia. B. Narrowed pulse pressure. C. Hypotension. D. Increasingly severe headache. D. Increasingly severe headache. A nurse is providing teaching about the gastrostomy tube feedings to the parents of a school age child. Which of the following instructions should the nurse take? A. Administer the feeding over 30 min. B. Place the child in as supine position after the feeding. C. Charge the feeding bag and tubing every 3 days. D. Warm the formula in the microwave prior to administration. A. Administer the feeding over 30 min. 2. A nurse is administering digoxin 0.125 mg Po to an adult client. For which of the following findings should the nurse report to the provider? A. Potassium level 4.2 mEq/L. B. Apical pulse 58/min. C. Digoxin level 1 ng/ml. D.Constipation for 2 days. B. Apical pulse 58/min A nurse is caring for a client who is comatose and has advance directives that indicate the client does not want life-sustaining measures. The client's family want the client to have life-sustaining measures. Which of the following action should the nurse take? A.Arrange for an ethics committee meeting to address the family's concerns. B. Support the family's decision and initiate life-sustaining measures. C. Complete an incident report. D.Encourage the family to contact an attorney. A. Arrange for an ethics committee meeting to address the family's concerns. A nurse is caring for a client who wears glasses. Which of the following actions should the nurse take? A. Store the glasses in a labeled case. B. Clean the glasses with hot water. A. Keep objects in the client's room in the same place. B. Ensure there is high-wattage lighting in the client's room. C. Approach the client from the side. D. Allow extra time for the client to perform tasks. E. Touch the client gently to announce presence. A. Keep objects in the client's room in the same place. B. Ensure there is high-wattage lighting in the client's room. D. Allow extra time for the client to perform tasks. A nurse is caring for a client who is newly diagnosed with pancreatic cancer and has questions about the disease. To research the nurse should identify that which of the following electronic database has the most comprehensive collection of nursing (Unable to read) articles? A. MEDLINE B. CINAHL. C. ProQuest. D. Health Source. B. CINAHL. A nurse in an emergency department is assessing newly admitted client who is experiencing drooling and hoarseness following a burn injury. Which of the following should actions should the nurse take first? A. Obtain a baseline ECG. B. Obtain a blood specimen for ABG analysis. C. Insert an 18-gauge IV catheter. D. Administer 100% humidified oxygen. D. Administer 100% humidified oxygen. A nurse is planning care for a client who has unilateral paralysis and dysphagia following a right hemispheric stroke. Which of the following interventions should the nurse include in the plan? A. Place food on the left side of the client's mouth when he is ready to eat. B. Provide total care in performing the client's ADLs. C. Maintain the client on bed rest. D. Place the client's left arm on a pillow while he is sitting. D. Place the client's left arm on a pillow while he is sitting. A nurse is caring for a client who is in a seclusion room following violent behavior. The client continues to display aggressive behavior. Which of the following actions should the nurse take? A. Confront the client about this behavior. B. Express sympathy for the client's situation. C. Speak assertively to the client. D. Stand within 30 cm (1 ft) of the client when speaking with them. C. Speak assertively to the client. A nurse is caring for a client who is receiving brachytherapy for treatment of prostate cancer. Which of the following actions should the nurse take? A. Cleanse equipment before removal from the client's room. B. Limit the client's visitors to 30 min per day. C. Discard the client's linens in a double bag. D. Discard the radioactive source in a biohazard bag B. Limit the client's visitors to 30 min per day. A nurse is assessing a client who has left-sided heart failure. Which of the following should the nurse identify as a manifestation of pulmonary congestion? A. Frothy, pink sputum. B. Jugular vein distention. C. Weight gain. D..Bradypnea A. Frothy, pink sputum. A nurse is caring for a client who is in labor and requires augmentation of labor. Which of the following conditions should the nurse recognize as a contraindication to the use of oxytocin. A. Diabetes mellitus. B. Shoulder presentation. C. Post term with oligohydramnios. D. Chorioamnionitis C. Post term with oligohydramnios. A nurse is caring for a 5-month-old infant who has