Comprehensive Predictor ATI 1st take_Q & A,100% CORRECT

Comprehensive Predictor ATI 1st take_Q & A 1. A nurse is caring for a child with sickle cell anemia and is having a vaso-occlusive crisis. Which intervention should the nurse implement first? D) Increase oral flui ...

Comprehensive Predictor ATI 1st take_Q & A 1. A nurse is caring for a child with sickle cell anemia and is having a vaso-occlusive crisis. Which intervention should the nurse implement first? D) Increase oral fluid 2. A nurse is caring for a 1-day-old newborns who has jaundice and is receiving phototherapy. Which of the following actions should the nurse take? Ensure that the newborn wears a diaper. 3. A nurse is preparing a client for a paracentesis. What action should the nurse take? Instruct the client to void prior to the procedure. 4. A nurse is providing dietary teaching to a client who has end-stage of kidney disease and a potassium level of 6. Which of the following is the best food the nurse to recommend? 1. Hard boiled eggs. 5. A director of nursing in a rehab facility is planning for measure of quality care provided. Which of the following should the nurse director plan to use after the client is discharged to gather information about quality of care? a. Outcome audit 6. A nurse is caring for a client who repeatedly refuses meals, a nurse overhears an AP telling the client “If you don’t eat, I’ll put restraint on you” … The nurse should intervene. a. Assault 7. A nurse is caring for a client who reports insomnia. Which of the following is a priority for the nurse to report to the provider? a. Wake up to urinate during the night. 8. A nurse is planning care for a client who has an L4 spinal cord injury. Which of the following interventions to prevent skin breakdown should the nurse include in the plan of care? a. Massage reddened area over bony prominences 9. charge nurse is teaching a group of newly licensed nurses about the correct use of restraints. Which of the following should the nurse include in the teaching? 1. Applying elbow immobilizers of an infant receiving cleft lip injury 10. A nurse preparing to initiate IV fluid via infusion pump to a client. Which of the following action should the nurse take? a. Check the expiration date? 11. A nurse is proving discharge instruction about newborn to client who is 2 days postpartum. Which of the following should be include? a. Use car seat when travelling by airplane 12. A nurse as identified task to delegate to a group of an AP. a. Evaluate to perform each task b. Communicate appropriate task to AP 13. Adverse effect of furosemide? a. Hearing loss 14. New diagnose of type 2 diabetes. Client readiness to learn: a. I like to wait when my partner is here so we can both learn together. 15. Diazepam overdose medication for reversal? a. Flumazenil 16. The nurse is planning a community health program about Parkinson’s disease. Which of the following intervention the nurse indicates as a tertiarily prevention strategy? a. Ambulation for client with Parkinson’s disease 17. A nurse is teaching a newly license nurse about incident report. Which of the following statement indicate understanding? a. They assist with quality improvement. 18. Peak expiratory flow meter teaching: Blow air as hard and quickly as possible. 19. A nurse is caring for an infant who has RSV. a. Suction prior to feeding. 20. A nurse is preparing to teach the parent of a child who has cystic fibrosis. Which of the following teaching should the nurse plan to include? a. Provide a diet high in protein and calories. 21. Taking Cyclosporine following a kidney transplant. Which Lab to report? a. Creatinine of 1.6 22. Auditory Hallucination teaching? a. Encourage the client listen to music. 23. A nurse is preforming a gastric lavage for a client who has upper gastrointestinal bleeding. Which of the following action should the nurse take? B. Insert a large-bore NG tube. 24. A nurse is planning care for a group of clients, which of the following measure should the nurse to manage time effectively? a. Gather supplies prior to completing a dressing change. 25. A nurse is teaching a group of newly licensed nurses about client advocacy. Which of the following statements by a newly licensed nurse indicates an understanding of the teaching? a. “I will intervene if there is conflict between a client and his provider” 26. A nurse is assessing a client who is pregnant and has new diagnosis of hyperemesis gravidarum. Which of the following finding should the nurse expect? a. Urine output of 20 mL/Hr. 27. Apply physical restraint: a. to maintain the patency of an IV line 28. A nurse is assessing a client who has anorexia nervosa. Which of the following finding indicates effectiveness of the treatment plan? a. The client has clinical manifestation of dehydration 29. A nurse is assessing and older adult for social isolation. The nurse should identify that which of the following statement by the client indicates a risk for social isolation? a. My hearing aids have lost so I don’t attend Bingo like I used to. 30. A nurse is teaching a client who is pregnant and has a new prescription for Iron supplement. Which of the following statement should the nurse include? a. You might become constipated while taking this medication. 31. Abdominal Assessment orders: a. Inspection; Auscultation; Percussion; Palpation. 32. First indication of Peritonitis? a. Abdominal pain 33. A nurse in an emergency department is caring for a 3-year-old child who has suspected epiglottitis. Which of the following action should the nurse take? a. Prepare client for intubation 34. A nurse is caring for a client who is 4 hours postpartum, client report urges to void but unable to void. Which of the following action should the nurse take? a. Massage the fundus 35. Screening an adolescent for idiopathic scoliosis, which of the following assessment should the nurse perform part of the screening? a. Measure the trunk location 36. Postpartum hemorrhage teaching? a. Inversion of the uterus. 37. 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. Attempts to understand both sides of the situation. 38. Kosher diet tradition food choice? a. Scramble eggs and toast with milk. 39. A nurse is caring for client who is 11 weeks’ gestation, which of the following immunization should the nurse recommends? a. Inactivated Influenza vaccine b. Tetanus diphtheria and acellular pertussis vaccine. 40. A home health nurse is preparing to make an initial visit to a family home from a local provider. Identify the sequence of the step the nurse should take when conducting a home visit. A. 3) Identify family needs interventions using the nursing process. B. 4) Record information about the home visit according to agency policy. C. 2) Contact the family to determine availability and readiness to make an appointment D. 5) Discuss plans for future visits with the family. E. 1) Clarify the reason for the referral with the provider’s office. E C A B D 41. A nurse is caring for a client who has preeclampsia and is receiving magnesium sulfate. The nurse should identify that which of the following finding as sign of magnesium toxicity. a. Hyperventilation 42. Newborn that has been circumcised. Which of the following instruction should the nurse include in the teaching? a. Apply petroleum jelly at each diaper changes 43. Discharge teaching for client with type 1 diabetes about preventing diabetic-keto- acidosis: a. I should check my blood sugar twice a day 44. The nurse is caring for a client who is obese, the client is crying “everyone is staring at me because my weight”, which of the following is the proper response should the nurse make? a. Do you feel uncomfortable around others? 45. A nurse is teaching about preventative measures to a female client who has chronic urinary tract infections. Which of the following interventions should the nurse include in the teaching? a. Void every 4 hours. 46. A nurse is teaching a client who has heart failure about engaging in exercise program. Which of the following statement by the client indicates an understanding of teaching? a. Make sure you can still talk while exercising 47. Leave against medical advice: a. Ask the client to sign a form. 48. A nurse is assessing a client who has opioid use disorder. Which of the following should the nurse expect for opioid withdrawal? a. Tachycardia 49. Client with COPD? a. Give the client autonomy and scheduling activity 50. Anti-embolic stocking: a. Make sure the client stockings are biding. 51. Pressure ulcer where Coccyx fat is visible is: a. Stage 3 52. Oxycodone? a. Avoid grapefruit juice 53. A nurse mangaer 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. “Administered 8 u regular insulin sq.” 54. Dressing change in a child? a. Explain in simple term how the procedure is going to affect the child. 55. Phenelzine what can you eat? a. Whole grain bread 56. 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. Apply fetal heart rate monitor 57. Teaching about security computerized? a. Information technology will install a firewall to protect client information. 58. Client advocacy a. …a client gets a second opinion for diagnosis. 59. 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. Food exchange lists for meal planning from the American Diabetes Association 60. 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. (Limit or remove?) IV bag from exposure to light. 61. The nurse is teaching a group of clients at a community health fair about genetic disease. Which of the following statements by a client indicates an understanding of the teaching? C. “My family has genetic risk for breast cancer, so I am considering a total mastectomy” 62. National notifiable disease: a. Lyme disease. 63. Intracranial pressure following a brain injury? 64. Positive Skin TB test for a client: a. 10 65. 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” 66. Postpartum hemorrhage medication: a. Methylergonovine 67. 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? . Place the client’s left arm on a pillow while he is sitting. 68. Child has been sexually abused by family member. a. Use leading statement to obtain information from the child. 69. A nurse realizes that the wrong medication has been administered to a client. Which of the following actions should the nurse take first? a. Monitor vital signs. 70. Client partner recently died; the nurse stays with the client: a. Beneficent b. RN Comprehensive Predictor 2019 Form A 1. A nurse in a pediatric unit is preparing to insert an IV catheter for 7-year-old. Which of the following actions should the nurse take? 1. Tell the child they will feel discomfort during the catheter insertion. 2. A nurse is caring for a client who has arteriovenous fistula Which of the following findings should the nurse report? Absence of a bruit. 3. A nurse is providing discharge teaching for a client who has an implantable cardioverter defibrillator which of the following statements demonstrates understanding of the teaching? 1. “I will wear loose clothing around my ICD” 4. A nurse is caring for a client who is at 14 weeks gestation and reports feelings of ambivalence about being pregnant. Which of the following responses should the nurse make? 1. “Describe your feelings to me about being pregnant” 5. A nurse is planning care for a client who has a prescription for a bowel- training program following a spinal cord injury. Which of the following actions should the nurse include in the plan of care? 1. Administer a rectal suppository 30 minutes prior to scheduled defecation times. 6. A nurse is caring for a client who is in active labor and requests pain management. Which of the following actions should the nurse take? 1. Place the client in a warm shower. 7. 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? 1. Below-the knee amputation 8. a nurse manager is updating protocols for the use of belt restraints. Which of the following guidelines should the nurse include? 1. Document the client’s condition every 15 min 9. A nurse is teaching an in-service about nursing leadership. Which of the following information should the nurse include about an effective leader? 1. Acts as an advocate for the nursing unit. 10. A nurse is reviewing the laboratory findings of a client who has diabetes mellitus and reports that she has been following her (unable to read) care. The nurse should identify which of the following findings indicates a need to revise the client’s plan of care. 1. Hba1c 10 % 11. 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? 1. Chlamydia 12. 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? 1. Use modeling to help the clients improve their interpersonal skills 13. A nurse is planning for a client who practices Orthodox Judaism. The client tells the nurse that (Unable to read) Passover holiday. Which of the following action should the nurse include in the plan of care? 1. Provide unleavened bread. 14. A nurse is caring for a client who has a pulmonary embolism. The nurse should identify the effectiveness of the treatment 1. The client reports feeling less anxious. 15. A nurse in an emergency department is assessing a client who reports ingesting thirty diazepam tablets (Unable to read) a 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. 1. Administer flumazenil to the client. 16. 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? 1. Elevated temperature 17. 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? B. Jitteriness 18. 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? 1. WBC 14,000/mm3 19. 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? 1. “The proxy can make treatment decisions if the client is under anesthesia.” 20. A nurse in the PACU is caring for a client who reports nausea. Which of the following actions should the nurse take first? 1. Turn the client on their side. 21. A nurse is caring for a client who has a history of depression and is experiencing a situational crisis. Which of the following actions should the nurse take first? 1. Confirm the client’s perception of the event 22. A nurse is caring for a client who has bipolar disorder and is experiencing acute mania. The nurse obtained a verbal prescription for restraints. Which of the following should the actions should the nurse take? 1. Document the client’s condition every 15 minutes. 25. A nurse is working on a surgical unit is developing a care plan for a client who has paraplegia. The client has an area of nonblanchable erythema over his ischium. Which of the following interventions should the nurse include in the care plan? 1. Place the client upright on a donut-shaped cushion 25. A nurse is caring for a client who is dilated to 10 cm and pushing. Which of the following pain-management (Unable to read) a safe option for the client? following is an appropriate nursing intervention? 1. Place the bedside table on the right side of the bed. 27. A nurse is assessing a client who has major depressive disorder. Which of the following findings should the nurse identify as the (Unable to read) (Most important?) 1. The client reports giving away personal items. 28. A nurse is providing teaching about immunizations to a client who is pregnant. The nurse should inform the client that she can receive which of the following immunizations during pregnancy? (Select all that apply) 1. Tetanus diphtheria and acellular pertussis vaccine 2. Inactivated influenza vaccine. 29. A nurse is caring for a client who has end-stage kidney disease. The client’s adult child asks the nurse about becoming a living kidney donor for her father. Which of the following condition in the child’s medical history should the nurse identify as a contraindication to the procedure? C. Hypertension 31. 