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- A nurse is collecting data from a client who is in severe pain. Which of the following questions should the nurse ask first? A. How have you managed pain in the past? B. Does anything make your pain worse? C. Where is your pain located D. Is the pain preventing you from performing any activities?
- A nurse is reinforcing discharge teaching about car seat safety with the guardian of a newborn. Which of the following statements indicates an understanding of the teaching? A. I will secure the care seat in the car by using the seatbelt. B. While traveling, I should use a blanket under- neath my baby for padding. C. When my baby is able to hold their head up- right, I can turn the seat forward- facing. D. I can place the car seat in the front passenger seat as long as there is a working airbag. 3. A nurse is reinforcing teaching with a client who
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2 / 121 Where is your pain located? When using the urgent vs. Non-urgent approach to collect data from a client who is hav- ing acute and severe pain, the nurse should first ask the client about location, severity, and qual- ity to identify appropriate nurs- ing interventions for pain relief. The nurse should collect more detailed data about the client's pain experiences after adminis- tering pain med, when the clients pain level is tolerable. I will secure the car seat by using the seatbelt. The nurse should instruct the guardian to secure the car seat by using the seatbelt. Feed the newborn at least every 3 is bottle feeding their full-term newborn with for- to 4 hours.
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4 / 121 day. D. If I forget to take a dose, I can take it later on the same day. it later on the same day.
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- A nurse in a long-term care facility is reviewing information about health care associated infec- tions with a newly licensed nurse. Which of the following information should the nurse include? A. Older adults are resistant to pathogens that cause infection. B. Use alcohol-based antiseptic hand cleansers after caring for a client with Clostridium difficile. C. Prolonged use of corticosteroid is a risk factor for infection. D. Blood pressure cuffs can be a source of en- dogenous infections.
- A nurse is collecting data from a client who has type 2 diabetes mellitus and is concerned about weight gain during pregnancy. Which of the fol- lowing responses should the nurse make? A. Your weight gain should be the same as for someone without diabetes. B. Weight gain should be 2 pounds during the first trimester and 2 pounds per week thereafter. C. Weight reduction during pregnancy is often necessary for clients who have diabetes. D. Your weight gain should average between 10 and 15 pounds. 8. A nurse is caring for a client who is 1 day post- operative and is unable to ambulate. Which of the following actions should the nurse take to
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7 / 121 promote the client's venous return? A. Encourage the client to cough and deep breath B. Maintain a sequential compression device. C. Elevate the head of the bed. D. Massage the client's legs.
- A nurse is caring for a female client who has an indwelling urinary catheter. Which of the follow- ing actions should the nurse take? A. Cleanse the catheter at the insertion site with an alcohol wipe daily. B. Gently irrigate the catheter and bladder once per shift. Sequential compression devices promote venous return by provid- ing intermittent periods of com- pression of the leg. Massaging the clients legs is con- traindicated due to risk of dis- lodging a thrombus. Wipe the drainage port with an antiseptic after emptying urine from the bag. To prevent the spread of infec- tion when emptying the drainage bag, the nurse should cleanse the clients drainage port with an anti- C.Wipe the drainage port with an antiseptic after septic wipe to remove any residual emptying urine from the bag. urine prior to securing the spout D. Ensure the urinary catheter bag is maintained back in place. at the level of insertion.
- A nurse at a long-term care facility is caring for a Yankauer catheter. client who requires oral suctioning. Which of the
following supplies should the nurse plan to use for the task? A. Water-soluble lubricant
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B.Y
a n k a u e r c a t h e t e r C.C hl o r h e xi di n e g l u c o n a t e D.A rt ificial oral airway A yankauer catheter is a clean suction catheter used when per- forming oral and oropharyngeal suctioning to remove secretions from the clients mouth to facilitate breathing or obtain a sample of diagnostic evaluation.
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10 / 121 measure against the job descrip- tion. To provide objective information, the statt nurse should compare the behavior of each AP to the facility job description. The nurse can provide specific information about how each AP either meets the standard or demonstrated a need for improvement. Check the client's temperature.
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11 / 121 B. Notify the client's provider. C. Instruct the AP to cover the client with a blan- ket. D. Review the procedure with the AP.
- A nurse on an acute care unit is collecting data from a school-age child who has cystic fibrosis (CF). Which of the following findings is the prior- ity for the nurse to report to the provider? A. Reports lack of appetite. B. Frothy stools with a foul odor. Reports lack of appetite. The nurse should identify that the greatest risk to a child who has a decreased appetite is pulmonary infection. Anorexia, along w/ oth- er manifestations, such as weight C. Height at the 55th percentile for age and gen- loss and lethargy, are commonly der. D. Report of gastroesophageal reflux.
