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A nurse is assessing an infant who has water intoxication. Which of the following findings should the nurse expect? - - correct ans- - bounding pulse A nurse is discussing the z-track administration of hydroxyzine with a newly licensed nurse. Which of the following statements indicates the newly licensed nurse understands the purpose of the technique - - correct ans- - a. This technique decreases the risk of subcutaneous infiltration

1. A nurse is creating a plan of care for a client who has anorexia nervosa. Which of the following interventions should the nurse include in the plan? - - correct ans- - a. Monitor the client for 1 hr after meals A nurse notices smoke coming from a client's room and discovers a fire in the wastebasket. After moving the client to safety, which of the followings is the priority action? - - correct ans- - a. Close the fire door on the unit A nurse is assessing a client who has delirium due to a febrile illness. Which of the following findings should the nurse expect? - - correct ans- - a. Hallucinations
2. A nurse is caring for a client following an open colectomy. Which of the following findings places the client at risk for delayed wound healing? - - correct ans- - hyperemesis
3. A home health nurse is reviewing treatment goals with a client who has diabetes mellitus. The nurse should evaluate which of the following laboratory tests to determine effective long-term management of blood glucose levels? - - correct ans- - A1C

1. A nurse is caring for a client who has neutropenia due to HIV. Which of the following precautions should the nurse take while caring for this client? - - correct ans- - a. Use a dedicated stethoscope
2. A nurse is caring for a client who reports difficulty falling asleep at night. Which of the following actions should the nurse take? - - correct ans- - Tell the client to avoid drinking fluids 1 hr before bedtime
3. A nurse is planning care for a newborn who has hyperbilirubinemia and is to receive phototherapy. Which of the following interventions should the nurse include? - - correct ans- - a. Place the newborn 45 cm from the light source
4. A nurse is planning care for a client who has schizophrenia and is having difficulty expressing their feelings. Which of the following referrals should the nurse make? - - correct ans- - social worker
5. A nurse is caring for a client who has heart failure and has started taking a loop diuretic. Which of the following findings indicates the client is experiencing an adverse effect of the medication - - correct ans- - decreased reflexes
6. At the start of an evening shift on a cardiac unit, a licensed practical nurse brings the nurse a list of client reports. Which of the following client reports should the nurse assess first? - - correct ans- - indigestion
7. A nurse is caring for a client who has just returned to the unit following a bronchoscopy. Which of the following actions by the assistive personnel requires the nurse to intervene? -

• correct ans- - offer oral fluids to the client

1. A nurse on a medical unit has just received change-of-shift report. Which of the following clients should the nurse assess first? - - correct ans- - a. A 68 year old client who had a myocardial infarction 2 days ago and reports chest pain as a 4 on a scale of 0 to 10
2. A nurse is assessing a client prior to performing a blood draw. The nurse should identify that an allergy to which of the following food can indicate that the client has an allergy to latex? - - correct ans- - avocados
3. A nurse is preparing to witness a client's signature on an informed consent for a total knee arthroplasty. Which of the following client statements indicates the nurse should contact the surgeon? - - correct ans- - a. I am thankful there are no serious complications from this type of surgery
4. A nurse is admitting a client who has antisocial personality disorder. Which of the following client behaviors should the nurse identify as consistent with this disorder? - - correct ans- - a. Uses others for personal gain
5. A nurse is teaching the parent of a school-age child who has scabies about the application of permethrin 5% cream. The nurse should include which of the following as a potential adverse effect of the medication? - - correct ans- - burning
6. A nurse is teaching a client who has a new prescription for digoxin. Which of the following statements should the nurse include in the teaching? - - correct ans- - muscle weakness
7. A nurse is planning teaching for a client who is at 10 weeks of gestation and has a history of urinary tract infections. Which of the following information should the nurse plan to include in the teaching about UTI prevention? - - correct ans- - a. Empty the bladder before and after intercourse

1. A nurse is providing discharge teaching to a client who is postpartum and plans to breastfeed. Which of the following should the nurse recommend the client increase in their diet during lactation? - - correct ans- - a. Calcium
2. A nurse is providing teaching about preventing mastitis to a client who is postpartum and breastfeeding her newborn. Which of the following instructions should the nurse include? -

• correct ans- - a. Try to have your baby empty your breasts with each feeding."