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? 1. “I can give you information about respite care if you are interested.” 31. 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. 32. 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? 1. “You can increase your dietary intake of folic acid by eating cereals and citrus fruits”. 33. 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. (Unable to read) (Picked this one) Medicaid? D. Understanding of infant care. 34. A nurse manager is planning to teach staff about critical pathways. Which of the following information should the nurse include? 1. decrease health care costs. 35. 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. 1. Sore throat. 36. A charge nurse is educating a group of unit nurses about delegating client tasks to assistive personnel D. “An RN evaluates the client needs to determine tasks to delegate” 37. A nurse is assessing a client who is in active labor. Which of the following findings should the nurse report to the provider? 1. FHR baseline 170/min 38. A nurse working in a rehabilitation facility is developing a discharge plan for a client who has left-sided hemiplegia the following actions is the nurse’s priority? 1. Ensure that the client has a referral for physical therapy. 39. 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? 1. A client who has depressive disorder and reports feeling hopeless. 40. A nurse is preparing to measure a temperature of an infant. Which of the following action should the nurse take? 1. Place the tip of the thermometer under the center of the infant’s axilla. 41. 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? 1. Encourage the client to take frequent rest periods 42. A nurse is admitting medications to a group of clients. Which of the following occurrences requires the completion of an incident report? 1. A client receives his antibiotics 2hr late 43. A nurse is caring for a client who is 24 hr. postpartum and is breast feeding her newborns. The client asks the nurse to warm up seaweed soup that the client’s partner brought for her. Which of the following responses should the nurse make? 1. “Does the doctor know you are eating that?” 44. a nurse is preparing an in-service for a group of nurses about malpractice issues in nursing. Which of the following examples should the nurse include in the teaching? 1. Administering potassium via IV bolus 45. a nurse is providing teaching to family members of a client who has dementia. Which of the following instructions should the nurse include in the teaching? 1. Establish a toileting schedule for the client 46. The nurse is reviewing the medical record of a client who is requesting combination oral contraceptives. Which of the following conditions in the client’s history is a contradiction to the use of oral contraceptives? B. Thrombophlebitis. 47. A nurse is admitting a client who has schizophrenia and experiences auditory hallucinations. The client states, “It’s hard not to listen to the voices.” Which of the following questions should the nurse ask the client? 1. “What helps you ignore what you are hearing?” 48. A charge nurse is teaching a group of newly licensed nurses about the correct use of restraints. Which of the following should the nurse include in the teaching? 2. Applying elbow immobilizers of an infant receiving cleft lip injury 49. 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 Respiratory alkalosis 50. A nurse is preparing to mix NPH and regular insulin in the same syringe. Which of the following 1. Inject air into the NPH insulin vial. 51. a Nurse is working with a client who has an anxiety disorder and is in the orientation phase of the therapeutic relationship. Which of the following statements should the nurse make during this phase? 2. “We should establish our roles in the initial session.” 51. 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? 1. Children who have varicella are contagious until vesicles are crusted. 52. A staff nurse is observing a newly licensed nurse suction a client’s tracheostomy. Which of the following requires intervention by the staff nurse? 1. Waits 2 minutes between suctions. 53. 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? 1. Use three pronged grounded plugs. 54. 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? 1. A client who has a T-tube following an open cholecystectomy. 55. 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? 1. “I will place pressure on the corner of my eye after using he eye drops” 56. 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? 1. Swelling of the face 57. 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? 1. “I can give you information about making end of life decisions”. 59. A nurse is caring for a client who is experiencing mild anxiety. Which of the following findings should the nurse expect? 1. Heightened perceptual field 60. 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? 2. Administer the medication. 61. 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? 1. Eat a light snack before bedtime 62. 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 nurse is caring for a client following insertion of a chest tube 12 hr. ago. The (Unable to read) following actions should the nurse take? 1. Report continuous bubbling in the water seal chamber. 64. 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? 1. Urinary retention. 65. 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?” 66. A nurse is providing dietary teaching to a guardian of a preschooler who has a new diagnosis of celiac disease. Which of the following statements by the guardian indicates an understanding of the teaching? 1. “I will put my child on a gluten-free diet”. 67. 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? 1. Prime IV tubing with 0.9% sodium chloride. 68. A nurse is admitting a client who has diabetic ketoacidosis. Which of the following types of continuous infusions should the nurse initiate? 1. 0.9% normal saline. 69. A nurse is teaching who has chronic pain about avoiding constipation from opioid medications. Which of the following should the nurse include in the teaching? 1. Increase exercise activity 70. A nurse is teaching about preventative measures to a female client who has chronic urinary tract infections. Which of the following interventions should the nurse include in the teaching? 1. “Drink 2 liters of warm water per day”. 71. 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? 1. A client who has a hip fracture and a new onset of tachypnea 72. 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? 1. Consume food high in bran fiber 73. A nurse is caring for a 1-day-old newborns who has jaundice and is receiving phototherapy. Which of the following actions should the nurse take? 2. Ensure that the newborn wears a diaper. 74. a nurse is teaching a group of newly licensed nurses about client advocacy. Which of the following statements by a newly licensed nurse indicates an understanding of the teaching? 1. “I will intervene if there is conflict between a client and his provider” 75. A nurse is preparing to reposition a client who had a stroke. Which of the following actions should the nurse take? 1. Evaluate the client’s ability to help with repositioning. 76. 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? B. “It allows preset pressure delivered during spontaneous ventilation.” 77. 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 78. a nurse is auscultating for crackles on a client who has pneumonia. Which of the following anterior chest wall locations should the nurse auscultate? 79. 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? 1. A statement that participants can leave the study at will. 80. A nurse is providing teaching to a client about the adverse effects of sertraline. Which of the following adverse effects should the nurse include? 1. Excessive sweating 81. 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? 1. The client develops hiccups. 82. 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? 1. Food exchange lists for meal planning from the American Diabetes Association 82. 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? 1. “You should push the button before physical activity to allow maximum pain control.” 83. 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? 1. Glargine insulin. 84. A nurse is caring for a toddler who has acute lymphocytic leukemia. In which of the following should the toddler participate? 1. Playing with a large plastic truck. 85. A nurse is caring for a client who is receiving intermittent feedings via a feeding via a feeding pump and is experiencing dumping syndrome. Which of the following actions should the nurse take? 1. (Unable to read) rate of the client’s feedings. 86. 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? 1. Administer oxygen 87. A nurse is caring for a client who has Raynaud’s disease. Which of the following actions should the nurse take? 1. Provide information about stress management. 88. 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? 1. Hyperlipidemia. 89. 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? 1. Magnesium hydroxide 30 ml PO. 90. A nurse overhears two assistive personnel (AP) discussing care for a client while in the elevator. Which of the following actions should the nurse take? 1. Report the incident to the AP’s charge nurse. 91. A nurse is planning care for a client who is receiving hemodialysis. Which of the following actions should the nurse include in the plan of care? 1. Check the vascular access site for bleeding after dialysis. 92. A nurse in the emergency department is caring for a client who reports intimate partner violence. Which of the following interventions is the nurse’s priority? 1. Determine if the client has any injuries. 93. A nurse is caring for a client who is in active labor and note the FHR baseline has been 100/min for the past 15 min. The nurse should identify which of the following conditions as a possible cause of fetal bradycardia? 1. Maternal hypoglycemia 94. A nurse is assessing a school-age child who has a urinary tract infection. Which of the following findings should the nurse expect? 1. Enuresis. 95. A charge nurse on a medical-surgical unit is assisting with the emergency response plan following an external disaster in the community. In anticipation of multiple client admissions, which of the following current clients should the nurse recommend for early discharge? 1. A client who is 1 day postoperative following a vertebroplasty 97. A nurse is providing teaching to the parents of a newborn genetic screening. Which of the following statement should the nurse include in the teaching? 1. “This test should be performed after your baby is 24 hours old.” 98. A nurse is providing discharge teaching to a client who is postoperative following a colon resection and has a new ascending colostomy. Which of the following statements by the client indicates an understanding of the teaching? 1. “I should avoid eating popcorn and fresh pineapple” 99. 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? 1. Place the client on NPO status. 100. 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? C. “Rise slowly when getting out of bed” 101. 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? C. Determine the client’s current pain level. 102. A nurse is caring for a client who has chronic pancreatitis. Which of the following dietary recommendations should the nurse make? C. Broiled skinless chicken breast with brown rice. 103. A nurse is caring for a client who asks for information regarding organ donation. Which of the following should the nurse make? C. “Your desire to be an organ donor must be documented in writing.” 104. A nurse is teaching a female client about personal hygiene. Which of the client actions indicates an understanding go the teaching? D. The client brushes her teeth twice daily. 107. A nurse is preparing to assess a 2-week-old newborn. Which of the following actions should the nurse plan to take? C. Auscultate the newborn’s apical pulse for 60 seconds. 108. 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? C. Nephrologist 109. 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 108. 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? D. WBC count 14,000 mm3 109. 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. 110. 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? B. “Ice chips” 111. 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? D. Contractions 112. 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? Apply fetal heart rate monitor. 113. 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) a. 3) Identify family needs interventions using the nursing process. b. 4) Record information about the home visit according to agency policy. c. 2) Contact the family to determine availability and readiness to make an appointment d. 5) Discuss plans for future visits with the family. e. 1) Clarify the reason for the referral with the provider’s office. E C A B D (My choice) 115. A nurse is caring for a client who is receiving intermittent eternal tube feeding. Which of the following places the client at risk for aspiration? B. A History of gastroesophageal reflux disease 116. A nurse is providing discharge teaching to a client who has chronic kidney disease and is receiving hemodialysis. Which of the following instructions should the nurse include in the teaching? C. Eat 1g/kg of protein per day 118. A nurse on a telemetry unit is assessing a client who is receiving continuous cardiac monitoring. The client’s heart rate is 69/min and the PR interval is 0.24 seconds. The nurse should interpret this finding as which of the following cardiac rhythms? A. First degree AV block 119. A nurse is supervising an assistive personnel (AP) who is feeding a client. The nurse observes that the client coughs after each bite. After asking the AP to stop feeding the client, which of the following actions should the nurse take next? 1. Listens to the client’s lung sounds. 120. A nurse is developing a plan of care for a client who has schizophrenia and is experiencing auditory hallucinations. Which of the following actions should the nurse include in the plan? A. Ask the client directly what he is hearing 120. The nurse is teaching a group of clients at a community health fair about genetic disease. Which of the following statements by a client indicates an understanding of the teaching? “My family has genetic risk for breast cancer, so I am considering a total mastectomy” 121. A nurse is planning discharge teaching about cord care for the parents of a newborn. Which of the following instructions should the nurse plan to include in the teaching? D. “Keep the cord stump dry until it falls off.” 122. A nurse is providing teaching to a client who is on glucocorticoid therapy. Which of the following statements by the client indicates an understanding of the teaching? B. “I take a calcium vitamin supplement daily” 123. 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? C. Uses a mechanical lift to move client from bed to chair. 124. A client is requesting information from a nurse about a nitrazine test. Which of the following statements should the nurse make? 2. “This test will determine if there is leaking amniotic fluid” 125. 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 126. 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? B. Contact child protective services. 127. A nurse is planning care for a client who has thrombocytopenia. Which of the following actions should the nurse include? Provide the client what a stool softener. 128. 