manifestations of severe dehydration and a prescription for paternal fluid therapy. The guardian asks. "What are the indications that my baby needs an IV?" Which of the following responses should the nurse make? A. "Your baby needs an IV because she is not producing any tears" B. "Your baby needs an IV because her fontanels are budging" C. "Your baby needs an IV because she is breathing slower than normal" D. "Your baby needs an IV because her heart rate is decreasing" A. "Your baby needs an IV because she is not producing any tears" A nurse is providing teaching to a client who has heart failure and a new prescription for furosemide. Which of the following statements should the nurse make? A. "Taking furosemide can cause your potassium levels to be high" B. "Eat foods that are high in sodium" C. "Rise slowly when getting out of bed" D. "Taking furosemide can cause you to be over hydrated" C. "Rise slowly when getting out of bed" A nurse is creating a plan of care for a newly admitted client who has obsessive-compulsive disorder. Which of the following interventions should the nurse take? A. Allow the client enough time to perform rituals. B. Give the client autonomy in scheduling activities. C. Discourage the client from exploring irrational fears. D. Provide negative reinforcement for ritualistic behaviors. A. Allow the client enough time to perform rituals. A nurse is caring for a client who has depression and reports taking ST. John's wort along with citalopram. The nurse should monitor the client for which of the following conditions as a result of an interaction between these substances? A. Serotonin syndrome B. Tardive dyskinesia C.Pseudo parkinsonism. D. Acute dystonia. A. Serotonin syndrome A nurse is assessing a client who is receiving packed RBCs. Which of the following findings indicate fluid overload? A. Low back pain. B. Dyspnea. C. Hypotension. D. Thready pulse. B. Dyspnea. A nurse is calculating a client's expected date of delivery. The client's last menstrual period began on April 12. Using Nagele's rule, what date should the nurse determine to be the client's expected delivery date? (Use mmdd format.) 0119 date A nurse is discussing group treatment and therapy with a client. The nurse should include which of the following as being a characteristic of a therapeutic group? A. The group is organized in an autocratic structure. B. The group encourages members to focus on a particular issue. C. The group must be led by a licensed psychiatrist. D. The group encourages clients to form dependent relationships. B. The group encourages members to focus on a particular issue. A nurse manger is reviewing documentation with a newly licensed nurse. Which of the following notations by the newly licensed nurse indicates an understanding of the teaching. A. "OOB with assistance for breakfast" B. "Given 2 mg MSO4 IM for report of pain" C. "Dressing changed qd" D. "Administered 8 u regular insulin sq." D. "Administered 8 u regular insulin sq." A nurse is preparing to administer eye drops to a school-age child. Identify the actions the nurse should take. (Move the steps into the box on the right, placing them in the order of performance. Use all the B. A client who has gout and states, "I can continue to eat anchovies on my pizza." A nurse is preparing to measure a temperature of an infant. Which of the following action should the nurse take? A. Place the tip of the thermometer under the center of the infant's axilla. B. Pull the pinna of the infant's ear forward before inserting the probe. C. Insert the probe 3.8 cm (1.5in) into the infant's rectum. D. Insert the thermometer in front of the infant's tongue. A. Place the tip of the thermometer under the center of the infant's axilla. A nurse in a pediatric clinic is teaching a newly hired nurse about the varicella rooster. Which of the following information should the nurse include? A. Children who have varicella are contagious until vesicles are crusted. B. Children who have varicella should receive the herpes zoster vaccination. C. Children who have varicella should be placed in droplet precaution. D. Children who have varicella are contagious 4 days before the first vesicle eruption. A. Children who have varicella are contagious until vesicles are crusted. A nurse is reviewing the laboratory report of a client who has been having lithium carbonate for the past 12 months. The nurse notes a lithium level of 0.8 mEq/L. Which of the following orders from the provider should the nurse expect? A. Withhold the next dose. B. Increase the dosage. C. Discontinue the medication. D. Administer the medication. D. Administer the medication. A nurse is caring for