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A nurse is caring for a client who is 2 days postoperative following an above-the- knee amputation. The client states he is experiencing a dull, burning pain in the leg that was amputated. Which of the following actions should the nurse take to treat the client's neuropathic pain? Administer a beta-blocking medication to the client. (The nurse should administer a beta-blocking medication to the client. This classification of medication has been shown to relieve the phantom limb pain manifestations of constant dull and burning type pain.) A newly licensed nurse asks a charge nurse where to find information about scope of practice for registered nurses. Which of the following responses should the charge nurse make? "The state board of nursing can provide this information" (each state develops a nurse practice act, which defines scope of practice for nurses in that state. This practice act is available on the board of nursing website for each state.) A nurse is planning care to prevent a catheter-related bloodstream infection for a client who is receiving IV fluid therapy. Which of the following interventions should the nurse include in the plan? Perform hand hygiene before touching the IV tubing. (The nurse should perform thorough hand hygiene before touching any part of the infusion system or the client to reduce the risk of catheter-related blood stream infections.) A nurse is creating a plan of care for a client who is non-ambulatory and has bladder and bowel incontinence. Which of the following interventions should the nurse include to prevent skin breakdown? Offer the client a glass of water every two hour when repositioning. (The nurse should offer the client a glass of water every two hours on the clients repositioning schedule. This helps prevent dehydration, which increases the risk of skin breakdown.)
A nurse is teaching a young adult female client about health screening for breast cancer. Which of the following statements by the client indicates an understanding of breast self-examination (BSE)? "I should expect to feel a firm ridge along the bottom curve of each breast." (The nurse should instruct the client at a firm ridge is expected along the bottom curve of each breast. The client should be able to feel this area during the BSE. Performing a BSE promotes breast self awareness so that the client knows how her breast normally feel. The awareness increases the clients ability to identify changes that require further evaluation.) A nurse is caring for an adolescent who is in critical condition following a motor vehicle crash which he was the passenger. The clients parent shout at the nurse, asking why her son is dying instead of the driver. Which of the following actions should the nurse take to provide emotional support to the parent? Inform the parent that anger is a natural response when dealing with loss. (The nurse should identify that the parent is in the anger stage of grief. The nurse should assist the parent to understand that anger is a natural response to loss and encourage her to talk about her feelings.) A nurse is teaching an older adult client about accessing electronic resources for healthcare information on the internet. Which of the following statements should the nurse include in the teaching? "Websites ending in '.gov' are reliable sites for obtaining health information from government agencies." (The nurse should teach the client how to select reliable internet websites when researching health care information. The nurse should identify that websites ending in '.gov' and '.edu' are considered reliable and credible sources for health information. Websites ending in '.com' should not be used for researching credible healthcare information.) A nurse enters a clients room and finds the client lying on the floor. The client states that on the way to the bathroom her "knee locked," causing her to fall. Which of the following actions should the nurse take first? Check the client for injuries.
- Assist the client to an upright position.
- Aspirate 5 mL of gastric contents.
- Test the pH of gastric aspirate.
- Measure gastric residual volume.
- Flush the NG tube with 30 mL of water. (First, the nurse should assist the client into high Fowler's position or raise the HOB at least 30 degrees to help prevent aspiration. Then, the nurse should verify the tubes placement by aspirating 5 mL of gastric contents and then testing the pH. Then, the nurse should check for gastric residual volume. Excessive GRV is an indication of delayed gastric emptying, which places the client at risk of aspiration if additional formula is given. Finally, the nurse should flush the tubing with 30 mL of water to ensure the tube is clear and patent.) A nurse is caring for a 47-year-old female client who had urinary incontinence. Which of the following actions should the nurse take first? Obtain a specimen from the client for culture. (The first action the nurse should take when using the nursing process is assessment. The nurse should obtain a urine specimen from the client to rule out a UTI. If it is a determined the client has RBC's and WBC's in the urine, the specimen will require a culture. If it is determined that the client has a UTI, this will require treatment before any further assessment of incontinence would be indicated.) A nurse is talking with a client who has a major depressive disorder. The client states, "Nobody cares if I'm around or not." Which of the following responses should the nurse make? "It sounds as though you're feeling hopeless." (This statement by the nurse is an example of restraining, which is a therapeutic response. This technique restates the main idea the client has expressed and allows the client to clarify any misunderstanding.) A charge nurse is teaching a group of newly licensed nurses how to prevent errors during administration of blood transfusions. Which of the following actions should the nurse include? Use a new blood administration tubing set for each blood bag infused.