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 131. 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? Place the client in high fowler’s position. 132. 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” 133. 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.” 133. 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? “We encourage you to participate in all decisions about your treatment” 134. 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. 136. 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? Notify the nursing manager about the suspected alcohol use. 137. A charge nurse is teaching new staff members about factors that increase a client’s risk to become violet. Which of the following risk factors should the nurse include as the best predictor of future violence? A. Previous violent behavior 137. A charge nurse is teaching a newly licensed nurse about medication administration. Which of the following information should the charge nurse include? Avoid preparing medications for more than two clients at one time. 138. A charge nurse is evaluating the time management skills of a newly licensed nurse. For which of the following actions by the newly licensed nurse should the charge nurse intervene? 1. Documents the clients care tasks at the end of the shift. 139. 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. 142. A nurse is developing an in-service about personality disorders. Which of the following information should the nurse include when discussing borderline personality disorder? “The client exhibits impulsive behaviors.” 142. A nurse is caring for a client who has a prescription for warfarin. When reviewing the client’s current medications, which of the following medications should the nurse identify as contraindicated for use with warfarin? (Select all that apply) 1. Aspirin 2. Gingko biloba. 3. Ibuprofen. 143. A nurse is completing an admission assessment for a client who has narcissistic personality disorder. Which of the following findings should the nurse expect? D. Preoccupied with aging 145. A nurses is assessing a preschooler who has recently experienced an unexpected death in the family. Which of the following should the nurse recognize as an expected finding? C. The child believes the person will return. 146. A nurse is assessing a client in the emergency department. Which of the following actions should the nurse take first? Exhibit 1 Laboratory Results Cerebrospinal fluid WBC 2,000/mm3 Neutrophils 88% Protein 320 mg/dl Glucose 35 mg/dl Cloudy in appearance Exhibit 2 History and Physical Reports severe headache and photophobia. Disoriented to person, place, and time. Lethargic. Exhibit 3 Vital Signs BP 166/96 mm Hg Respiratory rate 24/min Pulse rate 112/min Temperature 39.3C (102.8F) Pain of 6 on a scale from 0 to 10 Glasgow score 9 C. Obtain arterial blood gas levels. 147. A client is caring for a client following a paracentesis. Which of the following findings should the nurse identify as an indication of a complication? Tachycardia. 148. 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? C. “Informed consent is required prior to PICC placement.” 149. A nurse is reviewing admission prescriptions for a group of clients. Which of the following prescriptions should the nurse identify as complete? D. Metoprolol 5mg IV now. 150. A nurse is caring a child who has cystic fibrosis and requires postural drainage. Which of the following actions should the nurse take? D. Perform the procedure prior to meals 151. 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? C. A client who is taking warfarin and has an INR of 1.8 152. A nurse is caring for a client who is postpartum and request information about contraception. Which of the following instructions should the nurse include? C. “Place transdermal birth control patch on your upper arm” 153. 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? . “I will not publish public announcement about my baby’s birth” 154. 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? D. Measure the client’s urine output every hour 155. 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? 2. “Morphine 3 mg Subcutaneous 156. 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? 1. Metabolic acidosis. 157. A nurse realizes that the wrong medication has been administered to a client. Which of the following actions should the nurse take first? 1. Monitor vital signs. 158. recieves 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? B. “Use your thumb and forefinger to apply pressure to the (Unable to read) of your child’s 159. 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? 1. Ensure that the client’s identification band matches the number on the blood unit. 160. A nurse is transcribing new medication prescriptions for a group of client. For which of the following prescriptions should the nurse contact the provider for clarifications? 1. Lorazepam .5mg PO one tablet daily 161. A nurse is caring for a client who requires seclusion to prevent harm to others on the unit. Which of the following is an appropriate action for the nurse to take? A. Offer fluids every 2hr. B. Document the client’s behavior prior to being placed in seclusion. C. Discuss with the client his inappropriate behavior prior to seclusion. D. Assess the client’s behavior once every hour. 162. A nurse is providing teaching to a client who is experiencing preterm contractions and dehydration. Which of the following statements should the nurse make? B. “Dehydration can increase the risk of preterm labor” 164. A nurse is assessing a client who is postoperative following abdominal surgery and has an indwelling urinary catheter that is draining dark yellow urine at 25 ml/hr. Which of the following interventions should the nurse anticipate? C. Obtain a urine specimen for culture and sensitivity 165. 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? D. WBC count 2,900/mm3 167. 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 170. A nurse in a provider’s office is preparing to administer the inactivated influenza vaccine. The nurse should collect additional (Unable to read) for which of the following client prior to administering the vaccine? Client has a sensitivity to eggs. 171. A nurse is providing teaching about digoxin administration to the parents of a toddler which as heart failure. Which of the following statements should the nurse include in the teaching? “Have your child drink a small glass of water after swallowing the medication.” 172. A nurse is collecting a sputum specimen from a client who has tuberculosis. Which of the following actions should the nurse take? 1. Obtain the specimen immediately upon the client waking up. 173.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? 2. Potassium 3.1 mEq/L. 174. A nurse is caring for a client who wears glasses. Which of the following actions should the nurse take? 1. Store the glasses in a labeled case. 175. A school nurse is teaching a parent about absent seizures. Which of the following information should the nurse include? 1. “This type of seizure can be mistaken for daydreaming.” 176. 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? 1. Insertion of an indwelling urinary catheter 177. 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? 1. aPTT. 178. 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? Attempts to understand both sides of the issue 180.which of the following findings should the nurse identify as an indication of intercranial pressure? 1. Increasingly severe headache. RN Comprehensive Predictor 2019 Form B 1. 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. 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. C. Digoxin level 1 ng/ml. 3. 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. 4. 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. 5. A nurse is teaching a group of newly licensed nurses about measures to take when caring for a client who is on contact precautions. Which of the following should the nurse include in the teaching? C. Wear gloves when providing care to the client. 6.A nurse is planning on care for a client who is recovering from an acute myocardial infarction that occurred 3 days ago. Which of the following instructions should the nurse include? A. Perform an ECG every 12 hr. D. Obtain a cardiac rehabilitation consultation. 7. The nurse is reviewing the medical record of a client who is requesting combination oral contraceptives. Which of the following conditions in the client’s history is a contradiction to the use of oral contraceptives? A. Thrombophlebitis. 8 A nurse is caring for a client who request the creation of a living will. Which of the following actions should the nurse take? Evaluate the client’s understanding of life-sustaining measures. 9.A nurse is caring for an adolescent who has sickle-cell anemia. Which of the following manifestations indicates acute chest syndrome and should be immediately reported to the provider? Substernal retractions. 11. A nurse is providing care for a client who is in the advance stage of amyotrophic lateral sclerosis. (ALS). Which of the following referrals is the nurse’s priority? D. Speech-language pathologist. 12.A nurse is reviewing the laboratory results of a client who has rheumatoid arthritis. Which of the following findings should the nurse report to the provider? A. WBC count 8,000/mm3. . Erythrocyte sedimentation rate 75 mm/hr 13. A nurse is caring for a client who has generalized petechiae and ecchymoses. The nurse should expect a prescription for which of the following laboratory tests? Platelet count. 14. A nurse is caring for a client following application of a cast. Which of the following actions should the nurse take first? B. Palpate the pulse distal to the cast. 15. A nurse is caring for a client who has vision loss. Which of the following actions should the nurse take? (Select all that apply) 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. 16. 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? B. CINAHL. 17. 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. D. Administer 100% humidified oxygen. 18. 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? Place the client’s left arm on a pillow while he is sitting. 19. 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. 20. 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? B. Limit the client’s visitors to 30 min per day. 21. 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? Bradypnea 22. 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. C. Post term with oligohydramnios 23. 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? Bradypnea 25. 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? “Rise slowly when getting out of bed” 26. 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? Allow the client enough time to perform rituals. 27. 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? Serotonin syndrome 28. A nurse is assessing a client who is receiving packed RBCs. Which of the following findings indicate fluid overload? Dyspnea. 30. 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. The group encourages members to focus on a particular issue. 35.A public health nurse is managing several projects for the community. Which of the following interventions should the nurse identify as a primary prevention strategy? A. Teaching parenting skills to expectant mothers and their partners. 36. 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. 37. A nurse is performing physical therapy for a client who has Parkinson’s disease. Which of the following statements by the client indicates the need for a referral to physical therapy? C. “Lately, I feel like my feet are freezing up, as they are stuck to the ground” 38. A nurse is reviewing laboratory data for a client who has chronic kidney disease. Which of the following findings should the nurse expect? Increased creatine. 39. A nurse is administering a scheduled medication to a client. The client reports that the medication appears different than what they take at home. Which of the following responses should the nurse take? “I will call the pharmacist now to check on this medication” 40 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? Use three pronged grounded plugs. 41. A charge nurse is recommending postpartum client discharge following a local disaster. Which of the following should the nurse recommend for discharge? D. A client who delivered precipitously 36 hr. ago and has a second-degree perineal laceration. 42. A nurse in a provider’s office is reviewing the laboratory results of a group of clients. Which to report? Chlamydia 43. A nurse is providing discharge teaching for a group of clients. The nurse should recommend a referral to a dietitian 1. A client who has gout and states, “I can continue to eat anchovies on my pizza.” 44. 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. 45. 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. 46.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? Administer the medication. 47. A nurse is caring for a client who has fibromyalgia and requests pain medication. Which of the following medications should the nurse administer? Pregabalin 48. 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. 49. A nurse is caring for a toddler who has acute lymphocytic leukemia. In which of the following should the toddler participate? Playing with a large plastic truck. 50. A nurse is caring for a client who has chronic pancreatitis. Which of the following dietary recommendations should the nurse make? Broiled skinless chicken breast with brown rice. 51. A nurse is preparing to assess a 2-week-old newborn. Which of the following actions should the nurse plan to take? Auscultate the newborn’s apical pulse for 60 seconds. 52. 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? B. Apply fetal heart rate monitor. 53. 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 54. 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? Quality improvement. . 55. 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? Notify the nursing manager about the suspected alcohol use. 56. A nurse is caring for a client who has diaper dermatitis. Which of the following actions should the nurse take? Apply zinc oxide ointment to the irritated area. 66. 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? “I will not publish public announcement about my baby’s birth” 59. A nurse is providing teaching to a client who is experiencing preterm contractions and dehydration. Which of the following statements should the nurse make? B. “Dehydration can increase the risk of preterm labor” 61. 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? the nurse was going to do the interpretation 62 C 63 A 64. C 65. D 66.C 67 A 68.B . 69.A 70.C 71.D 72.C 73.D 74.C 75.A 76.C 77.C 78.B 80. D 81. A 82. B 83. A 84. A 85. A 86. C 87. A 88. C 89. D 90. C 91. A 92. A 93. A 94. A 95. C 96. C 97. D 98. D 99. D 100. D 101. A 102. B 103. B 104. D 105. A 106. A 107. D 108. B 109. C 110. B 111. D 112. C 113. B 114. C 115. A 116. D 117. B 118. D 119. D 120. A 121. C 122. A 123. A 124. C 125. D 126. D 127. Intradermal Injection areas B. Upper back. 128.A nurse is caring for a client who has left homonymous hemianopsia. Which of the following is an appropriate nursing intervention? ide of her body. 6. Place the bedside table on the right side of the bed. nurse is caring for a client who is scheduled for a thoracentesis. Prior to the procedure, which of the following actions should the nurse take? 1. Position the client in an upright position, leaning over the bedside table. 