a client who has fibromyalgia and requests pain medication. Which of the following medications should the nurse administer? A. Pregabalin B. Lorazepam C. Colchicine D. Codeine. A. Pregabalin A nurse is caring for a client who is to receive a transfusion of packed RBCs. Which of the following actions should the nurse take? A. Prime IV tubing with 0.9% sodium chloride. B. Use a 24-gauge IV catheter C. Obtain filter less IV tubing. D. Place blood in the warmer for 1 hr. A. Prime IV tubing with 0.9% sodium chloride. A nurse is caring for a toddler who has acute lymphocytic leukemia. In which of the following should the toddler participate? A. Looking at alphabet flashcards. B. Playing with a large plastic truck. C. Use scissors cut out paper shapes. D. Watching a cartoon in the dayroom. B. Playing with a large plastic truck. A nurse is caring for a client who has chronic pancreatitis. Which of the following dietary recommendations should the nurse make? A. Coffee with creamer. B. Lettuce with sliced avocados. C. Broiled skinless chicken breast with brown rice. D. Warm toast with margarine. C. Broiled skinless chicken breast with brown rice. A nurse is preparing to assess a 2-week-old newborn. Which of the following actions should the nurse plan to take? A. Obtain the newborn's body temperature using a tympanic thermometer. B. FACES pain scale. C. Auscultate the newborn's apical pulse for 60 seconds. D. Measure the newborn's head circumference over the eyebrows and below the occipital prominence. C. Auscultate the newborn's apical pulse for 60 seconds. A nurse is caring for a client who is at 38 weeks gestation, is in active labor, and has ruptured membrane. Which of the following actions should the nurse take? A. Insert an indwelling urinary catheter. B. Apply fetal heart rate monitor. C. Initiate fundal massage. D. Initiate an oxytocin IV infusion. B. Apply fetal heart rate monitor. A nurse is assessing a client who is 30 min postoperative following an arterial thrombectomy. Which of the following findings should the nurse to report? A. Chest pain B. Muscle spasms. C. Cool, moist skin. D. Incisional pain. A. Chest pain A nurse is completing an incident report after a client fall. Which of the following competencies of Quality and Safety Education for Nurse is the use demonstrating? A. Quality improvement. B. Patient (Unable to read) C. Evidence based practice. D. Informatics. A. Quality improvement. A nurse is talking with another nurse on the unit and smells alcohol on her breath. Which of the following actions should the nurse take? A. Confront the nurse about the suspected alcohol use. B. Inform another nurse on the unit about the suspected alcohol use. C. Ask the nurse to finish administering medications and then go home. D. Notify the nursing manager about the suspected alcohol use. D. Notify the nursing manager about the suspected alcohol use. A nurse is caring for a client who has diaper dermatitis. Which of the following actions should the nurse take? A. Apply zinc oxide ointment to the irritated area. B. (Unable to read) C. Wipe stool from the skin using store bought baby wipes. D. Apply talcum powder to the irritated area. A. Apply zinc oxide ointment to the irritated area. A nurse is reviewing the facility's safety protocols considering newborn abduction with the parent of a newborn. Which of the following statements indicates an understanding of the teaching? A. "Staff will apply identification band after first bath" B. "I will not publish public announcement about my baby's birth" C. "I can remove my baby's identification band as long as she is in my room" D. "I can leave my baby in my room while I walk in the hallway" B. "I will not publish public announcement about my baby's birth" A nurse is receiving a telephone prescription from a provider for a client who requires additional medication for pain control. Which of the following entries should the nurse make in the medical record? A. "Morphine 3 mg SQ every 4 hr. PRN for pain." B. "Morphine 3 mg Subcutaneous (Unable to read) C. "Morphine 3.0 mg sub q every 4 hr. PRN for pain." D. "Morphine 3 mg SC q 4 hr. PRN for pain." B. "Morphine 3 mg Subcutaneous (Unable to read) A nurse realizes that the wrong medication has been administered to a client. Which of the following actions should the nurse take first? A. Notify the provider. B. Report the incident to the nurse manager. C. Monitor vital signs. D. Fill out an incident report. A. Develop an hourly time frame for tasks B. Schedule daily activities C. Determine goals of the day D. Delegate tasks to the AP C. Determine goals of the day A nurse is providing teaching to an adolescent who