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A nurse is delegating client care assignments. Which of the following tasks should the nurse assign to the assistive personnel? Apply an anti-embolic stocking for a client who is 2 days post-op A nurse is caring for a client following an electroconvulsive therapy. What nursing action? Continuously reorient client after ECT A nurse is caring for a client who is taking multiple medications about the possible interactions. Which of the following members of the interdisciplinary team should the nurse make a referral to? Advance practice nurse A nurse manage is taking measures to increase cost effective. In which of the following client situations should the nurse manager intervene? A nurse uses sterile gauze pads to place a dressing on a surgical wound. A nurse is contributing to the plan of care for client who has ascites due to cirrhosis. Which of the following interventions should the nurse recommend including in the plan? Measure the client's abdominal girth daily A nurse in an urgent care clinic is caring for a client who reports recently using methylenedioxy-methamphetamine. Which of the following findings should the nurse expect? Hallucinations A nurse preparing a sterile field to perform a dressing change for a client's leg wound. Which of the following actions should the nurse take? Place sterile objects at least 2.5 cm from the edge of the sterile field. A nurse is reinforcing teaching with a client who has a new rx for transdermal nitroglycerin patches. Which of the following statements by the client indicates an understanding of the teaching? I will place the patch on a hairless area of skin A nurse is reinforcing with a new mother on facility security measures. Which of the following statements by the mother indicates an understanding of the teaching? I will have an ID band that matches the one my baby wears • A nurse begins to bathe a newly admitted client who reports that she has not had anything to eat that day, the nurse interrupts the bath and obtains a healthy meal for the client. This action by the nurse is an example of which of the following? Boundary crossing A nurse enters the room of a school aged child and finds him on the floor experiencing a tonic colonic seizure, which of the following actions should the nurse take? Place a pillow under the client's head A nurse is providing support to the family of a school aged child who has a new diagnosis of a terminal illness, which of the following actions should the nurse take? Provide the family with time to talk openly A nurse is checking for gastric residual volume on the client who is scheduled to receive an intermittent enteral feeding. The nurse finds that the client has a GRV greater than 250 mLs on two consecutive measurements, which of the following actions should the nurse take? Hold the feeding and recheck the GRV in one hour A nurse in a clinic is reviewing the medical record of a toddler and notes that he previously had a severe allergic reaction to a gelatin, which of the following immunizations should the nurse identify as unsafe for this client to receive? Measles Mumps and Rubella (MMR) A nurse is reinforcing teaching with a client who has a prescription for antibiotic therapy. The client tells the nurse that he always experiences diarrhea when taking antibiotics, which of the following food choices should the nurse recommend to lessen the occurrence of diarrhea? Yogurt A home health nurse is caring for a client who has Alzheimer's disease. the client's son is concerned about his mother becoming frustrated. which of the following interventions should the nurse include? make a schedule for daily tasks A nurse is caring for an adolescent client who has bulimia nervosa, which of the following actions should the nurse take? Observe the client during and after meals A nurse is participating in a performance improvement program which of the following actions should the nurse take to evaluate the effectiveness of the program? perform chart audits A nurse is talking to a client who refuses a blood transfusion for religious reasons. which of the following responses should the nurse make? you have the right to change your mind A nurse is assisting with staff education about hand hygiene. which of the following should the nurse include in the teaching? wash your hands with soap and water for 20 seconds A nurse is assisting with a community health course for family members of clients who half Alzheimer's disease. which of the following should the nurse include? limit the number of choices for the client • A nurse in a provider's office is collecting data from an 18-month-old toddler which of the following should the nurse identify as a potential indication of child mal-treatment? the toddler is overly affectionate towards the nurse A nurse is contributing to the plan of care for a client who has ascites due to chromosols, which of the following should the nurse recommend including in the plan? measure the client's abdominal girth A nurse is caring for a client who is experiencing alcohol withdrawal the nurse should prepare to administer which of the following medications? diazepam A nurse is preparing to delegate care to assistive personnel. Which of the following information should the nurse verify prior to delegation? The AP's job description A nurse is caring for a client who has paranoid schizophrenia and believes that she is being followed by the FBI agents who are pretending to be psychiatric staff. Which of the following responses should the nurse make? What makes you think the staff is following you? A nurse is reinforcing teaching with a client who has GERD and a prescription for ranitidine. Which of the following statements by the client indicates an understanding of the teaching? I should take this medication in the morning and at bedtime A nurse is reinforcing teaching with new parents about car seat safety. Which of the following instructions should the nurse include? Position the car seat at 90-degree angle A nurse is collecting data from a client who is 2 days postpartum. The client tells the nurse she cannot afford to pay for baby formula. The nurse should refer the client to which of the following members of the intra-professional team? Case manager A community health center is assisting in the development of a brochure about hypertension. Which of the following action should the nurse take? explain medical terminology using basic one syllable words A community health nurse is assisting with the development of a pamphlet regarding choking hazard for toddlers. Which of the following foods should the nurse include? grapes A nurse is caring for a who has a new diagnosis of diabetes mellitus and is refusing to learn how to self-administer insulin. Which of the following responses should the nurse make? "I'd like to hear your thoughts about giving yourself this medication" A nurse is implementing a bladder training program for a client who had a stroke. Which of the following interventions should the nurse make? check for residual after voiding A nurse is preparing change of shift report on a client who is 2 days postoperative following a total knee arthroscopy (or arthroplasty). Which of the following