134.A nurse is assessing a client following bronchoscopy. Which of the following findings should the nurse report to the provider? Bronchospasms 136.A nurse is caring for a client following a thoracentesis. Which of the following manifestations should the nurse recognize as risks for complications? (Select all that apply.) Dyspnea 138.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? 6. Apply sterile gauze to the insertion site. 140.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? Perform the Valsalva maneuver. 141.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? (Select all that apply.) Obtain a chest x-ray. 142.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? b. “It allows preset pressure delivered during spontaneous ventilation.” 143.A nurse is caring for a client who is experiencing respiratory distress. Which of the following early manifestations of hypoxemia should the nurse recognize? (Select all that apply.) 145.A nurse is caring for a client who has dyspnea and will receive oxygen continuously. Which of the following oxygen devices should the nurse use to deliver a precise amount of oxygen to Venturi mask 148.A nurse in a clinic is caring for a client whose partner states the client woke up this morning, did not recognize him, and did not know where she was. The client reports chills and chest pain that is worse upon inspiration. Which of the following actions is the nurse’s priority? 7. Obtain baseline vital signs and oxygen saturation. 150.A nurse in a clinic is assessing a client who has sinusitis. Which of the following techniques should the nurse use to identify manifestations of this disorder? 15. Palpation of the orbital areas 151.A nurse is teaching a group of clients about influenza. Which of the following client statements indicates an understanding of the teaching? “I should wash my hands after blowing my nose to prevent spreading the virus.” 153.A nurse is caring for a client 2 hours after admission. The client has an SaO2 of 91%, exhibits audible wheezes, and is using accessory muscles when breathing. Which of the following classes of medication should the nurse expect to administer? i. Beta2 agonist 154.A nurse is providing discharge teaching to a client who has a new prescription for prednisone for asthma. Which of the following client statements indicates an understanding in teaching? 10. “I will take my medication with meals.” 155.A nurse is assessing a client who has a history of asthma. Which of the following factors should the nurse identify as a risk for asthma? 15. Environmental allergies 156.A nurse is reinforcing teaching with a client on the purpose of taking a bronchodilator. Which of the following client statements indicates an understanding of the teaching? 18. “I take this medication to prevent asthma attacks.” 157.A nurse is providing discharge teaching to a client who has COPD and a new prescription for albuterol. Which of the following statements by the client indicates and understanding of the teaching? 1. 2. “I can have an increase in my heart rate while taking this medication.” 158.A nurse is preparing to administer a dose of a new prescription of prednisone to a client who has COPD. The nurse should monitor for which of the following adverse effects of this medication? (Select all that apply.) nurse is discharging a client who has COPD. Upon discharge, the client is concerned that he will never be able to leave his house now that he is on continuous oxygen. Which of the following is an appropriate response by the nurse? 1. “There are portable oxygen delivery systems that you can take with you.” nurse is instructing a client on the use of an incentive spirometer. Which of the following statements by the client indicates an understanding of the teaching? 1. “I will take in a deep breath and hold it before exhaling.” nurse is planning to instruct a client on how to perform pursed-lip breathing. Which of the following should the nurse include in the plan of care? 1. Take a deep breath in through your nose. nurse is caring for a client who has a new diagnosis of tuberculosis and has been placed on a multi-medication regimen. Which of the following instructions should the nurse give the client related to ethambutol? 1. “Watch for any changes in vision.” nurse is preparing to administer a new prescription for isoniazid (INH) to a client who has tuberculosis. The nurse should instruct the client to report which of the following findings as an adverse effect of the medication? 1. “You might notice tingling of your hands.” nurse is providing information about tuberculosis to a group of clients at a local community center. Which of the following manifestations should the nurse include in the teaching? (Select all that apply.) 1. Persistent cough 167.A nurse is caring for a group of clients. Which of the following clients are at risk for pulmonary embolism? (Select all that apply.) 168.A nurse is assessing a client who has a pulmonary embolism. Which of the following information should the nurse expect to find? (Select all that apply.) 6. Pleural friction rub 169.A nurse is reviewing prescriptions for a client who has acute dyspnea and diaphoresis. The client states she is anxious and is unable to get enough air. Vital signs are HR 117/min, respirations 38/min, temperature 38.4 C (101.2 F), and blood pressure 100/54 mm Hg. Which of the following nursing actions is the priority? Administer oxygen therapy.. 170.A nurse is caring for a client who has a new prescription for heparin therapy. Which of the following statements by the client should indicate and immediate concern for the nurse? 171.A nurse is caring for a client who is to receive thrombolytic therapy. Which of the following factors should the nurse recognize as a contraindication to the therapy? 172.A nurse is assessing a client following a gunshot wound to the chest. For which of the following findings should the nurse monitor to detect a pneumothorax? (Select all that apply.) 173.A nurse is reviewing the prescriptions for a client who has a pneumothorax. Which of the following actions should the nurse perform first? 174.A nurse is reviewing discharge instructions for a client who experienced a pneumothorax. Which for the following statement should the nurse use when teaching the client? 175.A nurse in the emergency department is assessing a client who has a suspected flail chest. Which of the following findings should the nurse expect? (Select all that apply.) a. Bradycardia e. Paradoxic chest movement 177.A nurse is orientation a newly licensed nurse on the purpose of administering vecuronium to a client who has acute respiratory distress syndrome (ARDS). Which of the following statements by the newly licensed nurse indicates understanding of the teaching? 177.A nurse is reviewing the health records of five clients. Which of the following clients are at risk for developing acute respiratory distress syndrome? (Select all that apply.) c. A client who has a hemoglobin of 15.1 mg/dL nurse is planning care for a client who has severe respiratory distress system (SARS). Which of the following actions should be included in the plan of care for this client? (Select all that apply.) 1. Provide supplemental oxygen. 179.A nurse is caring for a client who is receiving vecuronium for acute respiratory distress syndrome. Which of the following medications should the nurse anticipate administering with this medication? (Select all that apply.) a. Fentanyl c. Midazolam 180.A nurse is orienting a newly licensed nurse on the care of a client who is to have a line placed for hemodynamic monitoring. Which of the following statements by the newly licensed nurse indicates effectiveness of the teaching? “A chest x-ray is needed to verify placement after the procedure.” A nurse is preparing to replace a patient's transdermal fentanyl patch after 72 hours of use. After opening the packet with the new pouch, the patient refuses to accept it. Which action should the nurse take? B) Ask another nurse to witness the disposal of the new patch. A nurse is caring for a client with a PE. The client is receiving heparin IV at 1,200 units/hr and warfarin 5 mg PO daily. The morning lab values are aPTT 98 seconds and INR 1.8. Which action should the nurse take? C) Withhold the heparin infusion. The expected value for aPTT is 40 seconds. A therapeutic level of heparin increases the aPTT by a factor of 1.5 to 2, making the aPTT 60 to 80 seconds. An aPTT level of 98 is above the expected reference range, indicating that the dosage should be reduced, or the infusion withheld until the aPTT returns to the therapeutic range. A nurse at an urgent care clinic is assessing a patient with impaired vision in 1 eye. Which report from the patient should indicate to the nurse that the client has a detached retina? B) Floating dark spots A nurse is assessing an infant with hydrocephalus and is 6 hours post-op following placement of a VP shunt. Which finding should the nurse report to the provider? B) Irritability when being held A nurse is assessing a newborn's HR. Which action should the nurse take? D) Auscultate the apical pulse and count beats for at least 1 min. A nurse is caring for a client with a fecal impaction. Which action should the nurse take when digitally evacuating the stool? D) Insert a lubricated gloved finger and advance along the rectal wall. A nurse is providing dietary teaching to a patient taking phenelzine. Which food recommendations should the nurse make? (Select all) A) Broccoli B) Yogurt D) Cream cheese A nurse administers an incorrect dose of a med to a client. The nurse recognizes the error immediately and completes an incident report. Which fact related to the incident should the nurse document in the client's medical record? B) Time the medication was given A nurse on a pediatric unit received report on 4 children. Which child should the nurse assess first? D) A 10-year-old child who is awaiting surgery for an appendectomy and experienced sudden relief from pain Using the urgent vs. non-urgent approach to client care, the nurse should determine that the client to assess first is the child awaiting an appendectomy who suddenly experiences pain relief as this can be an indication of peritonitis from a ruptured appendix. A community health nurse is providing teaching about home safety with a group of elderly clients. Which statement should the nurse make? D) "Have grab bars installed around your bathtub and toilet." A nurse in the ED is assessing a school-age child who was brought in by her parents and has scald burns to both hands and wrists. The nurse suspects physical abuse. Which action should the nurse take? D) Contact child protective services. A nurse is caring for a patient with acute blood loss following a trauma. The patient refuses a blood transfusion that could save his life. Which action should the nurse take first? C) Explore the client's reasons for refusing the treatment. A nurse is teaching a client at 20 weeks gestation about common prenatal discomfort. Which statement by the client indicates an understanding of the teaching? D) "I will wear a supportive bra overnight." A nurse is providing discharge education to a patient who is to receive home oxygen therapy. Which instruction should the nurse include in the teaching? B) Wear clothing made with cotton fabrics while oxygen is in use. The nurse should teach the client to apply a water-soluble lubricant to soothe irritation of the mucous membranes, because products containing oils are flammable when near oxygen. A nurse manager is preparing an education session about advocacy to a group of nurses. The nurse manager should include what information in the teaching? A) Advocacy is a leadership role that helps others to self-actualize. A nurse is caring for a patient receiving continuous bladder irrigation following a transurethral resection of the prostate. The patient reports bladder spasms and the nurse observes a decreased urinary output. Which action should the nurse take? B) Irrigate the catheter with 0.9% sodium chloride irrigation. Decreased urine output and bladder spasms indicate internal obstructions of the catheter. Therefore, the nurse should irrigate the catheter with 0.9% sodium chloride irrigation and notify the provider if the obstruction does not clear. A nurse is caring for a child with sickle cell anemia and is having a vaso-occlusive crisis. Which intervention should the nurse implement first? D) Infuse IV fluids. The priority action the nurse should take when using the airway, breathing, circulation approach to client care is to infuse IV fluids to promote hydration and circulation. Increased fluid reduces the tissue and organ ischemia caused by the clumping of the RBCs. A nurse is providing patient education about the basal body temperature method of birth control. What information should the nurse include in the teaching? C) "Your body temperature might decrease slightly just prior to ovulation." The nurse should teach the client that a drop in body temperature of approximately 0.25° C (0.5° F) commonly occurs immediately prior to ovulation. A nurse in the ED is caring for a client who is unconscious and requires emergency medical procedures. The nurse is unable to locate members of the client's family to obtain consent. Which action should the nurse take? D) Proceed with provision of medical care. A nurse is caring for a client who has fluid volume overload. Which task should the nurse delegate to the AP? C) Measure the client's daily weight. A nurse is assessing a patient with hypocalcemia. Which site should the nurse tap to elicit a positive Chvostek's sign? C) cheek A nurse is reviewing the urinalysis report of a client with acute glomerulonephritis. Which finding should the nurse expect in the client's urine? B) Protein Increased glomerular permeability allows protein to filter into the urine. Therefore, this is an expected finding in a client who has glomerulonephritis. A nurse is creating a plan for care of a newly admitted child. Which action should the nurse include in the plan? (Click exhibit) D) Administer high dose antibiotic therapy. The nurse should include administering high-dose antibiotic therapy in the child's plan of care. Children who have cystic fibrosis metabolize antibiotics more rapidly and require higher doses of antibiotics to help fight aggressive infections such as Burkholderia cepacia. A nurse is caring for a client with cancer and is deciding between 2 treatment options. The client asks the nurse for assistance with the decision. Which response should the nurse make? B) "Tell me more about your understanding of the options." A nurse is caring for a patient receiving hemodialysis with an AV fistula in the right arm. Which intervention should the nurse include in the patient's plan of care? B) Auscultate the affected extremity for a bruit. A nurse in the oncology unit is administering doxorubicin to a client with breast cancer. Which action should the nurse take? D) Inspect the client's mucosa for petechiae every 8 hr. The nurse should inspect the client's mucosa for petechiae every 8 hr because this medication causes thrombocytopenia and increases the risk of bleeding. The nurse should also assess the client for hematuria, guaiac, and bruising. A hospice nurse is consulting with a patient and her family about receiving home services. Which statement should the nurse identify as an indication that the family understands home hospice care? A) "We can expect the hospice nurse to provide support for us after our mother's death." A nurse is caring for a patient with major depressive disorder and has signed an informed consent to receive ECT. The patient states "I'm not sure about this now. I'm afraid it's too risky." What response should the nurse make? B) "You have the right to refuse to have the ECT, even after you have agreed to it." A nurse is providing discharge instructions about newborn care to a client 2 days postpartum. Which statements indicate understanding of the teaching? (Select all) D) "I will cover my baby's body when I wash her hair." E) "I will use the bulb syringe first in her mouth and then in her nose." A nurse is assigning task roles for a group of patients in a community mental health clinic. Which task should the nurse assign to the mother of the group functioning as the orienter? B) Noting the progress of the group toward assigned goals A nurse must recommend clients for discharge to make room for several critically injured clients from a local disaster. Which client should the nurse recommend for discharge? A) A client who has cellulitis and is receiving oral antibiotics every 8 hr A nurse is developing a client education program about osteoporosis for older adult clients. What variable is a risk factor for osteoporosis? D) Sedentary lifestyle A charge nurse is providing an educational session about infection control for a group of staff nurses. Which statement by a staff nurse indicates understanding of isolation precautions? B) "A client who requires airborne precautions should be placed in a negative-pressure airflow room." A nurse is preparing to assist with a thoracentesis for a client who has pleurisy. What action should the nurse plan to perform? D) Instruct the client to avoid deep breathing during the procedure. It is important for the nurse to remind the client to avoid deep breathing during a thoracentesis to avoid puncturing the pleura. A nurse is caring for a school-age child taking valproic acid. The nurse should expect the provider to order which diagnostic test? B) Serum liver enzyme levels Valproic acid can cause hepatic toxicity. Therefore, the nurse should expect the provider to prescribe laboratory tests to assess the child's liver function. 