has peptic ulcer disease. Which of the following statements by the client indicates an understanding of the teaching? A. I will decrease my daily protein intake to 15 grams per day B. I will use ibuprofen as needed to control abdominal pain C. I will take sucralfate with meals three times per day D. I will avoid food and beverages that contain caffeine D. I will avoid food and beverages that contain caffeine A nurse is reviewing legal issues in health care with a group of newly licensed nurse. Which of the following recommendations should the nurse make? A. Place copies of incident reports in clients medical records. B. Overestimate clients acuity to prevent short staffing C. Ensure that each client has a living will on file prior to treatment D. Obtain personal professional liability insurance coverage D. Obtain personal professional liability insurance coverage A nurse is providing preoperative teaching about patient controlled analgesia (PCA) to a client. Which of the following statements should the nurse include in the teaching? A. The PCA will deliver a double dose of medication when you push the button twice B. You can adjust the amount of pain you receive by pushing on the keypad C. Continuous PCA infusions is designed to allow fluctuating plasma medication levels D. You should push the button before physical activity to allow maximum pain control D. You should push the button before physical activity to allow maximum pain control A charge nurse is teaching a newly nurse about clients designating a health care proxy in situations that require a durable power of attorney for health care (DPAHC). Which of the following should the charge nurse include? A. The proxy should make health care decisions for the client regardless of the clients ability to do so B. The proxy can make financial decisions if the need arises C. The proxy can make treatments decisions if the client is under anesthesia D. The proxy should manage legal issues for the client C. The proxy can make treatments decisions if the client is under anesthesia A nurse is caring for a client who has a history of depression and i experiencing a situational crisis. Which of the following actions should the nurse take first? A. Confirm the clients perception of the event B. Notify the clients support person C. Help the client identify identify personal strengths D. Teach the client relaxation techniques A. Confirm the clients perception of the event A nurse is caring for a client who has end stage kidney disease. The clients adult child asks the nurse about becoming a living kidney donor for her father. Which of the following conditions in the child medical history should the nurse identify as a contraindication to the procedure? A. Amputation B. Osteoarthritis C. Hypertension D. Primary Glaucoma C. Hypertension A nurse is planning care for a client who has bipolar disorder and is experiencing mania. Which of the following interventions should the nurse include in the plan? A. Encourage the client to spend time in the day room B. Withdraw the clients TV privileges if he does not attend group therapy C. Encourage the client to take frequent rest periods D. Place the client in seclusion when he exhibits signs of anxiety C. Encourage the client to take frequent rest periods A nurse is working with a client who has anxiety disorder and is in the orientation phase of the therapeutic relationship. Which of the following statements should the nurse make during this phase? A. Lets talk about how you can change your response to stress B. We should establish our roles in the initial session C. Let me show you simple relaxation exercise to manage stress D. We should discuss resources to implement in your daily life B. We should establish our roles in the initial session A staff education nurse is evaluating a group of nurses during a new employee orientation on the use of proper mechanics when lifting. Which of the following images indicates the appropriate use of ergonomic principles? Legs apart, Bending the knees, straight back A nurse is providing teaching to an older adult client about methods of promote nighttime sleep. Which of the following instructions should the nurse include? A. Stay in bed at least 1 hr if unable to fall sleep B. Take a 1hr nap during the day C. Perform exercises prior to bedtime D. Eat a light snack before bedtime. D. Eat a light snack before bedtime. A nurse is interviewing the partner of a client who was admitted in the manic phase of bipolar disorder. The partner states, I do not know what to do. Everything has been happening so quickly. Which of the following responses by the nurse is therapeutic? A. Can you talk