CORRECT WELL DETAILED
A nurse is reinforcing teaching with an adolescent who has a new prescription for cefazolin.
For which of the following findings should the nurse instruct the adolescent to monitor and
report to the provider? - ANSWER Depression
A nurse is caring for a school-age child who has epistaxis. Which of them following actions
should the nurse take? - ANSWER Apply pressure at the bridge of the child's nose
A nurse is reinforcing teaching with a group of expectant parents regarding the proper use of
a car seat. Which of the following statements by a parent indicates an understanding of the
teaching? - ANSWER I can place a rolled towel on each side of my newborns head until
he can hold his head up
A nurse working in an inpatient mental health facility is assisting with the plan of care for a
client who has anorexia nervosa. Which of the following should the nurse recommend to
include in the plan of care? - ANSWER Maintain continuity of staff members.
A nurse is assisting with an admission interview for a client who has schizophrenia. He tells
the nurse that he is receiving special audible messages from the Central Intelligence Agency
that no one else is able to hear. The nurse should identify that the client is having which of
the following alterations in perception? - ANSWER hallucination
A nurse is reinforcing teaching with a postpartum client about bathing her newborn. Which
of the following statements should the nurse include? - ANSWER "Wash your
newborn's head under a stream of running water."
1
,A nurse is caring for a client who has heart failure and reports difficulty limiting sodium in his
diet. Which of the following recommendations should the nurse provide? -
ANSWER Replace bottled salad dressing with homemade vinegar and oil dressing.
A nurse is reinforcing teaching with a client who is scheduled for a mammogram. Which of
the following instructions should the nurse include in the teaching? - ANSWER Refrain
from using deodorant on the morning of the test
A nurse is preparing a clients insulin regimen. Which of the following insulin's can be mixed?
- ANSWER Insulin aspart, regular insulin, insulin lispro
A nurse is reinforcing discharge teaching with a client who is postoperative following laser
surgery for open-angle glaucoma. Which of the following statements by the client indicates
an understanding of the instructions? - ANSWER I will take a stool softener to prevent
constipation
A nurse is collecting data from a child who has acute Glomerulonephritis. Which of the
following findings should the nurse expect? - ANSWER Periorbital edema
A nurse is preparing to administer a liquid medication to a 6-month-old infant who is crying.
Which of the following actions should the nurse take to reduce the risk of aspiration? -
ANSWER Administer using a needless syringe in the buccal cavity
A nurse is reinforcing teaching with a client who plans to bottle feed her newborn. Which of
the following statements indicates an understanding of the instructions? - ANSWER I
will feed my baby six to eight times a day
A nurse is administering a cleansing enema to a client who reports mild cramping during
instillation of the solution. Which of the following actions should the nurse take? -
ANSWER Slow the rate of instillation
2
, A nurse receives report on four clients. The nurse should first collect data about the client
who has which of the following? - ANSWER A decreased level of consciousness and
vomiting
A nurse is setting up a sterile field prior to performing a dressing change. Which of the
following actions should the nurse take? - ANSWER Open the outermost flap of the
wrapper toward the body
A nurse in long-term care facility has received change-of-shift report about four clients.
Which of the following clients should the nurse attend to first? - ANSWER A client who
has COPD and dementia and was agitated during the night shift
A nurse is collecting data from a client who has substance use disorder and reports recently
taking opioids. Which of the following findings should the nurse identify as a manifestation
of opioid intoxication? - ANSWER pinpoint pupils
A nurse in a urgent care clinic is collecting data from a client who reports having diarrhea for
the past 3 days. Which of the following findings indicates hypokalemia? -
ANSWER muscle weakness
A nurse is caring for a client who has bipolar disorder and is experiencing mania. Which of
the following actions should the nurse take? - ANSWER Frequently remind the client of
the expectations for her behavior
A nurse is caring for a client who has viral pneumonia. Which of the following actions should
the nurse take? - ANSWER Administer Azithromycin
A nurse who orienting to a medical-surgical unit is having difficulty finishing client care tasks
during his shift. Which of the following suggestions should the nurse's preceptor make to
help the nurse with time management? - ANSWER Try to complete a task before
moving on to the next.
