PN Comprehensive Predictor Latest Review

1. A nurse is caring for four clients. Which of the following client statements should the nurse attend to first?: "My heartburn pain is going into my jaw now." 2. A nurse is caring for a client who is receiving mechanical ventilation via an endotracheal tube. Which of the following actions should the nurse take?: Perform oral care every 2 hr. 3. A nurse is caring for a client who is receiving warfarin 5 mg PO daily. Which of the following laboratory values should the nurse check prior to administering the medication?: - PT - INR 4. A nurse is collecting data from a client who is at 9 weeks of gestation and has hyperemesis gravidarum. Which of the following findings should the nurse expect?: Weight loss 5. A nurse is reinforcing teaching with a client about the importance of a low sodium diet. Which of the following foods should the nurse recommend as the best choice to include in a low sodium diet?: 2 tbsp of peanut butter 6. A nurse is collecting data from an 18 month old toddler at a well child visit. Which of the following findings should the nurse report to the provider?: The toddler can say four words. 7. A nurse is collecting data from a client who has diabetes mellitus. Which of the following findings indicates that the client might be experiencing diabetic ketoacidosis?: Kussmaul respirations 8. A nurse is reinforcing teaching with a client who has a permanent pace- maker in place. Which of the following statements by the client indicates an understanding of the teaching?: "I need to record my pulse rate daily." 9. A nurse is caring for a client who is in mechanical restraints after becom- ing violent with a staff member. Which of the following actions should the nurse take?: Document in the clients medical record every 15 min. 10. A nurse is reinforcing teaching about self-administration of nasal drops with a client. Which of the following positions should the nurse recommend for instillation of the drops?: Supine 11. A nurse is preparing to administer furosemide to a client who has heart failure. Which of the following laboratory results should the nurse review prior to administering the medication?: Potassium 12. A nurse is caring for a client who has methicillin-resistant staphylococ- cus aureus (MRSA) infection. Which of the following actions should the nurse plan to take?: Don a gown and gloves when providing perineal care 13. A nurse is assisting with the plan of care for a client who has dementia and often wanders in the halls at night. Which of the following interventions should the nurse recommend including in the plan of care?: Labeling the clients bathroom door 14. A charge nurse is reinforcing teaching with a newly hired licensed prac- tical nurse about scope of practice. Which of the following responsibilities should the nurse include in the teaching?: Providing direct client care 15. A nurse is working on a mental health unit is meeting with a client who has been in the unit for 2 days. The nurse greets the client and asks, "What has been happening with you today?" Which of the following therapeutic techniques is the nurse using?: Reflecting 16. A nurse us reinforcing teaching with a group of expectant parents regard- ing the proper use of a car seat. Which of the following statements by a parent indicates an understanding of the teaching?: "I will secure the seat belt across my newborns lap." 17. A nurse from a medical surgical unit is floating to a postpartum unit. Which of the following clients is an appropriate assignment for the nurse to accept?: A client who underwent removal of a retained placenta 18. A nurse is assisting with planning care for a newly admitted client who has anorexia nervosa. Which of the following interventions should the nurse recommend to include in the plan of care?: Reinforce teaching about healthy eating during meals 19. A nurse is admitting a client who is scheduled for an elective surgery. Which of he following actions should the nurse take to verify the status of the clients advance directives?: Ask the client whether they have advance directives 20. A nurse is collecting data from a client who is receiving a continuous IV infusion of 0.9% sodium chloride. The nurse discovers the IV infusion pump was set incorrectly and the client received 200 ml more than prescribed. Data collection reveals that the client is stable. The nurse recognizes that this inci- dent is not considered malpractice for which of the following reasons?: The client was not harmed as a result of the incident 21. A nurse is caring for a client who has COPD. The nurse should identify that which of the following findings is the priority to report?: Productive cough with green sputum 22. A nurse is caring for a newborn who just had a circumcision. Which of the following findings should the nurse identify as a nonverbal sign of pain?: The newborn continues to cry despite efforts to console 23. A nurse is reinforcing teaching with a parent about appropriate snacks for a toddler. Which of the following foods should the nurse include?: Graham crackers 24. A nurse is caring for a client who is breastfeeding their 5-day old newborn. Which of the following should the nurse identify as an indication that the newborn is breastfeeding effectively?: Makes audible swallowing sounds 25. A nurse is reinforcing teaching with a client who has a new diagnosis of myasthenia gravis (MG) and a prescription for neostigmine. Which of the following information should the nurse include about the action of the medication?: Improves muscle strength 26. A nurse is reinforcing teaching with the parents of a newborn who had a circumcision. Which of the following client statements indicates understand- ing of the teaching?: "I will apply petroleum jelly to the penis with each diaper change." 27. A nurse is collecting data from a 3 month old infant who is 6 hr postoper- ative following a cleft palate repair. Which of the following pain rating tools should the nurse use?: FLACC scale 28. 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?: Pinpoint pupils 29. A nurse is checking the home environment of a client for safety hazards. Which of the following items require intervention by the nurse?: The dining room table has low chairs with no armrests 30. A nurse is preparing to administer medication to a newborn. Which of the following information should the nurse use to identify the newborn?: Name and medical record number Footprints and identification number