about what was happening with your partner at home? B. Why do you think your partner symptoms are progressing so quickly? C. You should make sure your partner takes the prescribed medication D. You did the right thing by bringing your partner in for treatment A. Can you talk about what was happening with your partner at home? A nurse is receiving change of shift report for a group of clients. Which of the following clients should the nurse plan to assess first? A. A client who has sinus arrhythmia and is receiving cardiac monitoring B. A client who has a hip fracture and a new onset of tachypnea C. A client who has epidural analgesia and weakness in the lower extremities D. A client who has diabetes mellitus and a hemoglobin A1C of 6.8% B. A client who has a hip fracture and a new onset of tachypnea A nurse is providing dietary teaching to a client who has a new diagnosis of irritable bowel syndrome. Which of the following recommendations should the nurse include? A. Consume food high in bran fiber B. Increase intake of milk products C. Sweeten foods with fructose corn syrup D. Increase intake of foods high in gluten A. Consume food high in bran fiber A nurse is caring for an infant who has coarctation of the aorta. Which of the following should the nurse identify as an expected finding? A. Weak femoral pulses B. Frequent nosebleeds C. Upper extremity hypotension D. Increased ICP A. Weak femoral pulses A nurse is providing teaching to a client about adverse effects of sertraline. Which of the following adverse effects should the nurse include? A. Excessive sweating B. Increased urinary frequency C. Dry mouth D. Metallic taste in mouth A. Excessive sweating A nurse is caring for a client who is in active labor and notes the FHR baseline has been 100 /min for the past 15 min. The nurse identify which of the following conditions as a possible cause of fetal bradycardia? A. Maternal fever B. Fetal anemia A nurse is caring for a child who has CF and requires postural drainage. Which of the following actions should the nurse take? A. Hold hand flat to perform percussions on the child B. Perform the procedure twice a day C. Administer a bronchodilator after the procedure. D. Perform the procedure prior to meals D. Perform the procedure prior to meals A nurse is reviewing the medical record of a client who has schizophrenia and is taking clozapine. Which of the following findings should the nurse identify as a contraindication to the administration of clozapine? A. HR 58 B. Fasting blood glucose 100 C. Hgb 14 D. WBC 2900 D. WBC 2900 A nurse is providing teaching about digoxin administration to the parents of a toddler who has heart failure. Which of the following statements should the nurse include in the teaching? A. Limit your child K intake while she is taking this medication B. You can add the medication to a half a cup of your child favorite juice C. Repeat the dose if your child vomits within 1 hour after taking the medication D. Have your child drink a small glass of water swallowing the medication D. Have your child drink a small glass of water swallowing the medication A school nurse is teaching a parent about absence seizures. Which of the following information should the nurse include? A. This type of seizure can be mistaken for daydreaming B. This type of seizure last 30 to 60 seconds C. The child usually has an aura prior to onset D. This type of seizure has a gradual onset A. This type of seizure can be mistaken for daydreaming A nurse is reviewing assessment data from several clients. For which of the following clients should the nurse recommend referral to dietitian? A. An older adult client who has a BMI of 24 B. A client who has a non healing leg ulcer C. AN older adult client who has presbyopia D. A client who has an albumin level of 3.7 B. A client who has a non healing leg ulcer A nurse is caring for a client who is receiving intermittent enteral tube feedings. Which of the following places the client is at risk for aspiration? A. Sitting in a high fowlers position during the feeding B. A history of gastro esophageal reflux disease C. Receiving a high osmolarity formula D. A residual of 65 ml 1 hr postprandial B. A history of gastro esophageal reflux disease A nurse is caring for several clients on a medical surgical unit. For which of the following nursing activities is it required that the nurse use sterile gloves? A. Inserting a NG-tube B. Administering total parenteral nutrition through a central venous access device C. Initiating an IV D. Performing tracheostomy care D. Performing tracheostomy care A nurse in a mental health clinic receives a request from a client who is undergoing