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 observation should the nurse identify as an indicator for potential violence? D) The client is pacing around the chair in which his partner is sitting. Hyperactivity and pacing indicates that this client is at risk for violent behavior. The nurse should assess the situation further and attempt to de-escalate the client by speaking to him in a low, calm voice using short sentences. A home health nurse is evaluating a school-age child with cystic fibrosis. The nurse should indicate a request for a high-frequency chest compression vest in response to which parent statement? C) "My child has only a small amount of mucus after percussion therapy." A nurse is creating a plan of care for a patient with left-sided weakness following a stroke. Which intervention should the nurse include in the plan? B) Support the client's left arm on a pillow while sitting. A nurse on an impatient unit is caring for a client with schizophrenia and recently started taking risperidone. Which action should the nurse take? A) Implement fall precautions for the client. Risperidone can cause orthostatic hypotension and dizziness, which can lead to falls. Therefore, the nurse should initiate fall precautions for the client. A nurse in the ED is caring for a child with a fever and fluid-filled vesicles on the trunk and extremities. Which intervention should the nurse identify as priority? D) Initiate transmission-based precautions. These findings indicate this child most likely has varicella, which is an infectious disease. Therefore, the first action the nurse should take is to initiate transmission-based precautions. A nurse is assessing a client for compartment syndrome. Which finding should the nurse expect? C) Edema A nurse has received report on 4 patients. Which should the nurse assess first? A) A client who is postoperative with abdominal distention and no bowel sounds A nurse is assessing a client after administering epinephrine for an anaphylactic reaction. Which finding should the nurse identify as an adverse effect of this medication? C) Report of chest pain The nurse should recognize that a report of chest pain by the client can indicate an adverse effect of the medication. Epinephrine increases cardiac workload and oxygen demand, which can result in angina. A nurse is providing teaching to a patient 24 weeks gestation and is scheduled for a 3 hour oral glucose tolerance test. Which instruction should the nurse include in the teaching? B) "You will need to fast the night before the test." A nurse is assessing an older adult client with pneumonia. Which finding should the nurse expect? C) Acute confusion An older adult client who has pneumonia will also typically have acute confusion, fatigue, lethargy, and anorexia. A nurse is providing teaching for a client about his right to confidentiality. Which statement should the nurse make? A) "You can provide a list of family members who can receive information about your diagnosis." A nurse in the ED is caring for a patient with nausea and vomiting for 2 days. Which finding should the nurse expect? B) Urine specific gravity 1.052 The nurse should recognize this urine specific gravity is significantly elevated, indicating dehydration from vomiting. A nurse is caring for a post-op patient after receiving moderate (conscious) sedation. The patient suddenly becomes restless and reports feeling lightheaded. Which action should the nurse take? D) Check the client's oxygen saturation level. A nurse is assessing a client at 11 weeks gestation and reports drinking ginger tea. Which finding indicates the client's use of ginger tea is effective? A) The client reports a decrease in episodes of nausea. A nurse is providing teaching to a patient with a new diagnosis of type 1 DM. The nurse should instruct the client to monitor which finding as a manifestation of hypoglycemia? A) Irritability A nurse is caring for a client who has a DVT. Which action should the nurse take? B) Instruct the client to elevate the affected extremity when sitting. A nurse is providing information to a client immediately before his scheduled Romberg test. Which statement should the nurse make? D) "I will be checking you once with your eyes open and once with them closed." A nurse is providing teaching to the parents of a child who has autism spectrum disorder. Which instruction should the nurse include? B) Use a reward system to modify the child's behavior. A nurse is providing teaching to a client who is to undergo ECT. The nurse should inform the client that which finding is an adverse effect of ECT? B) Short-term memory loss A nurse is caring for a client who has TB. Which action should the nurse plan to take to prevent the transmission of the disease? D) Have the client wear a surgical mask while being transported outside the room. A nurse on a mental health unit is conducting a mental status examination (MSE) on a newly admitted client. Which component of the MSE is priority for the nurse to assess? C) Ideas of self-harm A nurse is caring for a client who is taking chlorpromazine. Which finding should the nurse identify as an indication that the med is effective? B) Decreased hallucinations A nurse is assessing a client whose partner recently died. The client states "I don't know what to do without my partner. Life is just not worth living." Which of the following responses should the nurse make? B) "You seem to be having a difficult time right now." A nurse is developing a discharge plan for a school-age child with thrombocytopenia. The nurse should instruct the child to avoid what? D) Blowing the nose The nurse should instruct the child who has thrombocytopenia to avoid blowing the nose because it increases the risk for bleeding or hemorrhaging. A nurse is reviewing the lab report of a client who has end-stage kidney disease and received hemodialysis 24 hours ago. Which of the following lab values should the nurse report to the provider? D) Sodium 148 mEq/L A nurse is caring for a client with a magnesium level of 2.5. Which intervention should the nurse plan to take? A) Initiate continuous cardiac monitoring. The nurse should initiate continuous cardiac monitoring because a client who has hypermagnesemia is at risk for cardiac dysrhythmias and cardiac arrest. A nurse in an outpatient mental health clinic is caring for 4 patients. The nurse should recognize which client is effectively using sublimation as a defense mechanism? C) A client who channels her energy into a new hobby following the loss of her job A nurse is caring for a group of clients. Which client should the nurse see first? A) An older adult client who is anxious and attempting to pull out his IV line A nurse is preparing to teach about dietary management to a patient with Crohn's disease and an enteroenteric fistula. Which nutrient should the nurse instruct the client to decrease in his diet? D) Fiber The nurse should instruct the client who has Crohn's disease and an enteroenteric fistula to consume a low-fiber diet to reduce residue and decrease exacerbations. A nurse is caring for a client in the resuscitation phase of burn injury. Which findings should the nurse expect? C) Hyponatremia The nurse should expect the client to have a decrease in sodium levels because sodium is drawn to the edematous burn area and lost through plasma leakage. A nurse is teaching self-administration of insulin to a patient with a new prescription for a short- acting and intermediate-acting insulin. Which action by the client indicates an understanding of the teaching? C) Pinches the skin prior to injecting the insulin A nurse is providing teaching to a client 26 weeks gestation and is to have an oral glucose tolerance test. Which action should the nurse instruct the client to take before the test? C) Avoid caffeine. A nurse is caring for a client with hyperthyroidism. Which finding should the nurse expect? C) Tremors A nurse is caring for a newborn who has herpes simplex virus (HSV). Which isolation precaution should the nurse initiate? A) Contact An antepartum nurse is caring for 4 patients. Which patient should the nurse initiate seizure precautions? A) A client who is at 33 weeks of gestation and has severe gestational hypertension The nurse should initiate seizure precautions for a client who has severe gestational hypertension because an extremely elevated blood pressure in an antepartum client can trigger seizure activity. The nurse should provide the client with a quiet, darkened environment; place suction equipment and oxygen at the bedside; and place the call button within the client's reach. A nurse in a provider's office is assessing an adolescent who has been taking ibuprofen for 6 months to treat juvenile idiopathic arthritis. Which question should the nurse ask to assess for an adverse effect of this med? B) "Have you had any stomach pain or bloody stools?" A nurse is caring for an older adult client experiencing chronic anorexia and is receiving enteral tube feedings. Which lab values indicates the client needs additional nutrients added to the feeding? B) Albumin 2.8 g/dL A nurse is providing teaching to a school-age child with asthma about using albuterol mertered- dose inhaler. Which instructions should the nurse include? D) Take the medication 15 min before playing sports. A nurse is assessing a client who has decreased visual acuity due to cataracts. The nurse should identify which physiological change is the cause for the client's visual loss? C) Increased opacity of the lens A nurse at a mental health clinic is caring for 4 clients. Which client is using dissociation as a defense mechanism? B) A client who was abused as a child describes the abuse as if it happened to someone else. The nurse should recognize that this client is using dissociation because he is separating painful events from his conscious mind and is describing the events as if they happened to another person. A home health nurse is assessing a 2-week-old newborn who had a birth weight of 3.64 kg (8 lb) and is being breastfed. Which finding indicates effective breastfeeding? B) The newborn has six to eight wet diapers per day. A nurse is preparing to administer a blood transfusion to a client. Which procedure should the nurse follow to ensure proper client identification? D) Verify the client and blood product information with another licensed nurse. A nurse manager is reviewing clients' rights with the nurses on the unit. The nurse manager should tell the nurses that informed consent promotes which ethical principle? A) Autonomy A nurse is providing teaching about lithium to a client with bipolar disorder. Which statement should the nurse include in the teaching? B) "Notify your provider if you experience increased thirst." The nurse should recognize that an increase in thirst is a manifestation of lithium toxicity. The nurse should instruct the client to report increased thirst, vomiting, diarrhea, or tremors to the provider. During report, a night shift nurse informs the day shift nurse that a newly admitted client was disoriented and combative during the night. What action should the day shift nurse take? D) Move the client to a room near the nurses' station. A nurse in a provider's office is caring for an 19-month old toddler who has a blood lead level of 3. Which action should the nurse take? C) Recommend rescreening in 1 year. The nurse should schedule chelation therapy for a blood lead level greater than 45 mcg/dL. A nurse is assessing a client with bipolar disorder. Which alterations in speech is the client using? (Listen to the clip) B) Flight of ideas Flight of ideas is an alteration in speech in which the speaker talks continuously with sudden, frequent topic changes. A nurse working in the ED is triaging 4 patients. Which patient should the nurse recommend for treatment first? D) A middle adult client who has unstable vital signs A nurse is performing an admission assessment on a patient with a recent positive pregnancy test. The first day of her last menstrual period was May 8. According to Nagele's rile, which of the following dates should the nurse document as the patient's estimated date of birth? C) February 15 Using Nägele's rule, the nurse should add 7 days to the first day of the client's LMP (8 + 7 = 15) and then subtract 3 months. Therefore, the nurse should document the client's EDB as February 15th. A nurse is assessing a patient who received 2 units of packed RBCs 48 hours ago. Which finding should indicate the therapy is effective? A) Hemoglobin 14.9 g/dL A nurse is caring for a patient who recently signed an informed consent form to donate a kidney to her sibling who has end-stage kidney disease. The donor states "I don't want my brother to die, but what if I need this kidney one day?" Which response should the nurse make? C) "You're afraid that your other kidney will fail at some point after the organ donation." A nurse is preparing to administer an IM injection to a client who is obese. Which action should the nurse plan to take? C) Use the ventrogluteal site. A nurse is providing education to the parent of a school-age child with asthma. Which statement by the parent indicates an understanding of the teaching? D) "I will make sure my child receives a yearly influenza vaccination." Children who have asthma should be immunized and protected from infections. Therefore, the nurse should educate the parent to ensure the child receives a yearly influenza vaccine. A nurse is admitting a client with pneumonia. The nurse should initiate which isolation precaution? A) Droplet A nurse is assessing a client with COPD. Which finding should the nurse expect? D) pH 7.31 Respiratory acidosis is an