3
A nurse is reinforcing teaching with an adolescent who has a new prescription for cefazolin.
For which of the following findings should the nurse instruct the adolescent to monitor and
report to the provider? - ANSWER Depression
A nurse is caring for a school-age child who has epistaxis. Which of them following actions
should the nurse take? - ANSWER Apply pressure at the bridge of the child's nose
A nurse is reinforcing teaching with a group of expectant parents regarding the proper use of
a car seat. Which of the following statements by a parent indicates an understanding of the
teaching? - ANSWER I can place a rolled towel on each side of my newborns head until
he can hold his head up
A nurse working in an inpatient mental health facility is assisting with the plan of care for a
client who has anorexia nervosa. Which of the following should the nurse recommend to
include in the plan of care? - ANSWER Maintain continuity of staff members.
A nurse is assisting with an admission interview for a client who has schizophrenia. He tells
the nurse that he is receiving special audible messages from the Central Intelligence Agency
that no one else is able to hear. The nurse should identify that the client is having which of
the following alterations in perception? - ANSWER hallucination
A nurse is reinforcing teaching with a postpartum client about bathing her newborn. Which
of the following statements should the nurse include? - ANSWER "Wash your
newborn's head under a stream of running water."
1
,A nurse is caring for a client who has heart failure and reports difficulty limiting sodium in his
diet. Which of the following recommendations should the nurse provide? -
ANSWER Replace bottled salad dressing with homemade vinegar and oil dressing.
A nurse is reinforcing teaching with a client who is scheduled for a mammogram. Which of
the following instructions should the nurse include in the teaching? - ANSWER Refrain
from using deodorant on the morning of the test
A nurse is preparing a clients insulin regimen. Which of the following insulin's can be mixed?
- ANSWER Insulin aspart, regular insulin, insulin lispro
A nurse is reinforcing discharge teaching with a client who is postoperative following laser
surgery for open-angle glaucoma. Which of the following statements by the client indicates
an understanding of the instructions? - ANSWER I will take a stool softener to prevent
constipation
A nurse is collecting data from a child who has acute Glomerulonephritis. Which of the
following findings should the nurse expect? - ANSWER Periorbital edema
A nurse is preparing to administer a liquid medication to a 6-month-old infant who is crying.
Which of the following actions should the nurse take to reduce the risk of aspiration? -
ANSWER Administer using a needless syringe in the buccal cavity
A nurse is reinforcing teaching with a client who plans to bottle feed her newborn. Which of
the following statements indicates an understanding of the instructions? - ANSWER I
will feed my baby six to eight times a day
A nurse is administering a cleansing enema to a client who reports mild cramping during
instillation of the solution. Which of the following actions should the nurse take? -
ANSWER Slow the rate of instillation
2
, A nurse receives report on four clients. The nurse should first collect data about the client
who has which of the following? - ANSWER A decreased level of consciousness and
vomiting
A nurse is setting up a sterile field prior to performing a dressing change. Which of the
following actions should the nurse take? - ANSWER Open the outermost flap of the
wrapper toward the body
A nurse in long-term care facility has received change-of-shift report about four clients.
Which of the following clients should the nurse attend to first? - ANSWER A client who
has COPD and dementia and was agitated during the night shift
A nurse is collecting data from a client who has substance use disorder and reports recently
taking opioids. Which of the following findings should the nurse identify as a manifestation
of opioid intoxication? - ANSWER pinpoint pupils
A nurse in a urgent care clinic is collecting data from a client who reports having diarrhea for
the past 3 days. Which of the following findings indicates hypokalemia? -
ANSWER muscle weakness
A nurse is caring for a client who has bipolar disorder and is experiencing mania. Which of
the following actions should the nurse take? - ANSWER Frequently remind the client of
the expectations for her behavior
A nurse is caring for a client who has viral pneumonia. Which of the following actions should
the nurse take? - ANSWER Administer Azithromycin
A nurse who orienting to a medical-surgical unit is having difficulty finishing client care tasks
during his shift. Which of the following suggestions should the nurse's preceptor make to
help the nurse with time management? - ANSWER Try to complete a task before
moving on to the next.
3