psychotherapy to obtain a copy of the therapist one. Which of the following responses should the nurse make? A. We can provide a copy of your records, but the therapist notes are not included. B. I do not think you will benefit from reviewing the therapist notes right now C. Why are you interested in seeing the therapist notes? D. Are you not happy with your treatment? A. We can provide a copy of your records, but the therapist notes are not included. A nurse is developing a plan of care for a client who has preeclampsia and is to receive magnesium sulfate via continuous IV infusion. Which of the following actions should the nurse include in the plan? A. Monitor FHR via doppler every 30min B. Restrict the clients total fluid intake to 250 ml/hr C. Give the client protamine if signs of magnesium sulfate toxicity occur D. Measure the clients urine output every hour D. Measure the clients urine output every hour A nurse is assessing a client who is in active labor. Which of the following findings should the nurse report to the provider? A. Contractions lasting 80 sec B. FHR baseline 170/min C. Early decelerations in the FHR D. Temp 37.4 (99.3) B. FHR baseline 170/min A nurse is caring for a client who is in labor and has received an epidural. Which of the following actions should the nurse take? A. Decrease the maintenance infusion rate of IV fluid B. Have protamine sulfate available at the bedside C. Reposition the client side to side each hour D. Monitor the client for HTN C. Reposition the client side to side each hour A nurse is building a therapeutic relationship with a newly admitted client. Which of the following actions should the nurse palm to take during the orientation phase of the relationship? A. Determine previous coping skills used by the client B. Establish the responsibilities of the nurse and client C. Facilitate the clients problem solving skills D> Assist the client in expressing alternative behavior B. Establish the responsibilities of the nurse and client A nurse is reviewing the medical record of 4 clients. The nurse should identify that which of the following client findings requires follow up care? A. A client who received a Mantoux test 48 hr ago and has an induration B. A client who is schedule for a colonoscopy and is taking sodium phosphate C. A client who is taking warfarin and has an INR of 1.8 D. A client who is taking bumetanide and has potassium level of 3.6 A. A client who received a Mantoux test 48 hr ago and has an induration A nurse is caring for a client who is 2 hour pos op following a cardiac catheterization. Which of the following is the priority assessment finding? A. Report of burning sensation at the insertion site B. Absence of pedal pulse in the affected extremity C. Urinary output 25 ml/hr D. SpO2 91% B. Absence of pedal pulse in the affected extremity A nurse in a mental facility receives change of shift report for 4 clients. Which of the following clients should the nurse plan to assess first? A. A client placed in restraints due to aggressive behavior B. A client who will be receiving her first ECT treatment today C. A client who received a PRN dose of haloperidol 2 hr ago for increased anxiety D. A newly admitted client who has a history of 4.5kg weigth loss in the past 2 months A. A client placed in restraints due to aggressive behavior A nurse is providing discharge teaching about a car seat safety to a parent of a newborn. Which of the following statements by the parent indicates an understanding of the teaching? A. I can turn my baby car seat around when she weighs 15 pounds B. I can place my baby in the front seat with the airbag turned off C. I will place my baby in a forward facing car seat in my back seat D. I will position my baby at a 45 degree angle in the car seat D. I will position my baby at a 45 degree angle in the car seat A nurse in a clinic is assessing a 6 month old infant. Which of the following findings should the nurse report to the provider? B. Place the bedside table on the right side of the bed. A nurse is planning care for a client who has dysphagia and a new dietary prescription. Which of the following should the nurse include in the plan of care? SATA A. have suction equipment available B. Feed client thickened liquids C. Place foods on the unaffected side of the mouth D. Assign an assistive personnel to feed the client slowly. E. Teach the client to swallow with her neck flexed. A. have suction equipment available B. Feed client thickened liquids C. Place foods on the unaffected side of the mouth E. Teach the client to swallow with her neck flexed. A nurse is caring for a client who has global aphasia (both receptive