1. A nurse is caring for a client who reports chest pain. Which of the following findings indicates myocardial damage? - - correct ans- - a. Troponin I 1.8 ng/mL
2. A nurse is providing teaching about car seat safety to the parent of a term newborn. Which of the following statements by the parent indicates an understanding of the teaching? - - correct ans- - a. "I should place my baby's car seat rear-facing until 6 months of age."
3. A nurse is performing high-frequency chest compressions using a mechanical chest compression device for a child who has cystic fibrosis. Which of the following findings indicates the treatment has been effective? - - correct ans- - a. The child has increased sputum production
4. A nurse is caring for a client following a possible exposure to anthrax. Which of the following actions should the nurse take? - - correct ans- - antitoxin
5. A nurse is caring for a client who has a newly implanted sealed internal radiation device to treat cervical cancer. Which of the following is an appropriate action for the nurse to take? - - correct ans- - a. Keep a 3 foot distance from the radiation implant A nurse is admitting a client to the medical-surgical unit. Which of the following actions should the nurse take first? - - correct ans- - a. Observe the client's level of mobility

1. A nurse at a public health clinic is caring for a group of clients. Which of the following should the nurse identify as a reportable diagnosis to the CDC? - - correct ans- - hep A
2. A charge nurse is evaluating the time management skills of a newly licensed nurse. Which of the following actions should the charge nurse identify as an effective time management skill? - - correct ans- - a. Completes activities for one client before moving to the next client
3. A nurse is caring for a client who has opioid use disorder and is experiencing withdrawal. Which of the following findings should the nurse expect? - - correct ans- - a. Hyperreflexia
4. A nurse is planning to perform wound irrigation for a client who has an open secondary wound. When creating a sterile field, which of the following actions should the nurse take?

• • correct ans- - a. Hold the bottle of sterile solution with the palm over the label while pouring

1. A nurse is planning care for a client who has a sealed radiation implant and is to remain in the hospital for 1 week. Which of the following should the nurse include in the plan of care? - - correct ans- - a. Wear a dosimeter film badge while in the client's room
2. A nurse is assessing a client who was brought to the emergency department by his adult child. The client has visible contusions on all four extremities. Which of the following actions should the nurse take? - - correct ans- - a. Report the incident to Adult Protective Services
3. A nurse is assessing a client who is postoperative following abdominal surgery. The client states, "I feel like my incision ripped open." The nurse notes dehiscence of the incision. Which of the following actions should the nurse take? - - correct ans- - a. Extend the client's legs above heart level

1. A nurse is providing teaching to the parent of a 6 month old infant who is teething and having difficulty sleeping. Which of the following instructions should the nurse include? - - correct ans- - a. Administer acetaminophen drops to your child before bedtime
2. A nurse is providing dietary teaching to a client who has an increased cholesterol level. Which of the following foods should the nurse recommend? - - correct ans- - egg whites
3. A home health nurse is teaching a guardian about administering tube feedings to their 3 month old infant. Which of the following information should the nurse include in the teaching? - - correct ans- - a. Allow the infant to suck on a pacifier during feedings
4. A charge nurse is creating assignments for the next shift for several nurses and one of the nurses is pregnant. Which of the following clients should the charge nurse assign to a nurse who is not pregnant? - - correct ans- - a. A 60 year old client who is recovering from shingles
5. A nurse is assessing a client who has a magnesium level of 4.4 mEq/L. Which of the following findings should the nurse expect? - - correct ans- - a. Hypotension
6. A nurse is reviewing the medical record of a client who has a new prescription for gentamicin. The nurse should identify that concurrent use with which of the following current medications can increase the client's risk for ototoxicity? - - correct ans- - a. Furosemide
7. A nurse is performing triage following a natural disaster. Which of the following clients should the nurse identify as the highest priority to receive care? - - correct ans- - a. A client who has a traumatic arm amputation
8. A nurse is assessing a client who is gravida 2, para 1. The client is at 41 weeks of gestation and is receiving oxytocin for the augmentation of labor. The nurse should decrease the infusion rate for which of the following findings? - - correct ans- - a. Contractions occur every 90 seocnds