(The nurse should use a new blood infusion tubing set for each component of blood. A blood infusion set should not be reused, even for the same client.) A nurse is caring for a client who has C. diff infection and is incontinent of stool following a long-term antibiotic therapy. Which of the following actions should the nurse take? Wear a gown when providing care for the client. (The nurse should wear a gown when providing care for a client who has C. diff infection and is incontinent of stool. Applying a clean, water-resistant gown prior to entering the clients room prevents the nurses clothing from becoming contaminated while caring for the client. The nurse should remove the gown prior to exiting the clients room.) A nurse is providing discharge teaching about nutrition management to a client who has COPD. Which of the following instructions should the nurse include in the teaching? Have a high-calorie protein drink between meals. (The nurse should encourage a client who has COPD to drink a high-calorie protein drink between meals. Anorexia is a manifestation of COPD and this added nutritional intake promotes weight gain.) A nurse is caring for a client who has dysphagia following a stroke. Which of the following actions should the nurse take to facilitate safe swallowing and decrease the risk of aspiration? Delay the clients meal-time if he is fatigued. (To facilitate safe swallowing and decrease the risk of aspiration, the nurse should encourage the client to test prior to meal-time. If the client is fatigued, the nurse should delay the meal-time and give the client time to rest.) 120 mg x 0.8 mL/80 mg= 1.2 mL
A nurse is preparing to leave the room who is on isolation precautions. Which of the following actions should the nurse take when removing a tied surgical mask? Remove the mask by securely holding the ties and moving it away from the face. (The nurse should untie the bottom strings and then the top strings. Finally, while still holding the strings, the nurse should remove the mask from her face. This action prevents the nurse from touching the front of the mask, which is contaminated.) A nurse is searching electronic databases for clinical research about behavioral indicators. Which of the following online sources should the nurse select to research this infant care issue? Cumulative Index to Nursing and Allied Health Literature (CINAHL) (The nurse should select the Cumulative Index to Nursing and Allied Health Literature (CINAHL) to locate clinical research about health-related client care issues. CINAHL is a cumulative index that the nurse can search electronically to locate reliable data related to the specific topic being researched.) A nurse is preparing to administer three medications to a client who has an NG tube: a levothyroxine tablet, an ibuprofen gel cap, and a delayed-release omeprazole capsule. Which of the following actions should the nurse take? Crush the levothyroxine tablet into a powder and dissolve it into 30 mL of warm sterile water. (The nurse should prepare simple tablets for NG administration by crushing them into a fine powder and dissolving them in at least 30 mL of warm sterile water. Cold water can cause discomfort. Sterile water eliminates the possible problem of chemicals in tap water interacting with the medication.) A nurse is planning care who has an indwelling urinary catheter. Which of the following interventions include in the plan to prevent the development of a catheter-associated urinary tract infection (CAUTI)? Secure the catheter tubing to the client's leg. (The nurse should assess the client's need for urinary catheterization and should follow evidence-based practice to prevent or reduce the risk of CAUTI development. This
includes securing the catheter tubing to the client's leg so that the catheter does not move, reducing the risk of urethral trauma and introduction of bacteria into the urinary system.) A nurse is caring for a 2-year-old toddler who is immediately postoperative. Which of the following pain scales should the nurse use to access the toddler's pain level? FLACC scale (The nurse should use the FLACC scale to assess pain for a 2-year-old child. The FLACC scale assesses facial expression, leg movement, activity, cry, and consolability in children 2 months to 7 years of age. The nurse assigns a score of 0 to 2 for each area.) A nurse is caring for a client who has cancer and is planning discharge to home with hospice care. Which of the following statements by the client indicates that he is experiencing spiritual distress? "I wish God had not allowed this cancer to invade my body." (The nurse should identify that this statement indicates the client is experiencing spiritual distress, which occurs when there is a disturbance in a client's