expected finding for a client who has COPD. A pH level of 7.35 or less indicates respiratory acidosis. A nurse is providing teaching for a client who has a fracture of the right fibula with a short-leg cast in place. The client is non-weight bearing for 6 weeks. Which instruction should the nurse include in the teaching? B) Use a three-point gait. A three-point gait allows the client to be mobile without bearing weight on the affected extremity. A nurse is caring for a child with hypotonic dehydration and is receiving an oral rehydration solution. Which lab result indicates the treatment regimen is effective? C) Serum sodium 136 mEq/L A child who has hypotonic dehydration has a serum sodium level below 130 mEq/L. A serum sodium level of 136 mEq/L, which is within the expected reference range, indicates that this child is responding well to the oral rehydration solution. A nurse is assessing a client with pulmonary edema. Which finding should the nurse expect? A) Pink, frothy sputum A nurse has received report on 4 patients. Which patient should the nurse intervene to prevent a potential food and medication interaction? D) A client who is receiving an MAOI and is requesting a cheeseburger for dinner A nurse is assessing a client following a vaginal delivery and notes heavy lochia and a boggy fundus. Which med should the nurse expect to administer? C) Oxytocin A client should receive oxytocin, a hormone that stimulates uterine contractions, to prevent bleeding. A nurse on a med-surg unit is caring for a patient with a new diagnosis of terminal cancer. The patient wants to go home to be with family and loved ones. What action should the nurse take? C) Make a referral for social services. A nurse is caring for a patient taking valproic acid for seizure control. Which adverse effect should the nurse monitor and report? B) Jaundice The nurse should monitor the client for jaundice and report any indication to the provider. Clients who take valproic acid are at risk for liver damage, which can lead to jaundice. A nurse manager is planning to use a democratic leadership style with the nurses on the unit. Which action by the nurse manager demonstrates a democratic leadership style? B) Seeks input from the other nurses 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 the forearms. These behaviors are characteristics of which personality disorder? A) Borderline The nurse should recognize that clients who have borderline personality disorder are unstable emotionally, have troubled interpersonal relationships, and often engage in harmful behaviors such as cutting, substance use, and suicidal thoughts. A nurse preceptor is evaluating the performance of a newly licensed nurse. Which action by the newly licensed nurse requires intervention by the preceptor? B) Starts a task then determines what supplies are needed A nurse is providing teaching about advance directives to a middle adult client. Which client response indicates an understanding of the teaching? A) "I can designate my partner as my health care surrogate." A nurse educator is teaching a group of newly licensed nurses about the need to complete an incident report. Which example should the nurse include as a reportable incident and an indication for completing a report? D) A nurse administered a medication via the wrong route. A nurse is caring for a newborn immediately after delivery. Which intervention should the nurse implement to prevent hearing loss by conduction? C) Use a protective cover on the scale when weighing the infant. A nurse is caring for a client in the 4th stage of labor and is receiving oxytocin via continuous IV infusion. Which assessment is the nurse's priority? A) Amount of vaginal bleeding A nurse is preparing to transfer a patient from ICU to medical floor. The patient was weaned from mechanical ventilation following a pneumonectomy. Which information should the nurse include in report? C) The time of the client's last dose of pain medication A charge nurse notices that one of the nurses on her shift frequently violates unit policies by taking an extended amount of time for her break. Which statement should the charge nurse make to address this conflict? A) "I would like to talk to you about the unit policies regarding break time." A nurse is providing discharge teaching about disease management for a client who has a new diagnosis of type 1 DM. Which activity is the nurse's priority? D) Ensure that the client understands the medication regimen. A nurse is caring for a patient with GI bleeding and an NG tube in place. While performing gastric lavage, which action should the nurse take? C) Ask the client to lie on the left side. The nurse should ask the client to lie on the left side because this position limits the flow of the instilled solution out of the stomach and prevents aspiration. A nurse is planning to delegate client care tasks to an AP. Which task should the nurse plan to delegate to the AP? A) Perform gastrostomy feedings through a client's established gastrostomy tube. A nurse is providing teaching to a client who has a peripheral arterial disease. Which client action indicates understanding of the teaching? C) Applies lubricating lotion to her feet A nurse is providing discharge teaching for the parents of a preschoo;-age child taking amoxicillin/clavulanate suspension. Which instructions should the nurse include in the teaching? (Select all) B) "Shake the medication bottle well before each dose is given." C) "Store the medication in the refrigerator." D) "Report diarrhea to the provider immediately." A nurse is caring for a patient with COPD and becomes extremely SOB. Which intervention by the nurse requires completion of an incident report? D) Increasing oxygen via nasal cannula to 6 L/min A nurse is assessing for correct placement of a client's NG feeding tube prior to administering a bolus feeding. Which action should the nurse take? B) Aspirate contents from the tube and verify the pH level. A nurse is preparing to transfer a client who had a stroke to a rehab facility. The client's family tells the nurse they are concerned about the level of care the client will receive. What action should the nurse take? A) Facilitate an interdisciplinary conference at the new facility for the family. A nurse is caring for a client receiving continuous heparin infusion. What lab test should the nurse review prior to adjusting the client's heparin? A) aPTT Prior to adjusting the client's continuous heparin infusion, the nurse should review the client's activated partial thromboplastin time (aPTT). The expected reference range for the aPTT is 40 seconds. Clients who are receiving continuous heparin therapy should have an aPTT of 60 to 80 seconds, which is 1.5 to 2 times of the expected aPTT level. The nurse should increase or decrease the heparin infusion according to this value. A nurse is providing care for a client with a colostomy. Which action should the nurse take? C) Place the skin barrier over the stoma and hold it for 30 seconds. A nurse is preparing to mix haloperidol lactate 5 mg/mL and diphenhydramine 25 mg/1.5 mL to administer IM for a client who is agitated. Which action should the nurse take? C) Inject air into both vials prior to withdrawing the medications. The nurse should avoid administering more than 1 mL of medication into the deltoid site. Both haloperidol and diphenhydramine should be administered deep into a large muscle mass. The nurse should plan to use a 2-in needle for an IM injection of the combination of the 2 medications. A nurse is talking with a patient who has stage 4 breast cancer. The nurse should recognize which statement by the client as a constructive use of a defense mechanism? C) "I told my doctor that I would like to start a support group for other women who are sick in my community." This statement indicates that the client is using the constructive defense mechanism sublimation by devising a socially acceptable alternative to facing a reality that she does not wish to accept. A nurse is preparing a sterile field to perform a sterile dressing change. Which intervention should the nurse use to maintain surgical aseptic technique? D) Maintain sterile objects within the line of vision. Objects out of the line of vision are not considered sterile. Therefore, the nurse should keep sterile objects in direct sight to maintain surgical asepsis. A nurse manager is preparing to teach a group of newly licensed nurses about effective time management. Which step of the time management process should the nurse manager include as priority? C) Making a list of activities to complete A nurse is reviewing the ABG values of a client. pH 7.20, PaCo2 60, and HCO3 25. What acid- base imbalance does the client have? C) Respiratory acidosis A client is receiving IV fluids at 150 mL/hr. Which finding indicates the client is experiencing fluid overload? C) Dyspnea A nurse is caring for a patient who is 2 days postpartum. Which behavior indicated the client is bonding with her newborn? C) The client tells visitors how much the newborn looks like her sister. Comparing physical and behavioral attributes to those of family members demonstrates acceptance and bonding behaviors. A nurse in the ED is assessing a preschooler who has a facial laceration. Which finding is a potential indication of sexual abuse? A) The child exhibits discomfort while sitting. A nurse enters a client's room and sees smoke coming from a small fire in the trash can. What should the nurse do first? A) Remove the client from the room. 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 gathers information from which source? A) Agency for Healthcare Research and Quality The nurse should gather data from the Agency for Healthcare Research and Quality (AHRQ) regarding health care services for migrant farmworkers. The AHRQ strives to improve the quality of health care services for all populations, including low-income groups and minorities. This data should help the nurse to develop an evidence-based plan to improve health care services for specific populations. A nurse is assessing a newborn following a vaginal delivery. Which finding should the nurse report to the provider? B) Nasal flaring A nurse manager in a long-term care facility is having difficulty with staffing weekend shifts and is planning to implement changes to the scheduling procedure. Which action should the nurse manager take first? A) Form a committee of staff members to investigate current staffing issues. A nurse is assessing a client who has depressive disorder and is taking amitriptyline. Which finding is an adverse effect of this medication? D) Blurred vision 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 action should the nurse take first? D) Survey the scene for potential hazards to staff and children A nurse manager is preparing an educational session for nursing staff about how to provide cost- effective care. Which method should the nurse include in the teaching? A) Delegate non-nursing tasks to ancillary staff. A nurse is creating a plan of care for a child with acute lymphoid leukemia and an absolute neutrophil count of 400. Which intervention should the nurse do? ) Administer granulocyte colony-stimulating factor to the child. A nurse is providing teaching to a client who speaks a different language than the nurse about an upcoming diagnostic procedure. What action should the nurse take? B) Use pictures to illustrate the procedure to the client. A nurse is caring for a client with a prescription for continuous passive motion (CPM) machine following a TKA. Which action should the nurse take? A) Turn off the CPM machine during mealtime. A nurse is caring for a client receiving PEEP via mechanical ventilation. What is an adverse effect of PEEP? B) Tension pneumothorax A nurse is performing an abdominal assessment. Identify the sequence of actions the nurse should take. B) Inspection A) Auscultation D) Percussion C) Palpation A nurse is caring for a patient taking clonidine. Which finding is an adverse effect of this medication? B) Dry mouth A nurse is reviewing the lab results of a toddler with hemophilia A. Which aPTT value should the nurse expect? D) 45 seconds This value is above the expected reference range, indicating a risk for spontaneous bleeding, which is a manifestation of hemophilia A. A nurse is updating the plan of care for a patient 48 hours post-op following a laryngectomy and is unable to speak. What action should the nurse take first? A) Determine the client's reading skills. A nurse is caring for a patient who asks about taking ginseng to improve her appetite. Ginseng can decrease the effectiveness of which med? B) Timolol A nurse is preparing a client for a paracentesis. What action should the nurse take? A) Instruct the client to void. An RN is observing an LPN and an AP move a client up in bed. Which situation should the nurse intervene? C) The LPN and the AP grasp the client under his arms to lift him up in bed. A nurse on a med-surg unit is assessing a client who had a stroke. Which finding indicates a need for a referral for occupational therapy? A) Difficulty performing ADLs A nurse is assessing a client taking propranolol. Which finding should indicate to the nurse the client is experiencing an adverse reaction to propranolol? B) Coughing at night A nurse is conducting a visual acuity test using the Snellen letter chart for a school-age child with eyeglasses. Which instructions should the nurse give to the child? D) "You should keep both eyes open during the testing." A nurse is caring for a multiparous client following a vacuum-assisted birth. The nurse should assess the client for which complication related to this birth method? C) Cervical laceration 1. A nurse is performing tracheostomy care for a client who is postop following a laryngectomy. Which of the following actions take when suctioning the client’s airway? a. Apply suction for 10 seconds 2. A nurse is preparing to administer a long acting insulin to a client who has DM. Which of the following actions should the nurse take first? a. Check the correct dose with another licensed nurse 3. A nurse is caring for an older adult client in the PACU following gen anesthesia. Which of the following should the nurse report to the provider? a. Audible stridor 4. A nurse is planning an educational session for staff nurses about working with parents whose terminally ill children are candidates for donating their organs. Which of the following information should the nurse plan to include? a. The family can have the child in an open casket without fearing that the organ donation might disfigure the child’s body. 5. A nurse manager is planning to make changes to the current scheduling system on the unit. To facilitate the staff’s acceptance of this change, which of the following actions should the nurse manager take first? a. Provide information about scheduling issues to the staff 6. A nurse is assessing a client who is receiving a blood transfusion. Which of the following findings should indicate to the nurse that the client is having a hemolytic transfusion reaction? a. Low back pain 7. A nurse is assessing a client who has macular degeneration. Which of the following findings should the nurse expect? a. Decreased central vision 8. A nurse who is working in a long-term care facility is assessing an adult client. Which of the following findings places the client at risk for development of a pressure injury? a. Recent weight loss 9. A nurse is teaching about TPN and IV lipid emulsion with a client who has an extensive burn injury. Which of the following information should the nurse include? a. “you will receive finger sticks for blood glucose testing.” 