and expressive.). Which of the following should the nurse include in the client's plan of care? SATA A. Speak to the client at a slower rate B. Assist the client to use flash card with pictures C. Speak to the client in a loud voice. D. Complete sentences that the client cannot finish. E. Give instructions one step at a time A. Speak to the client at a slower rate B. Assist the client to use flash card with pictures E. Give instructions one step at a time A nurse is assessing a client who has experienced a left-hemispheric stroke. Which of the following is an expected finding? A. Impulse control difficulty B. Poor judgement C. Inability to recognize familiar objects D. Loss of depth perception C. Inability to recognize familiar objects A nurse is caring for a client who is scheduled for a thoracentesis. Prior to the procedure, which of following actions should the nurse take? A. Position the client in an upright position, leaning over the bedside table. B. Explain the procedure. C. Obtain ABG's. D. Administer benzocaine spray. A. Position the client in an upright position, leaning over the bedside table. A nurse is reviewing ABG laboratory results of a client who is in respiratory distress. The results are pH 7.47, PaCo2 32 mm Hg. HCO3 22 mm Hg. The nurse should recognize that the client is experiencing which of the following acid-base imbalances? A. Respiratory acidosis B. Respiratory alkalosis C. Metabolic acidosis D. Metabolic alkalosis B. Respiratory alkalosis A nurse is assessing a client following bronchoscopy. Which of the following findings should the nurse report to the provider? A. Blood-tinged sputum B. Dry, nonproductive cough C. Sore throat D. Bronchospasms D. Bronchospasms A nurse is caring for a client who is scheduled for a thoracentesis. Which of the following supplies should the nurse ensure are in the client's room? SATA A. Oxygen equipment B. Incentive spirometer C. Sterile dressing D. Suture removal kit E. Pulse oximeter A. Oxygen equipment C. Sterile dressing E. Pulse oximeter A nurse is caring for a client following a thoracentesis. Which of the following manifestations should the nurse recognize as risks for complications? SATA A. Dyspnea B. Localized bloody drainage on the dressing C. Fever D. Hypotension E. Report of pain at the puncture site A. Dyspnea C. Fever D. Hypotension A nurse is preparing to care for a client following chest tube placement. Which of the following items should be available in the client's room? SATA A. Oxygen B. Sterile water C. Enclosed hemostat clamps D. Indwelling urinary catheter E. Occlusive dressing A. Oxygen B. Sterile water C. Enclosed hemostat clamps E. Occlusive dressing A nurse is caring for a client who has a chest tube and drainage system in place. The nurse observes that the chest tube was accidentally removed. Which of the following actions should the nurse take first? A. Obtain a chest x-ray B. Apply sterile gauze to the insertion site. C. Place tape around the insertion site. D. Assess respiratory status. B. Apply sterile gauze to the insertion site. A nurse is assessing a client who has a chest tube and drainage system in place. Which of the following are expected findings? SATA A. Gentle Constant bubbling in the suction control chamber B. Rise and fall in the level of water in the water seal chamber with inspiration and expiration C. Exposed sutures without dressing. D. Drainage system upright at chest level A. Gentle Constant bubbling in the suction control chamber B. Rise and fall in the level of water in the water seal chamber with inspiration and expiration A nurse is assisting a provider with the removal of a chest tube. Which of the following should the nurse instruct the client to do? A. Lie on it left side. B. Use the incentive spirometer. C. Cough at regular intervals. D. Perform the valsalva maneuver D. Perform the valsalva maneuver A nurse is planning care for a client following the insertion of a chest tube and drainage system. Which of the following should be included in the plan of care? SATA A. Encourage the client to cough every 2 hours B. Check the continuous bubbling in th suction chamber C. Strip the drainage tubing every 4 hours. D. Clamp the tube once a day. E. Obtain a chest x-ray A. Encourage the client to cough every 2 hours B. Check the continuous bubbling in th suction chamber E. Obtain a chest x-ray A nurse is orientation a newly licensed nurse who is caring for a client who is receiving mechanical ventilation and is receiving mechanical ventilation and is on pressure support ventilation (PSV) mode. Which of the following statements by the newly licensed nurse indicates and understanding of PSV?