belief system. This client is expressing spiritual anger and not accepting his condition.) A nurse is planning care for a client who has breast cancer and is scheduled for chemotherapy. The client reports experiencing chemotherapy-induced nausea and vomiting (CINV) during her previous round of treatment. Which of the following interventions should the nurse include in the client's plan of care? Administer ondansetron to the client prior to chemotherapy administration. (The nurse should incorporate evidence-based practice interventions into the client's plan of care to prevent and treat CINV. Evidence-based research indicates that prevention of CINV is best achieved when antiemetics, such as ondansetron, are given prior to the administration of chemotherapy.) A nurse in a long-term care facility is admitting a new client following a brief stay in acute care. In adherence with the Joint Commission National Patient Safety
"Have your child rest with his head elevated after meals." (The nurse should instruct the parent to have the child rest with his head elevated after meals. This will allow for easier digestion and help to decrease the nausea associated with eating.) A nurse is preparing to document care in a client's medical record. In adherence with the Joint Commission National Patient Safety Goals regarding communication errors, which of the following entries should the nurse make? "Client medicated with morphine 5 mg IM for pain." (The nurse is using approved abbreviations and providing accurate and detailed information, which should reduce communication errors according to the Joint Commission National Patient Safety Goals.) A nurse on a medical-surgical unit is caring for a group of clients. Which of the following clients should the nurse monitor for the development of reflex urinary incontinence? A client who has a T12 spinal cord injury. (The nurse should identify that a client who has a C1 to S2 spinal cord injury is at risk of developing reflex urinary incontinence. With this type of incontinence, the client is unaware that the bladder is full and therefore lacks the urge to void, resulting in the involuntary loss of urine. The nurse should monitor for this form of incontinence and implement interventions such as intermittent catheterization.) A nurse is reviewing a client's new prescriptions that were just documented in the client's medical record by the provider. Which of the following abbreviations should the nurse clarify with the provider? Enoxaparin 40 mg SQ QD (The nurse should clarify this prescription with the provider. The abbreviations "SQ" and "QD" are considered error-prone and should not be used in documentation. The nurse should clarify that the provider intends the prescription to be administered subcutaneously once daily. "Subcutaneous" or "subcut" should be used instead of "SQ" and "daily" should be used instead of "QD.")
A community health nurse is participating in a task force initiative to reduce the incidence of disease from injection drug use among the city's homeless population. Which of the following plans should the nurse recommend as part of tertiary prevention? Start a needle-exchange program. (Initiating a program for needle exchange and treating clients who are homeless for any diseases they may have already acquired are examples of tertiary prevention.) A nurse is performing a focused assessment on a client who has chronic pain due to fibromyalgia. Which of the following questions should the nurse ask to access the quality of the client's pain? "Can you describe what your pain feels like?" (The nurse should ask the client to describe her pain when assessing pain quality. The quality of a client's pain can be expressed using adjectives such as "piercing," "stabbing," and "aching.") A nurse is planning to use an interpreter to assist her when interviewing a client who does not speak the same language as the nurse. Which of the following actions should the nurse plan to take? Ensure the client and the interpreter are compatible. (The nurse should ensure that the client is comfortable with the interpreter. The nurse should consider the client's age, gender, and culture when using an interpreter.) A community health nurse is planning interventions to promote Healthy People 2020 initiatives in the community. Which of the following actions should the nurse plan to take first? Determine the level of health equity groups among groups in the community. (Health equity among all groups in the community is a Healthy People 2020 initiative. Using the nursing process, the first action the nurse should take is to assess the needs of the community. By identifying disparities in community health, the nurse can develop interventions targeted at the community's specific needs.)