1. A nurse is caring for a client who has constricted pupils, delayed reflexes, and decreased blood pressure. The nurse should identify that these findings are potential manifestations of which of the following? - - correct ans- - a. Opioid intoxication
2. A nurse is precepting a nursing student who brings the following client observations to the nurse's attention. Which of the following clients should the nurse assess first? - - correct ans- - a. A client who is coughing up pink-tinged sputum following a bronchoscopy and lung biopsy 1 hr ago
3. A nurse manager is reviewing documentation standards with a group of newly licensed nurses. Which of the following statements should the nurse manager include in the teaching? - - correct ans- - a. Include the complete name of the medication morphine sulfate
4. A community health nurse is performing a vision screening on a 4 month old infant. When shining a light source into the infant's visual field, which of the following is an expected finding? - - correct ans- - the infant closes their eyes
5. A nurse is teaching a client and their family about home hospice care. Which of the following information should the nurse include in the teaching? - - correct ans- - a. Hospice care improves quality of life through palliative care
6. A nurse is preparing to administer eye drops to a client. Which of the following nursing actions is appropriate? - - correct ans- - a. Use aseptic technique and drop the medication into the conjunctival sac
7. A nurse manager at a public health clinic is concerned about the rising number of sexually transmitted infections in the community. The purpose of which of the following is to generate new ideas to address the public health concern? - - correct ans- - a. A brainstorming session with nurses

1. A nurse is teaching a group of farmworkers who work with pesticide about minimizing exposure. Which of the following information should the nurse include in the teaching? - - correct ans- - a. Change clothes after working in the field
2. A nurse is caring for a client who has cirrhosis of the liver. Which of the following actions should the nurse take? - - correct ans- - a. Monitor for abdominal ascites
3. A nurse is caring for a client who is receiving systematic desensitization therapy to treat agoraphobia. Which of the following client statements should indicate to the nurse that the treatment has been effective? - - correct ans- - a. I was able to sit on a park bench for 30 minutes
4. A nurse is caring for a client who is receiving a blood transfusion at 125mL/hr and develops a hemolytic reaction. Which of the following actions should the nurse perform? - - correct ans- - a. Infuse 0.9% sodium chloride IV
5. A nurse is caring for a client who had a partial laryngectomy and is receiving continuous enteral feedings at 65mL/hr through a gastrostomy tube. Which of the following findings requires immediate intervention by the nurse? - - correct ans- - a. The gastric residual volume is 250 mL following 2 hr of infusion
6. A nurse is providing postoperative teaching to a client who has a newly-inserted pacemaker. Which of the following statements by the client indicates that the teaching has been effective? - - correct ans- - a. I will go to my cardiologist's office when the battery needs to be changed
7. A nurse in a mental health facility is evaluating the effectiveness of mechanical restraints for a client who threw a chair in the day room. The nurse should identify which of the following findings as an indication to remove the restraints? - - correct ans- - a. The client apologizes for their aggressive behavior

1. A nurse is preparing to administer an IV bolus of albumin 5% to a client who is receiving a continuous IV infusion. After confirming compatibility, which of the following actions should the nurse take? - - correct ans- - a. Occlude the IV tubing above the injection port
2. A nurse is caring for a client who is postpartum and has a new prescription for methylergonovine for vaginal bleeding refractory to fundal massage and oxytocin. When reviewing the client's medical history, the nurse should recognize which of the following diagnoses as a contraindication to the administration of methylergonovine? - - correct ans-

