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A charge nurse in a long term care facility notices an assistants repeated failure to
provide oral care for clients. Which of the following actions should the nurse take? -
CORRECT ANSWER Discuss the unacceptable behavior with the AP while reinforcing
expectation
owns.
A Nurse is reinforcing teaching with a male client who is uncircumcised about obtaining
a clean-
catch midstream urine specimen. Identify the sequence of actions the client should take
after washing his hands. - CORRECT ANSWER -Retract the foreskin to expose
the glans
-Cleanse the penis using an antiseptic swab
-Begin to urinate
-Pass the urine container
into the stream
-Collect the specimen
-Move the container out of the stream
-Replace the foreskin
A nurse is reinforcing teaching with a client who has a new diagnosis of type diabetes
mellitus and inquires about information concerning oral anti diabetic agents. I in addition
to the provider, where should the nurse refer the client for information? - CORRECT
ANSWER A pharmacist
Package inserts
American Diabetes Association
A nurse is reinforcing discharge instructions with the parent of an
infant who has rote iris. which of the following statements by the parent indicates an
understanding of the teaching? - CORRECT ANSWER "I will amply diaper cream to my
baby's skin during each diaper change."
A nurse is caring for a client who is scheduled for surgery in the morning. The nurse I
earns that the client has decided not to have surgery even though he has already
signed the informed consent form. Which of the following actions should the nurse take?
- CORRECT ANSWER Report the situation to the provider who obtained the
informed consent.
,A nurse has to administer medications to a group of clients. For which of the following
client situations should the nurse complete and incident report? - CORRECT ANSWER
The nurse administered insulin lisper to a client who has diabetes mellitus and is NPO.
a nurse is collecting data from a client who is experiencing a situational crisis following
the loss of a job. The client states, I don't think I can go through this again. Which of the
following actions is the nurse's priority? - CORRECT ANSWER Determine if the client is
experiencing psychotic thinking.
A nurse is reinforcing discharge teaching with a client who is 48 hr. post op from a ma
otectomy. Which of the following statements by the client indicates an understanding of
the teaching? - CORRECT ANSWER "I will wear rubber gloves whenever I wash dishes
or do yard work."
A nurse is reinforcing teaching with a client who has a type 2 diabetes mellitus and
reports waking during the night with tremors and anxiety. which of the following inform
action should the nurse provide to help the client manage his symptoms? - CORRECT
ANSWER Eat a bedtime snack
a Nurse is reinforcing teaching about home care for conjunctivitis with the parent of a
school age child. which of the following information should the nurse include? -
CORRECT ANSWER Separate the child's used washcloth from those of others.
A Nurse prescribes levothyroxine 0.3 PO daily for a client.
Available is levothyroxine 1 50mcg/tablet. How many tablets should the nurse
administer? - CORRECT ANSWER 2
a nurse is collecting data from an older adult client during routine physical exam. Which
of the following client statements should the nurse identify as a possible indication of
abuse? - CORRECT ANSWER "My son took my wallet so he can keep track of what I'm
spending."
A nurse is assisting with a presentation at a community center about personal disaster
preparedness. which of the following strategies should the nurse recommend for
preparing a home disaster supply kit? - CORRECT ANSWER Have a supply of
prescribed medications.
A nurse is reinforcing teaching on food selection with a client who has a moderate burn
injury. Which of the following foods should the nurse recommend as being high in
Vitamin C. - CORRECT ANSWER tomatoes
A nurse on a medical surgical unit is delegating tasks to an assistant. Which of the
following tasks should the nurse delegate to the Assistant? - CORRECT ANSWER
Obtaining a client's vital signs prior to discharge
, A Nurse is caring for a client in Buck's Traction. Which of the following actions should
the nurse take? - CORRECT ANSWER Allow the weights to hang freely.
A nurse in a long term care facility is contributing to the plan of care for a client who has
a new ostomy. Which of the following
actions should the nurse plan include? - CORRECT ANSWER Change the appliance
two times each week.
A nurse is receiving report on 4 clients Which of the following clients should the nurse
plan to see first. - CORRECT ANSWER A client who has pneumonia and a new onset
of confusion
A nurse is reinforcing discharge teaching with a client who has a t Tube in place follow
wing a cholecystectomy. Which of the following instructions should the nurse include in
the teaching? - CORRECT ANSWER Empty the drainage bagses each day at the same
time.
A nurse is assisting with monitoring a client who is in labor and has spontaneous
rupture of membranes following a vaginal examination. The provider reports the client's
car vex is dilated to 1 cm with an unengaged presenting part. Which of the following
actions should the nurse take? - CORRECT ANSWER Apply the external fetal heart
rate monitor.
A Nurse is collecting data from a client who has bipolar disorder and is experiencing
acute mania. Which of the following findings is the nurse's priority? - CORRECT
ANSWER lack of sleep
A nurse is assisting with the plan of care for a client following a
transurethral resection of the prostate. Which of the following interventions should the
nurse include in the plan of care? - CORRECT ANSWER The nurse should irrigate the
bladder using strict sterile technique and maintain closed catheter drainage system to
minimize the risk of infection.
A nurse is reviewing a client's electronic medical record and finds that an assistive per
sonnet recorder the client's temperature as 35.3 degrees Celsius (95.5 degrees F) 2
hrs. earlier. Which of the following actions should the nurse take first? - CORRECT
ANSWER check the clients temp
A nurse is receiving change-of-
shift report for four clients. Which of the following clients should the nurse see first? -
CORRECT ANSWER A client whose urinary output was 100mL for the past 12 hrs.
A nurse in reinforcing teaching about weight loss with a female older adult client who is
overweight. Which of the following statements should the nurse include in teaching? -
CORRECT ANSWER keep fat intake to no more that 30% of daily caloric intake.