select in the artwork below. Select only the hot spot that corresponds to your answer.) ~A is incorrect. The outer posterior aspect of the upper arms is a site commonly used for subcutaneous injections. However, it is not recommended for administration of low molecular weight heparins such as enoxaparin. The nurse should select another subcutaneous injection site to promote absorption of the enoxaparin. ~B is correct. The nurse should administer low molecular weight heparins, such as enoxaparin, into the anterolateral aspect of the client's abdomen to promote absorption of the medication. Other recommended subcutaneous sites for this medication include the posterolateral aspect of the client's abdomen, the buttocks, and the upper thighs. ~C is incorrect. The abdomen is a site commonly used for subcutaneous injections. However, it is not recommended to administer medications within 5 cm (2 in) of the umbilicus. The nurse should select another site to administer the enoxaparin. A nurse is providing teaching about nutrition management to the parent of an 18- month-old toddler who has phenylketonuria. Which of the following foods should the nurse recommend? Baked potato (The nurse should recommend low-protein foods to the parent of a toddler who has phenylketonuria. The nurse should also recommend the parent offer the toddler fruits, juices, and cereals with limited phenylalanine.) A nurse on a medical-surgical unit is caring for a group of clients. The nurse should identify that which of the following types of pain are classified as neuropathic? (Select all that apply.) ~Spinal nerve pain is correct. Neuropathic pain occurs when there is damage to or impaired function of nerves due to an injury or illness. Spinal nerve pain is a type of neuropathic pain. ~Postherpetic neuralgia pain is correct. Neuropathic pain occurs when there is damage to or impaired function of nerves due to an injury or illness. Postherpetic neuralgia pain is a type of neuropathic pain. ~Phantom limb pain is correct. Neuropathic pain occurs when there is damage to or impaired function of nerves due to an injury or illness. Phantom limb pain is a type of neuropathic pain.
~Fractured hip pain is incorrect. Nociceptive pain occurs when the client's nerves are intact and functioning properly. Damage to surrounding tissue, such as with a fractured hip, causes the client to experience this type of pain. ~Osteoarthritic pain is incorrect. Nociceptive pain occurs when the client's nerves are intact and functioning properly. Chronic damage to joints and surrounding tissue, such as with osteoarthritis, causes the client to experience this type of pain. A nurse is assessing for acute pain in a client who is postoperative. The client has dementia and is nonverbal. Which of the following findings should the nurse identify as a need for administration of a PRN pain medication? Rapid breathing (The nurse should identify shallow, rapid breathing as a nonverbal indicator of acute pain. This change in breathing is a sympathetic nervous system response to acute pain. The nurse should further assess the client's respiratory status and administer a PRN pain medication. Other nonverbal indicators of pain include muscle tension, restlessness, and moaning.) 1,000 mL/8 hr = 125 mL/hr A nurse is teaching a client about strategies to prevent recurrent constipation. Which of the following instructions should the nurse include? (Select all that apply.) ~"Perform moderate exercises daily" is correct. Physical activity helps increase peristalsis, which helps prevent constipation. ~"Add more whole grains to your diet" is correct. Whole grains, fresh fruits and vegetables, and legumes promote regular defecation by adding fiber to the diet, which helps prevent constipation. ~"Increase your fluid intake" is correct. Consuming at least 1,500 mL of water and fruit juice each day helps soften stool and prevent constipation.
A nurse in a community health clinic is screening a 10-year-old girl for scoliosis. Which of the following instructions should the nurse give the child for this examination? "Bend forward at the waist and let your arms hang down." (During a scoliosis screening, the nurse should have the child bend forward at the waist, keeping her back parallel with the floor and having her arms dangle freely. In this position, the nurse can observe asymmetry of the ribs and flanks.) A nurse in a mental health facility is preparing an educational program for a group of staff nurses about the proper use of restraints. Which of the following information should the nurse plan to include? An adult client may be in a mechanical restraint for up to 4 hours. (The nurse should specify that a client who is 18 years or older may be in a restraint for no more than 4 hours. Children who are 9 to 17 years old are limited to 2 hours and children who are younger than 9 years old are limited to 1 hour.) A nurse is providing dietary teaching to a client who has diarrhea. Whihc of the following instructions should the nurse include? "Increase your intake of potassium-rich foods while you are experiencing diarrhea." (The nurse should instruct the client to increase his intake of foods containing potassium, such as tomatoes and potatoes, while he is experiencing diarrhea. The increased intake of potassium helps reduce the risk of electrolyte imbalance due to fluid loss.) A nurse is planning to implement bladder retraining for a client who has urge urinary incontinence. Which of the following actions should the nurse plan to take? Gradually lengthen the time between the client's scheduled voids. (The nurse should gradually lengthen the time between scheduled voids when implementing bladder retraining. The client is encouraged and taught to suppress the urge to void between scheduled voids through the use of pelvic exercises, distraction, and abdominal breathing. When the client is successfully able to suppress the urge, the