• hypertensio

1. A nurse is caring for a client who has a prescription for vancomycin 1 g IV every 12 hr. The client is scheduled to have the morning dose at 0700. The nurse should schedule the trough level to be drawn at which of the following times? - - correct ans- - 1800
2. A nurse is performing a skin assessment for a client who is on bedrest. Which of the following actions should the nurse take to prevent a pressure injury? - - correct ans- - a. Apply a donut ring pillow under the client's sacral area
3. A nurse from the State Health Development is instructing a group of nurses regarding reportable infections. Which of the following infections should the nurse report to the Centers for Disease Control and Prevention? - - correct ans- - lyme disease
4. A home health nurse is admitting a client who is prescribed peritoneal dialysis. Which of the following actions should the nurse take first? - - correct ans- - a. Demonstrate how to perform the procedure
5. A nurse is performing an admission assessment for a client who is to undergo a colonoscopy. The client informs the nurse that he took his prescribed medications before coming to the clinic. Which of the following medications is the priority to report to the provider? - - correct ans- - a. Metformin

1. A client asks the nurse if it is safe to take a glucosamine supplement. The nurse should assess for which of the following potential contraindications? - - correct ans- - shellfish allergy
2. A nurse is providing discharge teaching to a client who has schizophrenia and is starting therapy with clozapine. Which of the following is the highest priority for the client to report to the provider? - - correct ans- - fever
3. 2 hr postoperative following an ileal conduit procedure bladder cancer - - correct ans- - dusky colored stoma
4. Administer an injection to a client when the client states, "I dont want that injection. The last time I got that was sore for a week - - correct ans- - battery
5. Assessing client who systemic lupus erythematous SLE which of the following is an expected findings - - correct ans- - dry rasied fasical rash
6. Caring for a client who has a new prescription for chlorpromazine by IM injection - - correct ans- - a. check ortho bp 1 hr after administration
7. Charge nurse on pediatric unit is making assignments for a float nurse from the medical unit. Pt to see first? - - correct ans- - a. a 10-year old who has pneumonia and is receiving respiratory treatments.
8. Child who is unresponsive has increased intracrainal pressure - - correct ans- - pad rails
9. A client hopitialized for a bone marrow transplant is in protective isolation while undergoing total body radiation and intense chemotherapy. The clients sibling comes to visit but has obvious manifestations of an upper respiratory infection. - - correct ans- - a.

Allow the sibling to visit after donning a sterile gown, mask, gloves but prohibits physical contact

1. Client who has given birth to a stillborn - - correct ans- - a. Acknowledging the reality of the nb death
2. Client who is receving a controlled epidural analgesia infusion - - correct ans- - a. Covering the insertion site with a transparent dressing
3. delegates the following tasks to the assistive personnel bathe four clients distribute fresh water obtain morning vital signs - - correct ans- - a. set a clear time frame for the completion of each task
4. Diagnosis of antisocial personality disorder - - correct ans- - a. poor impulse control
5. Haloperidol for the treatment of schizophrenia - - correct ans- - a. screen the client for tardive dyskinesia
6. In patient psychiatric unit is setting short-term goals for an adolescent who was admitted for treatment of anorexi nervosa - - correct ans- - a. The client will develop personalized meal plan
7. A nurse in a pediatric unit is caring for a group of clients. Which of the following diseases should the nurse implement droplet precautions? - - correct ans- - a. Pertussis
8. A nurse in the emergency department is caring for a client following a motor vehicle crash. priority? - - correct ans- - c spine

1. A nurse is admitting a client who has chronic gout what med should the nurse admin? - - correct ans- - allopurinol
2. nurse is admitting an unidentified female who was brought to the emergency department

• • correct ans- - 3 month old

1. A nurse is caring for a client who has a typical depression and is taking phenelzine. what can you eat? - - correct ans- - low fat yogurt
2. A nurse is caring for a client who is manic. Which of the following activities is appropriate for the nurse to suggest? - - correct ans- - taking walks
3. a nurse is caring for a client who is receiving gentamicin. Which of the following findings indicates the client is developing toxicity - - correct ans- - a. tinnitus
4. nurse is caring for a client who will be, receiving a transfusion of platelets - - correct ans-