information about the client should the nurse include in the report? time of last pain medication A nurse is caring for a client who is 2 days following an above-the-knee amputation. Which of the following actions should the nurse take to promote progression to independence and mobility for the client? Encourage the client to use the overhead trapeze . A nurse at a pediatric clinic is checking the vital signs of a 2 month old infant prior to administering immunization. The nurse should recognize respiratory rate is 30/min. This indicates that the respiratory rate is? Within the expected range A nurse in a clinic is collecting data with a client who had a vaginal birth 6 weeks ago. Which of the following findings should the nurse expect? Reported Lochia Alba A nurse is reinforcing discharge teaching with a family of a client who has dependent personality disorder. What action should the nurse take? Encourage the client to be assertive A charge nurse in the long-term care facility notices the smell of alcohol from one of the nurse's breath. Which oc the following actions should the nurse take first? Remove the nurse from the client care area A nurse is supervising an assistive personnel. Which of the following actions by the AP indicates an effective use of client care materials? Wears clean gloves when assisting client with oral care A nurse is preparing to administer spironolactone and lisinopril to a client who reports anxiety, dyspnea, and weakness of the leg. Which of the following actions should the nurse take first? Withhold the prescribed medication A nurse is assisting with the care of a client who is receiving chemotherapy and radiation for advanced breast cancer. The client states, "I'm "Tell me more about what you are thinking." A nurse is RT with a client who is 35 weeks gestation who will undergo a contraction stress test. WOTF information should the nurse include in the teaching? You will lie flat on your back for the test A nurse is collecting data from a client who represents the facility and who reports vomiting. WOTF findings indicate that the client is experiencing Fluid Volume deficit? Orthostatic hypotension A nurse is reinforcing dietary teaching for a client who is 37 weeks gestation and has gestational hypertension. WOTF foods should the nurse recommend? (SATA) - raw apple - cooked carrots A client who has cancer is being discharged to home with hospice services. The client has a prescription for oxycodone for pain control. WOTF medications should the nurse remind the client to take regularly to prevent a common adverse effect of this medication? Docusate Sodium (stool softener) A nurse is caring for an adolescent client who has been hospitalized for several weeks. WOTF actions should the nurse take relative to the client's developmental stage? Arrange for uninterrupted visitations with friends A nurse is RT with a parent of a preschool age child who has a new diagnosis of varicella. WOTF statements indicate an understanding of the teaching? I will apply an antipruritic cream to my child's skin A nurse is caring for a client who is experiencing urge incontinence and limited dexterity. WOTF actions should the nurse take? Establishing urinary habit program A nurse is reinforcing teaching with a client about intermittent catheterization to measure residual urine. WOTF information should the nurse include in the teaching? You will need to urinate before A nurse at a long-term care facility is reviewing the PoC of a client who has a prescription for mitten restraints. WOTF tasks does the nurse assign to the assistive personnel? Assist with ROM of the hand A nurse is RT with a client who has primary open-angle glaucoma and a new prescription for Timolol eye drops. WOTF statements by the client indicates an understanding of the teaching? I should check my heart rate while taking this medication A nurse is obtaining a health history from a client who wants to take oral contraceptives. WOTF findings is the nurse's priority? smoking A home health nurse is preparing to set up a continuous passive motion machine for a client who is post-op following a total knee replacement. WOTF actions should the nurse respond to take first? Inspect the CPM machine and electrical cords for possible damage A nurse is preparing to administer morphine 30mg to a client who reports pain. Available morphine is 20mg/mL 1.5 mL A nurse is RT about hand hygiene to a newly licensed nurse. WOTF information should the nurse include in her teaching? Interlace the fingers while rubbing hands together A nurse is reinforcing dietary teaching with a client who experienced a myocardial infarction. The nurse should encourage the client to limit WOTF? Saturated fats A nurse is RT with the family of a client who is terminally ill about the grief process. WOTF information should the nurse include in the teaching? Anger towards the health care staff is expected A nurse is collecting data from a client who has diabetic Ketoacidosis. WOTF should the nurse expect? fruity breath A nurse in the long term facility is caring for an older adult client who has a history of hypertension. WOTF findings should the nurse recognize as an indicative sign of a Transient Ischemic Attack? Pain radiating down the left arm 28. A nurse is planning care for a client who recently attempted suicide. WOTF actions should the nurse plan to take? Ensure the client swallows each dose of medicine 29. A nurse is caring for a client who has upper gastrointestinal bleed. WOTF actions should the nurse take first? Check bowel sounds 30. A nurse is assisting with the admission of an adolescent client who is suspected of having bacterial meningitis. Nuchal rigidity 31. A nurse is transcribing a prescription from the provider. The prescription reads Gentamicin 2 gtt OD q4h. WOTF information should the nurse clarify with the provider? dosage 33. A nurse is reinforcing teaching with a parent of a child who has a new prescription for ferrous sulfate in liquid form. WOTF statements by the parent indicates an understanding of the teaching? I will give the iron through a straw 34. A nurse is collecting data from a client who has cholecystitis. WOTF findings should the nurse expect? Pain in the right upper abdomen 35. A nurse is caring for a 3 year old child at a well-child visit. The parents report that their son has been playing with imaginary friends. WOTF responses should the nurse make? This is a common behavior for children at this age 36. A nurse is assisting with the physical examination on a 7-year-old child. WOTF options should the nurse take? Explain the purpose of the equipment used 37. A nurse is delegating client care assignments. WOTF tasks should the nurse assign to the assistive personnel? Apply an antiembolic stocking for a client who is 2 days post-op 38. A nurse is caring for a client who had a femoral popliteal bypass graft 2 days ago. When monitoring peripheral pulses, the nurse is unable to locate the pulses in the affected leg. WOTF actions should the nurse take? Notify the charge nurse about the findings 39. A nurse is caring for a client who has multiple sclerosis and has a new prescription for baclofen. WOTF indicates that the medication is having its desired effect? Improved dexterity