time between voids is slightly increased. This process of scheduled voiding promotes retraining of the bladder and decreases urge incontinence.) A nurse is assessing a client who has fibromyalgia. Which of the following treatment modality prescriptions should the nurse expect for the client's mixed pain? Pregabalin PO twice daily. (The nurse should expect a prescription for an antidepressant medication such as pregabalin. The mixed pain experienced by a client who has fibromyalgia has components of both nociceptive and neuropathic pain, which responds best to adjunctive treatment modalities such as antidepressants. These medications work to increase the release of serotonin and norepinephrine neurotransmitters in the brain.) A nurse is counseling a client who has a family history of colorectal cancer about management of nutrition to help prevent gastrointestinal cancers. Which of the following images indicates a food or beverage the nurse should encourage the client to include liberally in his diet? To help reduce the risk of cancers of the GI system, the nurse should instruct the client to consume at least 2.5 cups of fruits and vegetables per day. A hospice nurse is planning care for a client who has terminal cancer. The client tells the nurse that she practices Hindu religion. Which of the following interventions should the nurse include in the plan of care to support the client's religious beliefs? Allow time for a family member to perform a ritual bath after the client dies. (The nurse should recognize a client who practices the Jewish, Muslim, or Hindu religions might want a ritual bath after death. This ritual bath can be performed by a family member or by certain members of the client's faith.) A nurse in an emergency room is caring for an infant who requires emergency surgery. The infant is accompanied by his 16-year-old mother and his maternal grandfather. Which of the following actions should the nurse take when assisting with informed consent?
A nurse is talking with a client who reports difficulty adjusting to the death of her partner. Which of the following responses by the nurse demonstrates the therapeutic communication technique of reflecting? "What do you think would help you cope with your loss?" (The nurse uses the technique of reflecting when asking this question. Reflecting encourages the client to explore her personal thoughts about a situation so that a plan can be developed to meet the clients individual needs.) A community health nurse is developing a brochure about the use of smokeless tobacco. Which of the following information should the nurse plan to include? Smokeless tobacco provides a higher dose of nicotine than cigarettes. (Smokeless tobacco is placed in the mouth, where nicotine is then absorbed sublingually. A higher dose of nicotine is delivered with the use of smokeless tobacco compared to smoking cigarettes, because heat destroys nicotine.) A nurse is preparing to administer an immunization via IM injection into an adults clients deltoid muscle. Which of the following actions should the nurse take? Select a 1-inch needle for the injection. (The nurse should select a 1-inch needle for an IM injection into the deltoid muscle. Depending on the clients weight, the nurse might need to use a 1 1/2 inch needle to ensure injection of the vaccine into the muscle.) A charge nurse is observing a newly licensed nurse prepare medication for a client. Which of the following actions by the newly licensed nurse adheres to safe medication administration practices? The nurse compares the medication label with the clients medication administration record. (When preparing medications for administration, safe practice includes comparing the medication label with the clients medication administration record a minimum of three times; prior to removing the medication from the drawer, when removing medication from the drawer, and at the clients bedside prior to administering the medication.)
A nurse is preparing to administer a medication via IV bolus to a client who is receiving a continuous infusion via an infusion pump. The client's IV fluid solution is incompatible with the bolus. Which of the following actions should the nurse plan to take first? Stop the continuous IV infusion. (According to evidence-based practice, the nurse should first stop the continuous IV infusion. This action prevents the solution from flowing through the tubing while the nurse administers the mediation. An infusion will alarm if the tubing is clamped before the pump is stopped.) A nurse is providing teaching to the patient of a 6-year-old girl about preventing urinary tract infections. Which of the following statements by the parent indicates an understanding of the teaching? "I will increase her intake of foods high in fiber." (Constipation increases the risk of development of a UTI. Therefore, the nurse should instruct the parent to increase the child's daily intake of fiber to prevent constipation. Other interventions include increasing physical activity and using a stool softener as needed.) A nurse is developing a plan of care for an older adult client who is experiencing functional incontinence following hip arthroplasty. Which of the following interventions should the nurse include? Place grab bars by the toilet. (The nurse should place grab bars by the toilet and install a raised toilet seat. These aid the client in reaching and sitting on the toilet, decreasing the chance of incontinence.) A nurse is planning the menu for a client who practices Seventh-Day Adventism. Which of the following food selections should the nurse make? Scrambled eggs (The nurse should select scrambled eggs in the clients dietary meal plan for a client who practices Seventh-Day Adventism. Most clients who practice Seventh-Day