• a. Decrease in bleeding from puncture sites

1. nurse is caring for a client with fractured ribs, has developed thrombophlebitis, and is being treated with a heparin drip. The client develops hematuria and has an activated partial thromboplastin time aPTT of 100 seconds - - correct ans- - turn off heparin drip
2. A nurse is caring for a postoperative client. Which of the following interventions will reduce the risk of deep-vein thrombosis - - correct ans- - boots
3. nurse is caring for a preschool-age child who has a short-leg, plaster cast applied 1 hr ago. - - correct ans- - pillow

1. a nurse is interviewing a client who presents with multiple injuries that are consistent with intimate partner abuse. After establishing trust and rapport, which of the following should the nurse say? - - correct ans- - lets talk about what happened to you
2. a nurse is teaching a prenatal class about evidence of effective breastfeeding to a group of parent - - correct ans- - swallowing sounds are audible stool are yellow and seedy after 7 days maternal breasts become soft following feeds
3. Windshield survey - - correct ans- - religous A nurse is reviewing the lab report of a client who has a mag level of 1.0mEq/L. Which of the following should the nurse expect? - - correct ans- - Cardiac dysrrhythmia A nurse is caring for a client who has breast cancer and has been receiving chemotherapy. which of the lab values will you report to the provider? - - correct ans- - WBC 3, A nurse is planning teaching for a client who is at 10 weeks of gestation and has a history of urinary tract infections. Which of the following information should the nurse plan to include in the teaching about UTI prevention? - - correct ans- - Empty the bladder before and after intercourse A nurse is teaching a client about nutritional intake. include in the teaching - - correct ans- - Carbs should be atleast 45%-65% of you caloric intake A nurse is performing high-frequency chest compressions using a mechanical chest compression device for a child who has cystic fibrosis. Which of the following findings indicates the treatment has been effective? - - correct ans- - The child has increased sputum production

A nurse is discussing the z-track administration of hydroxyzine with a newly licensed nurse. Which of the following statements indicates the newly licensed nurse understands the purpose of the technique? - - correct ans- - This technique decreases the risk of subcutaneous infiltration A nurse is caring for a client who has heart failure and has started taking a loop diuretic. Which of the following findings indicates the client is experiencing an adverse effect of the medication - - correct ans- - Decreased reflexes client who had a CVA. perform to prevent foot dropping - - correct ans- - Place positing boots on the client's feet A nurse in a provider's office is teaching a client 16 weeks of gestation and has a new prescription for ferrous sulfate. What should the nurse include in the teaching - - correct ans- - Take you iron with fluids other than coffee and tea A nurse is caring for a client who has a newly implanted sealed internal radiation device to treat cervical cancer. Which of the following is an appropriate action for the nurse to take? -

• correct ans- - Keep a 3 foot distance from the radiation implant A charge nurse is evaluating the time management skills of a newly licensed nurse. Which of the following actions should the charge nurse identify as an effective time management skill? - - correct ans- - Completes activities for one client before moving to the next client A nurse is performing an admission assessment for a client who is to undergo a colonoscopy. The client states he took all his meds before coming. which of the following medication is priority to report to the provider - - correct ans- - Clopidegrel

Four clients to an emergency department. The nurse should plan to see which of the following first? - - correct ans- - 50 - year old client who has slurred speech, disoriented and reports a headache placenta previa. Which of the following client findings should the nurse include? - - correct ans- - Bring red vaginal bleeding A nurse is caring for a client who has constricted pupils, delayed reflexes, and decreased blood pressure. The nurse should identify that these findings are potential manifestations of which of the following? - - correct ans- - Opioid intoxication A nurse in a clinic is teaching a client who is postmenopausal about estrogen therapy. What should the nurse include in the teaching - - correct ans- - estrogen therapy increase the risk for thrombus formation A nurse administers a dose of metoclopramide to a client prior to a chemotherapy treatment. The client develops uncontrolled contraction of the head and neck muscles. Which of the following medications should the nurse administer - - correct ans- - diphenhydramine A nurse on a med-surg unit is caring for a group of clients. Which of the following clients would benefit from a three-way indwelling catheter - - correct ans- - female who is prone to development of blood clots in the urine A nurse is assessing the vital signs of a newborn who was born 8hrs ago. Which of the following findings require interventions by the nurse? - - correct ans- - blood pressure windshield survey - - correct ans- - The availability of religious facilities.