- A nurse in a long-term care facility is observ- ing a newly licensed nurse who is providing tra- cheostomy care for a client. The nurse identifies proper performance of the procedure when the seen in children who have CF with an infection exacerbation. Typical manifestations of pulmonary in- fection, such as fever and tachyp- nea, might not be seen in a child who has CF. Additionally, a child who's anorexic is at increased risk for diminished lung function. Hydrogen peroxide. The nurse should identify that sterile hydrogen peroxide solu- newly (^) licensed nurse selects which of the follow- tion is used to loosen secretions ing solutions to clean the inner cannula?
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13 / 121 C. Povidone-iodine 1% D. Hydrogen peroxide
- A nurse is reinforcing discharge teaching with a client who is postoperative following an open Perform Kegel exercises daily. radical (^) prostatectomy. Which of the following in- The nurse should instruct the structions (^) should the nurse include in the teach- client to perform Kegel exercises ing? A. Drink up to 15,000 mL of fluid daily. B. Contact your provider if you experience urine dribbling. C. Perform Kegel exercises daily. D. Take ibuprofen as needed for pain.
- A nurse is reinforcing teaching with a group of clients about the Heimlich maneauver dur- ing a first-aid class. The nurse should include in the teaching that which of the following man- ifestations indicates the need for the Heimlich maneauver to be performed? Select all that ap- ply. A. Difficulty breathing B. Coughing c. Erythema D. Presence of stridor E. Thready pulse
- A nurse is reinforcing discharge teaching with a client who has undergone vein ligation and stripping to treat varicose veins. Which of the following instructions should the nurse include in the teaching?
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14 / 121 to promote the control of urine flow and reduce incontinence. Avoid NSAIDS, ie ibuprofen due to the increased risk of bleeding. Client should increase fluid to 3,000 mL per day to keep the urine clear. Diflculty breathing. Coughing. Presence of stridor. Walk for 1 to 2 hours each day. The nurse should instruct the client to walk for at least 1 to
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16 / 121 should the nurse include in the discharge teaching? A. Demonstrate assertiveness interaction with the client because it demonstrates to the client that the nurse is listening and is inter- ested in what the client is sharing. Demonstrate assertiveness. Clients who have dependent personality disorder demonstrate fear of separation and abandon-
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17 / 121 B. Refrain from engaging in power struggles. C. Permit expression of rituals. D. Avoid crowded environments.
- A nurse is positioning a client who is scheduled for a lumbar puncture. The nurse should assist with the client into which of the following posi- tions? A. Semi-Fowler's B. Lateral recumbent C. Reverse Trendelenburg D. Prone
- A nurse is collecting data from a client who has myasthenia gravis (MG). Which of the following ment. Therefore reinforcing as- sertive behaviors will allow the client to become more indepen- dent. Lateral recumbent. The nurse should assist the client into the lateral recumbent posi- tion for a lumbar puncture to en- sure the proper placement of the needle. Ptosis. There is abnormal droop- ing of the upper eyelid. Ptosis, images should the nurse identify as an indication along with diplopia (double vi- that the client is experiencing ptosis? Pictures
- A nurse is observing an assistive personnel (AP) caring for a client. For which of the following actions by the AP should the nurse intervene? sion), are early signs of MG. D. Hodeolum (external stye) in- correct The AP reports client information to the oncoming AP in the hall- way. A. The AP documents care in the client's electron- The nurse should intervene when
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19 / 121 D. The AP reports client information to the on- coming AP in the hallway.
- A nurse is reinforcing teaching with a client regarding prescribed asthma medications. The nurse should instruct the client to use which of the following medications for treatment of an acute asthma attack? A. Zafirlukast B. Montelukast C. Albuterol D. Cromolyn
- A nurse is reinforcing teaching with a client who has dumping syndrome about measures to re- duce manifestations. Which of the following in- Albuterol. The nurse should instruct the client to use albuterol, a bron- chodilator, the relieve the bron- chospasms of an acute asthma at- tack. Zafirlukast, Montelukast, and Cro- molyn is used for prevention, rather than treatment, of an acute asthma attack. Avoid food with high sugar con- tent. structions (^) should the nurse include in the teach- The nurse should instruct the ing? A. Increase fluid intake with meals. B. Avoid food with high sugar content. C. Sit upright for 30 min after each meal. D. Take a mild laxative each day. client to avoid sweet foods, which often increases the manifesta- tion of dumping syndrome. These manifestations include nausea, sweating, abdominal pain, diar- rhea, and weakness. Minimize fluid intake; speeds pas- sage of food out of
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20 / 121 stomach. The nurse should instruct the pt to lie flat for 30 min after each meal to delay passage of food out of stomach.