10. A nurse is caring for a client who has dehydration secondary to nausea and vomiting. The nurse should identify which of the following findings as an indication of fluid volume deficit? a. Orthostatic hypotension 11. A nurse is caring for a client who is in labor at 39 weeks of gestation. During the second stage of labor, the nurse observes early decelerations on the monitor tracing. Which of the following actions should the nurse take? a. Continue observing the fetal heart rate 12. A nurse is caring for a client who requires physical therapy following discharge. Which of the following actions should the nurse take? a. Involve the client in the selection of a physical therapy provider 13. A nurse is assessing a client who has sickle cell anemia. The nurse should identify which of the following findings as a manifestation of vaso-occlusive crisis? a. Hematuria 14. A nurse is teaching a group of guardians about child safety measures. Which of the following statements by a guardian indicates an understanding of the teaching? a. I should have my child avoid sun exposure between 10am and 2pm 15. A nurse is caring for four clients at the beginning of a shift. After receiving change of shift report, which of the following clients should the nurse attend to first? a. A client who is confused and has been attempting to get out of bed. 16. A nurse is assessing a client who has been taking lithium carbonate for the past month to treat bipolar disorder. Which of the following assessment findings should the nurse identify as the priority? a. Confusion 17. A nurse manager is on a planning committee to develop an emergency preparedness plan. The nurse should recommend that which of the following actions takes place first when implementing an emergency preparedness plan? a. Notify the incident commander 18. A nurse is planning care for a client who is receiving hemodialysis via an established AV fistula in the right arm. Which of the following interventions should the nurse include in the client’s plan of care? a. Auscultate the affected extremity for a bruit 19. A nurse receives a request from a client to review the information in his medical record. Which of the following responses should the nurse give? a. There is a protocol for reviewing your medical record, and I can initiate the process 20. A nurse is assessing a client who has OSA. For which of the following complications should the nurse monitor? a. Hypertension 21. A nurse in an ED is assessing a client who reports taking MDMA. Which of the following should the nurse expect? a. Diaphoresis 22. A nurse is caring for a client who has a terminal illness and requests no lifesaving measure if a cardiac arrest occurs. Which of the following statements should the nurse make? a. I will provide you with information about medical treatment to include in your living will 23. A nurse is administering cyclophosphamide orally to a school-aged child who has neuroblastoma. Which of the following actions should nurse take when administering this medication? a. Maintain hydration with liberal fluid intake 24. A nurse is reviewing the UA report of a client who has glomerulonephritis. Which of the following findings should the nurse expect? a. Protein 25. A nurse is providing colostomy care for a client using a two-piece pouching system. Which of the following actions should the nurse take? a. Place the skin barrier over the stoma and hold it for 30 seconds 26. A nurse is administering meds to a client who has a percutaneous gastrostomy tube for enteral feedings. Which of the following actions should the nurse take to prevent clogging of the tube? a. Flush the client’s gastrostomy tube with 30 mL of water before administering the medication 27. A night shift nurse is giving change of shift report to the day shift nurse who is ready for discharge. Which of the following information is the priority for the nurse to communicate to the oncoming nurse? a. The client needs assistance when transferring from the bed to a wheelchair 28. A nurse is planning teaching about allowable foods for a client who has a history of uric acid-based urinary calculi formation. Which of the following food should the nurse include in the teaching? a. Oranges 29. An RN is planning care for a group of clients and is working with a LPN and AP. Which of the following tasks should the RN delegate to the LPN? a. Insertion of nasogastric tube 30. A nurse is caring for a newborn who has HSV. Which of the n=following isolation precautions should the nurse initiate? a. Contact 31. A nurse is performing gastric lavage for a client who has GI bleeding and an NG tube in place. Which of the following actions should the nurse take? a. Use NS for irrigation of the NG tube 32. A nurse is providing discharge instructions to a client following total hip arthroplasty. Which of the following instructions should the nurse include? a. Install a raised toilet seat at home 33. A nurse is reviewing lab findings of a client who is experiencing chest pain. The nurse should identify that an elevation in which of the following lab values indication cellular injury of myocardial tissue? a. Troponin 34. A nurse is talking with the partner of a client who attempted suicide. Which of the following statements by the client’s partner should the nurse identify as the priority? a. My husband doesn’t know that I’ve already moved out and filed for divorce 35. A nurse is interviewing a client who is now without a home due to a natural disaster. After ensuring the client’s safety, which of the following actions should the nurse take first? a. Determine the client’s perception of the personal impact of the crisis 36. An AP and a nurse are turning a client onto the right side. Which of the following actions by the AP requires the nurse to intervene? a. places a pillow under the client’s right arm 37. a community health nurse is performing triage tagging following a mass casualty incident. On which of the following clients should the nurse place a black tag? a. A client who has significant head trauma and agonal respirations 38. A nurse is caring for a client who has MRSA in an abd wound. Which of the following precautions should the nurse implement? a. Contact 39. A nurse is teaching a client about foods high in vitamin A. which of the following foods should the nurse recommend as having the highest amount of vitamin A? a. 1 medium raw carrot 40. a nurse is caring for a client who has a recent stroke. Prior to transferring the client to the bedside commode, which of the following actions should the nurse take first? a. Assess the client for functional limitations 41. A nurse is conducting visual acuity testing using the Snellen letter chart for a school aged child who has eyeglasses. Which of the following instruction s should the nurse give to the child? a. You should keep both eyes open during the testing 42. A nurse is caring for a client who is at 37 weeks of gestation and is experiencing abruptio placentae. Which of the following findings should the nurse expect? a. Persistent uterine contraction 43. A nurse is assessing a client who raynaud’s disease. Which of the following findings should the nurse expect? a. Blanching of the fingers and toes 44. A nurse is preparing to administer 15 units of regular insulin along with 20 units of NPH insulin. Which of the following actions should the nurse plan to take? a. Inject 20 units of air into the NPH insulin vial 45. A nurse is creating a plan of care for a child who has acute lymphoid leukemia and an absolute neutrophil count of 400/mm3. Which of the following interventions should the nurse include in the plan? a. Withhold administering the varicella vaccine to the child 46. A nurse is preparing a sterile field in order to insert an indwelling urinary catheter for a male client. Which of the of the following techniques should the nurse use to maintain surgical aseptic technique? a. Set the catheter tray on the overhead table at waist height 47. A home health nurse is assessing a 2 week old newborn who has a birth weight of 3.64 kg and is being breastfed. Which of the following findings indicates effective breastfeeding? a. The newborn has 6-8 wet diapers per day 48. A community health nurse is reviewing the medical records of four newly diagnosed clients. The nurse should identify which clients as having a nationally notifiable infectious condition? a. An adolescent client who has foodborne botulism b. 49. A nurse is caring for a client who has bipolar disorder. The nurse observes that the client is becoming increasingly restless. The client is pacing and speaking rapidly, frequently using profanities and sexual references. Which of the following actions should the nurse take first? a. Move the client to a quiet place away from others 50. A nurse in an outpatient mental health clinic is working with a client who has post- traumatic stress disorder and asks the nurse to recommend a nonpharm therapy to use to provide relief of the manifestations. Which of the following complementary therapies should the nurse teach the client to use to help alleviate the distress? a. Guided imagery 51. A case manager is reviewing the medical records of several clients. For which of the following clients should the nurse requests an inter-professional care conference a. A client who has DM and has had repeated hospitalizations for diabetic ketoacidosis 52. A nurse is caring for a client who states, “My boss accused me of stealing yesterday. I was so angry I went to the gym and worked out.” The nurse should recognize the client is demonstrating which of the following defense mechanisms? a. Sublimation 53. A nurse is caring for an older adult client. Which of the following findings should the nurse recognize as a physiological change associated with aging? a. Decreased lung expansion 54. A client who is 24 hr postop following abdominal surgery refuses to ambulate. Which of the following actions should the nurse take first? a. Ask the client to rate their pain 55. A nurse is providing discharge instructions to a client who has a new prescription for warfarin. Which of the following client statements should the nurse identify as indication that the client understands the teaching? a. I should report change in the color in my stools 56. A nurse is providing discharge teaching to a new parent about care seat safety. Which of the following statements should the nurse include in the teaching? a. Secure the retainer clip at the level of your baby’s armpits 57. A nurse is caring for a client who has an STI that must be reported to the state health department. Which of the following actions should the nurse take? a. Explain to the client to a social worker for counseling 58. A nurse is teaching a client who has a new prescription for digoxin about manifestations for toxicity. Which of the following should the nurse include in the teaching? a. Nausea 59. A nurse is providing dietary teaching to the parents of a 6-month =-old infant. Which of the following instructions should the nurse include? a. Introduce new foods one at a time over 5 to 7 days. 60. A nurse is assessing a client during the immediate postpartum period. Which of the following findings requires immediate intervention by the nurse? a. Boggy uterus 61. A nurse is caring for a client who has end-stage Alzheimer’s disease. The adult child of the client says to the nurse, “I don’t know why I bother to visit my mother anymore.” Which of the following responses should the nurse take? a. It seems like you feel your visits are a waste of time.” 62. A nurse is planning care for a client who is receiving heparin to treat a deep-vein thrombosis of the left lower leg. Which of the following should the nurse include in the plan of care? a. Elevate the affected leg 63. A nurse is an acute mental health facility as planning care for a client who has anorexia nervosa. Which of the following interventions should the nurse include in the client’s plan of care? a. Supervise the client during and after eating 64. A nurse is providing discharge instructions to a client who has a new prescription for amitriptyline to treat depression. The nurse should identify that which of the following client statements indicates an understanding of the teaching? a. I should watch for common reactions like dry mouth and constipation 65. A nurse manager is assisting with the orientation for a newly licensed nurse. Which of the following actions by the nurse requires the nurse manager to intervene? a. Tells the hospital chaplain a client’s diagnosis 66. A nurse is caring for a client who is in the first trimester of pregnancy. The client reports using acupressure bands on both wrists. Which of the following statements by the clients indicates that this therapy is having the desired effect? a. I have not vomited as much recently 67. A nurse manager is reviewing unit records and discovers that client falls occur most frequently during the hours of 0530 and 0730. Which of the following actions should the nurse take when conducting a root cause analysis a. Investigate environmental factors that might be contributing to client injury during these hours 68. A nurse is caring for a client who is immediately post op following a total vaginal hysterectomy. Which of the following actions should the nurse take first? a. Measure the client’s vital signs 69. A nurse is assessing a client who is 2 hr postop following a cardiac cath. Which of the following information should the nurse report to the provider? a. Neurologic status 70. A nurse is caring for a client who is 12 hr post op, is receiving PCA for pain control, and requires a blood pressure check in 10 min. which of the following staff members should the nurse assign to collect this information? a. An AP who is assisting a client to return to bed. 71. A nurse is planning care for a client who has a deficit with cranial nerve II. Which of the following actions should the nurse plan to take? a. Clear objects from the client’s walking area. 72. A nurse is teaching the parent of a school-age child about administering ear drops. Which of the following responses by the parent indicates an understanding of the teaching? a. I should pull the top of the ear upward and back while instilling the medication 73. A nurse is assessing a preschooler who has CF and has been receiving O2 therapy for the nurse the past 36 hr. Which of the following findings should the nurse identify is an indication that the client has developed oxygen toxicity? a. Substernal pain 74. A nurse working on a med surg unit receives a phone call requesting the status of a client from an individual who identifies themselves as the client’s parent. Which of the following actions should the nurse take? a. Ask the caller for verification of their identity 75. A nurse is assessing a client who has a skeletal traction for a femur fracture. Which of the following findings should the nurse identify as the priority? a. Upper chest petechiae 76. A charge nurse overhears two staff nurses in the hallway discussing the nutrional status of a client who has anorexia nervosa. Which of the following actions should the charge nurse take? a. Tell the nurses to stop the discussion 77. A nurse is assessing a client who has antisocial personality disorder. Which of the following manifestations should the nurse expect? a. Lack of remorse 78. A charge nurse assigns a newly licensed nurse to care for a client who has a chest tube. The nurse expresses concern about having limited experience with monitoring chest tube drainage. Which of the following actions should the nurse take first to provide teaching about chest tubes? a. Ask the nurse about their knowledge of the procedure 79. A nurse is caring for a client who has a fractured femur and has had a fiberglass leg cylinder for 24 hours. Which of the following assessment findings should the nurse identify as the priority? a. The clients heal is redden and tender. 