A nurse is caring for a postoperative client. Which of the following interventions will reduce the risk of DVT - - correct ans- - apply venous plexus foot pumps A nurse is providing teaching about car seat safety to the parent of a term newborn. Which of the following statements by the parent indicates an understanding of the teaching? - - correct ans- - "I should place a rolled blanket along each side of my baby's head in the car seat." A nurse is providing teaching about nutrition to the parents of a preschooler who has chronic renal failure. Which of the following indicates understanding teaching - - correct ans- - I should limit my child's intake of protein A nurse is assessing a client who has COPD and experienced recent weight loss. Which of the following findings should the nurse report to the provider? - - correct ans- - Coughing and wheezing after eating Risk for metabolic alkalosis - - correct ans- - A client who has severe hyperemesis At the start of an evening shift on a cardiac unit, a licensed practical nurse brings the nurse a list of client reports. Which of the following client reports should the nurse assess first? - - correct ans- - Indigestion A nurse is assessing an infant who has water intoxication. Which of the following findings should the nurse expect? - - correct ans- - elevated urine specific gravity A nurse is caring for a group of clients in an inpatient mental health facility. Which of the following task should the nurse delegate to the AP - - correct ans- - Sit with the client who has anorexia nervosa during meals obtaining a culuture - - correct ans- - 1. Assess the appearance of the wound

2. Obtain the specimen from granulation tissue of the wound
3. Place the swab in the culture tube.
4. Cleanse the would with 0.9%
5. Cover the wound with a sterile dressing A nurse is teaching the parent of a school-age child who has scabies about the application of permethrin 5% cream. The nurse should include which of the following as a potential adverse effect of the medication? - - correct ans- - burning A community health nurse is performing a vision screening on a 4 month old infant. When shining a light source into the infant's visual field, which of the following is an expected finding? - - correct ans- - the infant closes their eyes A nurse is caring for a client who has opioid use disorder and is experiencing withdrawal. Which of the following findings should the nurse expect? - - correct ans- - hyperreflexia The patient states they do not want the injection but the nurse gives it anyways - - correct ans- - battery Client taking phenelzine - - correct ans- - cheddar cheese A home health nurse is reviewing treatment goals with a client who has diabetes mellitus. The nurse should evaluate which of the following laboratory tests to determine effective long-term management of blood glucose levels? - - correct ans- - HbA1C A nurse manager at a public health clinic is concerned about the rising number of sexually transmitted infections in the community. The purpose of which of the following is to generate new ideas to address the public health concern? - - correct ans- - A brainstorming session with nurses

hip arthroplasty and notes the dressing is saturated with sanguineous drainage. Which of the following actions should the nurse take? - - correct ans- - Reinforce the dressing with sterile gauze bathe four clients, distribute fresh water, and obtain the morning vital signs. At noon the nurse ask the AP to transport one client to physical therapy. The nurse delegate more effectively in the future? - - correct ans- - Plan a more reasonable job assignment A nurse is preparing to administer enoxaprin to a client. Which of the following actions should the nurse plan to take? - - correct ans- - Inject the medication in the lateral abdominal wall systemic lupus - - correct ans- - dry raised facial rash common manifestation of food allergies - - correct ans- - vomiting sterile field - - correct ans- - open the first flap away from the body A nurse on a mental health unit receives report on four client. Which of the following clients should the nurse attend to first - - correct ans- - A client who is having auditory hallucination and is becoming agitated A nurse is assessing a full-term newborn who is 24hr old. What should be reported to the provider - - correct ans- - newborn neck is short and surrounded by skin folds A nurse on an orthopedic floor is completeing the morning assessments on several clients. Which client is more at risk for a fat embolism - - correct ans- - 24 yr old male who has a casted femur fracture

A community health nurse is caring for a client who request a referral for family therapy. The nurse should include who from interdisciplinary team? - - correct ans- - Social worker A nurse manager is reviewing documentation standards with a group of newly licensed nurses. Which of the following statements should the nurse manager include in the teaching? - - correct ans- - Include the complete name of the medication morphine sulfate A nurse is performing triage following a natural disaster. Which of the following clients should the nurse identify as the highest priority to receive care? - - correct ans- - A client who has a traumatic arm amputation A nurse is caring for a client who is manic. Which of the following activities is appropriate for the nurse to suggest? - - correct ans- - take a daily walk on the hospital grounds A nurse is teaching a group of farmworkers who work with pesticide about minimizing exposure. Which of the following information should the nurse include in the teaching? - - correct ans- - Change clothes after working in the field A nurse is admitting a client to a med-surg unit. What action should the nurse take first - - correct ans- - Assess the clients level of mobility A nurse is reviewing the medical records of four clients. Which of the following prescriptions correct documentation? - - correct ans- - Enoxaparin 30 mg SC every 12 hr Adolescent who has anorexia nervosa - - correct ans- - hypokalemia a nurse is preparing to discharge a newborn who has atrial septal defect. Who should the nurse expect the provider to recommend - - correct ans- - occupational manager

gentamicin toxicity - - correct ans- - tinnitus A nurse is creating a plan of care for a client who has anorexia nervosa. Which of the following interventions should the nurse include in the plan? - - correct ans- - Monitor the client for 1 hr after meals A nurse is caring for a client following a possible exposure to anthrax. Which of the following actions should the nurse take? - - correct ans- - Begin prophylactic treatment with ciprofloxacin Report to the CDC - - correct ans- - Hepatitis A levels a depression in the skin 8mm deep - - correct ans- - 4+edema A nurse is teaching a client who is at 35 week of gestation about amniocentesis. Which of the following statements should the nurse include in the teaching? - - correct ans- - you should monitor for the onset of contractions after the test A nurse is caring for a client who has heart failure and a potassium level of 3 mEq/L. The nurse should obtain verification of which of the following prescriptions from the provider - - correct ans- - digoxin 0.125mg po daily A home health nurse is admitting a clinet who is prescribed peritoneal dialysis. Which of the following actions should the nurse take first - - correct ans- - Clarify the client's actual and perceived health needs. A nurse is assessing a client who has delirium due to a febrile illness. Which of the following findings should the nurse expect? - - correct ans- - Hallucinations

diagnosis of antisocial personality disorder - - correct ans- - poor impulse control A nurse is caring for a client who is post right-modified radial mastectomy. Which of the following should the nurse recognize as a priority finding. - - correct ans- - emesis of 110ml of thick yellow fluid dysphagia, what should the client recommend - - correct ans- - oatmeal A nurse is assessing a client who was brought to the emergency department by his adult child. The client has visible contusions on all four extremities. Which of the following actions should the nurse take? - - correct ans- - Report the incident to Adult Protective Services Run cats spin the rain throwing procedures mechanical paper lake - - correct ans- - word salad eye drops - - correct ans- - maintain the child in a sitting position 3 mins after report to the CDC - - correct ans- - syphilis A nurse is teaching a client who has a new prescription for digoxin. Which of the following statements should the nurse include in the teaching? - - correct ans- - notify your provider if you experience muscle weakness A nurse is assessing a client who has preeclampsia and is receiving magnesium sulfate via continuous IV fusion. Which of the following should be reported to the provider - - correct ans- - Mag levels 9mEq/L

meningitis. What assessment to perform? - - correct ans- - Brudzinski sign A nurse is providing dietary teaching to a client who has an increased cholesterol level. Which of the following foods should the nurse recommend? - - correct ans- - egg whites A nurse is planning care for a child who is unresponsive and has increased ICP. Which of the the following actions should the nurse take? - - correct ans- - place the child in trenedelenburg position A nurse is caring for a child who has a new prescription for chlorpromazine by IM injection. Which of the following is an appropriate action? - - correct ans- - Check orthostatic blood pressure 1hr after administration mononucleosis. What findings - - correct ans- - splenomegaly malaise sore throat meningitis - - correct ans- - initiate droplet precaution continuous bubbling in the water-seal chamber - - correct ans- - check for an air leak A client asks the nurse if it is safe for him to take a glucosamine supplement - - correct ans-