80. A nurse is caring for a client who has a potassium level of 3mEq/L. for which of the following manifestations should the nurse monitor? a. Decreased deep tendon reflexes 81. A nurse is caring for a client who is 4 hour postpartum and has a boggy uterus with heavy lochia. Which of the following actions should the nurse take first? a. Massage the uterus to expel clots 82. A charge nurse observes a staff nurse document a dressing change in client’s chart that was not performed. Which of the following actions should the charge nurse take first? a. Gather more information about the nurse’s actions 83. A nurse is caring for an adolescent client who has a new diagnosis of terminal cancer. When discussing the client’s prognosis with the parents, the nurse should recognize which of the following responses by the parents as an example of rationalization? a. Maybe this is better for our child because we don’t want any suffering through chemotherapy treatments 84. A nurse is assessing a client who has schizophrenia and is chlorpromazine. Which of the following findings is the priority for the nurse to report to the provider a. Temperature 39.4 85. A home health nurse is providing teaching to a client who has hep A. which of the following instructions should the nurse include? a. Use hydrogen peroxide to clean kitchen surfaces 86. A nurse manager is preparing a newly licensed nurse’s performance appraisal. Which of the following methods should the nurse manager use to evaluate the nurse’s time management skills? a. Maintain regular notes about the nurse’s time management skills 87. A nurse is preparing to administer enoxaparin to a client. Identify the area the nurse should use to administer the injection a. Periumbilical area 88. A nurse is assessing a client who has multiple sclerosis. Which of the following should the nurse expect? a. Nystagmus 89. A nurse is reviewing the ABG results of client who has COPD. The results include a ph of 7.3, Pa O2 56mmHg, CO2 54, HCO3 26, O2 87 a. Uncompensated respiratory acidosis 90. A nurse is caring for a newborn whose parent asks why the baby is receiving vit k. the nurse should explain to the parent that the newborn should receive vit k to prevent which of the following? a. Bleeding 91. A nurse should is caring for a toddler who has infectious gastroenteritis. Which of the following actions should the nurse take? a. Initiate oral rehydration therapy for the toddler 92. A nurse is assessing a client who is experiencing autonomic dysreflexia. Which of the following should the nurse expect? a. Facial flushing, nasal congestion, headache 93. A nurse in a clinic receives a call form a guardian whose child has varicella. The guardian asks when the child can return to school. Which of the following should the nurse make? a. When crusts have formed on every lesion 94. A nurse is caring for a client who si at 28 weeks of gestation. The client asks the nurse to explain what causes her to have constipation. Which of the following responses should the nurse make? a. The enlarged uterus compresses the intestines and causes constipation 95. A nurse is initiating dc planning for a client who has a stroke and is experiencing right- sided weakness. Which of the following actions should the nurse take first? a. Request a referral for the client to receive physical therapy 96. A nurse is providing teaching to an adolescent following insertion of a tunneled central venous catheter. Which of the following information should the nurse include in the teaching? a. You should keep the catheter clamped when not in use 97. A nurse is assessing a client who has schizophrenia. The nurse should identify the following alteration in speech as which of the following? a. Clang association 98. A nurse is taking caring of a child who is experiencing a tonic-clonic seizure. Which of the following actions should the nurse take? a. Place the child in a side lying position 99. A nurse is preparing to administer 2 units of fresh frozen plasma to a client. Which of the actions should the nurse plan to take? a. Enter the plasma product number into the client’s medical record 100. A home health nurse is planning care for an older adult client who has impaired vision. Which of the following interventions should the nurse include in the plan of care to prevent injury at home? a. Mark the edges of stairs for contrast 101. A nurse is providing teaching about improving nutrition for a client who has multiple sclerosis. Which of the following instructions should the nurse include? a. A speech pathologist, should rest before eating meal, thicken beverages before drinking 102. A nurse in the delivery room is caring for a newborn immediately after birth. Which of the following actions should the nurse take? a. Dry the newborn 103. A home health nurse is proving teaching about infection prevention to a client who has cancer and is receiving chemotherapy. Which of the following statements by the client indicates an understanding of the teaching? a. I will walk short distances throughout the day 104. A nurse is teaching a newly admitted client who has heart failure about advance directives. Which of the following statements should the nurse make? a. You should complete advanced directives in the event you cannot express your own wishes 105. A nurse is teaching a client who has a new prescription for estradiol. For which of the following adverse effects of this medication should the nurse instruct the client to monitor and report to the provider? a. Headaches 106. A nurse in an emergency department is preparing to dc a client who has experienced intimate partner violence. Which of the following actions should the nurse take first? a. Develop a safety plan with the client 107. A nurse is caring for a client who is the manic phase of bipolar disorder. Which of the following manifestations should the nurse expect? a. Grandiose delusions 108. A charge nurse is observing a newly licensed nurse administer enteral feedings via NG tube. Which of the following actions by the newly licensed nurse indicates an understanding of the procedure? a. Keeps the HOB elevated to 45 degrees for 1 hr after feedings 109. A nurse is proving client education to a post-partum client who has decided to bottle feed the newborn. Which of the following instructions should the nurse include in the teaching to help prevent the discomfort of engorgement? a. Place ice packs on the breasts for 15 min several times a day 110. A nurse is preparing to perform an intermittent urinary cath for a client who has urinary retention. Which of the following images indicates the catheter the nurse should use? a. Straight cath 111. A nurse is teaching a client who has opioid use disorder about methadone. Which of the following information should the nurse include in the teaching? a. Sedation is a common adverse effect of this medication 112. A charge nurse is planning care for a client who has mechanical restraints in place. Which of the following interventions should the nurse include in the plan? a. Provide a staff member to stay with the client continuously 113. A nurse is assessing a newborn who is 2 hr old. Which of the following findings should be reported to the provider? a. Axillary temp 36.2 114. A nurse is teaching a client who is to start taking misoprostol and currently is on long-term therapy with NSAIDs for arthritis. The nurse should provide the client with which of the following instructions? a. Complete a serum pregnancy test before taking the medication 115. A nurse is caring for a client who vomits on a reusable BP cuff. Which of the following actions should the nurse take? a. Place the BP cuff in a labeled bag to send it for decontamination 116. A nurse is teaching home wound care to the family of a child who has a large wound. Which of the following interventions should the nurse recommend? a. Double bag soiled dressings in plastic bags for disposal 117. A charge nurse is preparing to administer 0900 medications and is told by the pharmacy staff that the medications are not available. Medication availability has been an ongoing problem, and the charge nurse previously discussed this issue with the pharmacy staff. Which of the following actions should the charge nurse take first? a. Inform the nurse manager of the issue. 118. A nurse is providing discharge teaching to a client with who has colorectal cancer and a new colostomy. The client states, “Im worried about being discharged because I live alone, and my insurance does not cover ostomy supplies.” a. Refer client to community based social worker, initiate a consult with a home health care provider, give the client information about local support group 119. A nurse is caring for a client who has hypertension and is taking captopril. Which of the following tasks should the nurse delegate to an assistive personal? a. Obtain the client’s blood pressure before the nurse administers medication 120. A nurse is caring for a group of clients. For which of the following events should the nurse complete an incident report? a. A client’s IV pump delievers an inadequate dose of medication 121. A nurse is teaching the parents of a toddler about snacks. Which of the following foods should the nurse recommend? a. Diced steamed carrots 122. A mental health nurse is conducting the first of several meetings with a client whose partner recently died. The nurse should perform which of the following actions to establish trust during the orientation phase of the nurse-client relationship? a. Establish the termination date of therapy 123. A nurse is providing teaching to a client about newborn safety. Which of the following statements should the nurse include in the teaching? a. Set your hot water heater temp at or below 120 degrees F 124. A nurse is assessing a client who has a stage II pressure injury. Which of the following wound characteristics should the nurse expect? a. Partial-thickness skin loss 125. A nurse on a mental health unit is caring who tells the nurse that she does not want to receive a scheduled dose of lorazepam IM. Which of the following actions should the nurse take? a. Document the client’s refusal of the medication 126. A nurse is caring for a toddler who is admitted to the pediatric unit for surgery. Which of the following should the nurse include in the toddler’s plan of care? a. Encourage the parents to bring toys from home 127. A nurse is caring for a client who has generalized anxiety disorder and is to begin taking alprazolam. Which of the following actions should the nurse take? a. Initiate fall precautions 128. A client is receiving lorazepam IV for panic attacks and develops a resp rate of 6/min and a BP of 90/44 mmHg. Which of the following medications should the nurse anticipate administering? a. Flumazenil 129. A nurse is assessing a 2-month old during a well-baby exam. Which of the following action should the nurse take to assess the infant’s rooting reflex? a. Stroke the infant’s cheek 130. A charge nurse is observing a newly licensed nurse performing a physical assessment on a client. Which of the following actions by the nurse indicates that the charge nurse should intervene? a. The newly licensed nurse writes detailed notes while performing the head-to-toe assessment 131. A charge nurse is teaching a newly licensed nurse how to identify true labor. Which of the following should the nurse include in the teaching? a. The cervix transitions to an anterior position 132. A nurse is performing an admission assessment of a preschooler who is in the acute phase of kawasaki disease. Which of the following findings should the nurse expect? a. Fever unresponsive to antipyretics 133. A nurse is caring for client who is receiving TPN solution by continuous IV infusion at 60mL/hr. The nurse discovers the infusion pump has stopped working. Which of the following actions should the nurse take while waiting for a new infusion pump? a. Provide dextrose 10% in water solution using manual drip tubing at 60ml/hr 134. A nurse is teaching the parents of a preschooler about sleep promotion. The parents report that their child is demonstrating reluctance in going to bed at night and states, “im not tired.” Which of the following statement by the parents indicates an understanding of the teaching? a. We should read a story together every night before bedtime 135. A nurse is caring for four clients. Which of the following should the nruse assign to an AP to assist with meals? a. A client who has Alzheimer’s disease and is demonstrating aphasia. 136. A nurse is providing teaching to a parent of a child who has a permanent trach tube. Identify the sequence of steps to the parent should follow to perform trach care. a. Remove inner cannula, remove soiled dressing, clean stoma, change trach collar 137. A nurse is caring for a client who has a closed head injury and is receiving mechanical ventilation. The nurse should expect to administer which of the following medications to reduce intracranial pressure? a. Mannitol 138. A nurse on a med-surg unit is caring for a client prior to surgical procedure. Which of the following findings should indicate to the nurse that the client has the ability to sign the informed consent? a. The client is able to accurately describe the upcoming procedure 139. When caring for a child, a nurse plans to use nonpharm interventions to enhance the effectiveness of pain medications. Which of the following strategies incorporates visualization techniques to help decrease the child’s discomfort? a. Blowing bubbles with liquid soap to “blow the hurt away” 140. A community health nurse is assisting with the development of a disaster management plan. The nurse should include which of the following nursing responsibilities in the disaster response stage of the plan? a. Performing a rapid needs assessment 141. A nurse is planning care for a client who has thrombocytopenia. Which of the following instructions should the nurse include in the client’s plan of care a. Avoid venipunctures when possible 142. A nurse is reviewing the medical record of a client who has schizophrenia and is to start taking clozapine. Which of the following findings should the nurse identify as a contraindication for the client to receive clozapine? a. WBC count 2,800/mm3 143. A nurse in an emergency department is admitting a client who has cardiac tamponade. Which of the following assessment findings should the nurse expect? a. Pulsus paradoxus 144. A community health nurse is preparing a health education program for a local rural community. Which of the following actions should the nurse plan to take first? a. Identify health-related issues within the community 145. A nurse is providing discharge teaching to a client following a cataract extraction. Which of the following statements by the client indicates an unerstadning of the teaching? a. I will bend at my knees when picking an object off the floor 146. A nurse is preparing to insert an indwelling urinary cath for a client. The nurse should assess the client for which of the following conditions prior to starting the procedure? a. Latex allergy 147. A nurse is assessing a school aged child who has CF. which of the following findings is the priority for the nurse to report to the provider? a. Hemoptysis 275mL/hr 148. A nurse is assessing a client who has delirium. Which of the following manifestations should the nurse expect? a. Rapid speech