• shellfish allergy A nurse is caring for a client who has a new prescription for lithium carbonate. Prior to administering the first dose, which of the following laboratory values should the nurse evaluate? - - correct ans- - Thyroid hormones

A nurse is preparing to administer an IV bolus of albumin 5% to a client receiving a continuous IV infusion. What action should the nurse take - - correct ans- - use the injection site farthest away from the IV insertion site breech of client confidentiality - - correct ans- - Discussing the clients reaction to the transfer with another staff nurse A nurse is caring for a client who has cirrhosis of the liver. Which of the following actions should the nurse take? - - correct ans- - Monitor for abdominal ascites A nurse is caring for a client following an open colectomy. Which of the following findings places the client at risk for delayed wound healing? - - correct ans- - Hyperemesis A nurse is delegating task to an AP. For which of the following can the nurse assign to the AP to measure vital signs - - correct ans- - A client who is requisition pain medication 2 days after surgery A circulating nurse is implementing a "time-out" before moving a client who is having total hip arthroplasty to the surgical site. Which of the following actions should the nurse take. - - correct ans- - confirm the provider has market the surgical site A nurse is assessing a client prior to performing a blood draw. The nurse should identify that an allergy to which of the following food can indicate that the client has an allergy to latex? - - correct ans- - avocados allopurinol. Which of the following lab findings to determine the effectiveness - - correct ans- - uric acid level haloperidol for the treatment of schizophrenia - - correct ans- - screen the client for tardive dyskinesia

A nurse is caring for a preschool-age child who has a short-leg plaster cast applied 1 hr ago. Which of the following is an appropriate intervention - - correct ans- - support the affected leg on a pillow A nurse is assessing a client who has pericarditis. Which of the following findings is the priority? - - correct ans- - substernal chest pain bone marrow transplant is in protective isolation while undergoing total body radiation and intense chemo. - - correct ans- - Allow the silbling to wave at the client through the window of the door A client who is 8hr postpartum asks the nurse id she will nee to receive Rh immune globulin. The client is gravid 2, para 2, and her blood type is AB negative. The newborn's blood type is B positive. Which of the following statement is appropriate? - - correct ans- - should be given 72 hrs after delivery receiving lasted Ringer's to treat fluid volume deficit. Indicates a therapeutic response to the treatment - - correct ans- - Increased blood pressure neutropenia about food safety to prevent food borne illness - - correct ans- - Refrigerate leftover with 2 hrs A nurse is caring for a female client who has bruises on her arms that she explains are result of physical abuse by her partner. - - correct ans- - Insit that the client report the abusive behavior to the proper authority providing postoperative teaching to a client who has a newly inserted pacemaker - - correct ans- - I will use my cellphone on the ear opposite of my pacemaker

a nurse is providing discharge teaching to a client who has schizophrenia and is starting therapy with clozapine. Which of the following is priority to report to the provider - - correct ans- - blurred vision/ fever A nurse is performing a vision screening for a client. Which of the following finding should the nurse identify as an indication that the client has cataract - - correct ans- - increased opacity of the lens of the eye A nurse is caring for a client who reports difficulty falling asleep at night. Which of the following actions should the nurse take? - - correct ans- - Tell the client to avoid drinking fluids 1 hr before bedtime A nurse is providing discharge teaching to a client who is postpartum and plans to breastfeed. Which of the following should the nurse recommend the client increase in their diet during lactation? - - correct ans- - calcium A nurse is planning to perform wound irrigation for a client who has an open secondary wound. When creating a sterile field, which of the following actions should the nurse take?

• • correct ans- - Hold the bottle of sterile solution with the palm over the label while pouring A nurse is assessing a client who is postoperative following abdominal surgery. The client states, "I feel like my incision ripped open." The nurse notes dehiscence of the incision. Which of the following actions should the nurse take? - - correct ans- - place the client in low fowler's A nurse is caring for a client who has a newly implanted sealed internal radiation device to treat cervical cancer. Which of the following is an appropriate action for the nurse to take? -
• correct ans- - Wear a lead apron