Comprehensive Practice A

RN Comprehensive Practice A **A client is postoperative following a lumbar discectomy and is having difficulty voiding. The nurse should recognize that which of the following medications place the client at risk for urinary retention? Ketorolac Hydromorphone (Dilaudid) Bethanechol (Urecholine) Tobramycin (Nebcin) **A nurse is caring for an older adult client in a long-term care facility who is disoriented and continues to get out of bed without assistance. Which of the following images indicates the nurse is using an appropriate intervention to minimize the risk of injury due to a fall? D **A practical nurse (PN) on medical-surgical unit is beginning her shift and is working with a registered nurse (RN) and an assistive personnel (AP). The PN should expect to be assigned which of the following tasks? Teach a client who has a new diagnosis of diabetes mellitus how to self-administer insulin. Create a plan of care for a newly admitted client. Obtain a stool specimen from a client who has ulcerative colitis---- Administer an NG tube feeding to a client who had a stroke **A nurse on an acute mental health unit observes a client who begins to speak loudly in the common room, saying that he can’t hear the TV. Which of the following is an appropriate response by the nurse? You will need to go to your room until you can calm down okay The TV is loud enough for everyone to hear it You are being inconsiderate. Please stop talking so loudly Let’s go to another room to talk about what is upsetting you **A client tells a nurse that he would like to observe kosher dietary laws. The nurse should recognize which of the following? A vegetarian diet is the preferred diet Dairy products are served separately from meat Fasting during daylight is required during a month-long holiday Fish with scales and fins should not be eaten **A nursing unit receives new glucose monitoring equipment from staff development with the promise that in-service education will be given soon. Which of the following instructions should the nurse give to the assistive personnel (AP) who is preforming glucose monitoring on the unit? Contact the staff development department for instruction Continue using the current glucose monitors Check for accuracy and proper functioning of the new monitor Read the instruction manual before attempting to use the new monitor **Which of the following should the nurse document as an indication of the IV infiltration in a client’s forearm? Redness along vein Tissue sloughing at the site Forearm that is warm to the touch Pallor surrounding the infusion site **A client requests information about advanced directives. Which of the following is the appropriate response by the nurse? Advanced directives are written instructions regarding end of life care Advanced directives provide education on palliative care issues Advanced directives require the provider’s approval before changes can be implemented Advanced directives help determine legal competency **A nurse is caring for a client who is on telemetry. Which of the following ECG findings should the nurse report to the charge nurse? One P wave prior to each QRS complex PR interval 0.24 seconds QRS duration 0.06 seconds Ventricular rate 75/min **A nurse is checking the reflexes of a newborn. Which of the following techniques should the nurse use to elicit the Babinski reflex? Startle the infant by clapping hands Stroke the sole of the infant’s foot upward and toward the great toe Hold the infant upright and allow one foot to touch the table’s surface Place an object in the palm of the infant’s hand **A charge nurse in a long-term care facility notices an assistive personnel’s (AP) repeated failure to provide oral care for clients. Which of the following actions should the nurse take? Provide oral care for clients after the AP has completed other care Develop an educational session about the importance of oral care for all Aps Discuss the unacceptable behavior with the AP while reinforcing expectations Suspend the AP for 3 days pending disciplinary action **A nurse is caring for a client who has terminal cancer. Which of the following statements by the client’s family should indicate the nurse that they are coping with their situation? Dad I remember the time we all went to the lake fishing Dad I truly believe that it’s not your time to leave us I feel like I don’t know what to do anymore I think we need to concentrate on whose house we plan to meet at for our holiday get-together **A nurse is performing a dressing change for a client who had abdominal surgery 5 days ago. The nurse notes organs protruding from the incision. Which of the following actions should the nurse take? Apply an abdominal binder Have the client lie flat in bed. Cover the exposed area with sterile, saline-soaked dressing Place gentle pressure on the exposed organ with sterile gauze **A nurse in a skilled nursing facility is caring for a client who is receiving warfarin (Coumadin) therapy following a total hip replacement. An assistive personnel reports a positive guaiac. Which of the following laboratory values should the nurse report to the provider? Hematocrit 40% International normalized ratio of 4.5 Hemoglobin 15 g/dL-- Prothrombin time 18 seconds ** A nurse is reinforcing teaching with a client who has hypertension and is beginning medication therapy with captopril (Capoten). Which of the following over-the-counter medications should the nurse instruct the client to avoid? Acetaminophen (Tylenol) Diphenhydramine Ibuprofen (Advil) Guaifenesin (Robitussin) **A nurse is reinforcing teaching for a client who is in her first trimester of pregnancy. Which of the following physiological changes should the nurse instruct the client to expect during the first trimester? Leukorrhea Shortness of breath Pedal edema Perineal pressure ** A nurse is collecting data from a client who has a peptic ulcer disease. Which of the following should the nurse identify as the priority finding? Gnawing epigastric pain Heartburn Regurgitation Hematemesis **A nurse is collecting data from a client who has posttraumatic stress disorder (PTSD). Which of the following behavioral indications should the nurse expect? Dependence Euphoria Memory Loss Hypervigilance **A nurse is collecting data from a client who has schizophrenia. Which of the following statements by the client should the nurse identify as a delusion? My doctor’s glasses have lasers that will burn holes in my brain if I look at him The movie had an explosion. I once drove a green truck. Where is the ketchup The voice keeps telling me to go kick the table over. Why won’t it stop I can’t sit here because the purple monkey on the ceiling will jump on me **A nurse is caring for a client who sustained a broken leg while assisting other from a structural fire. The client states I am glad those people were saved but I sure wish I was not hurt. Which of the following is an appropriate response by the nurse? You are a real hero. I am sure that makes your injuries worthwhile It is difficult to experience personal injuries for whatever reason Things will get better before long Let’s talk about this later when we have more time **A nurse is reinforcing teaching for a client who has a new prescription for lithium carbonate (Lithobid). Which of the following instructions should the nurse include? Eliminate all foods containing tyramine Drink 2 to 3 liter of fluid each day Take lithium carbonate on an empty stomach Reduce your daily sodium intake to 1,000 mg **A nurse in a provider’s office is reinforcing teaching with a client who is receiving peritoneal dialysis via a newly inserted catheter. For which of the following should the nurse instruct the client to contact the provider? Bloody peritoneal fluid Clear peritoneal fluid Cloudy peritoneal fluid Straw-colored peritoneal fluid **A child is brought to the clinic by his parents with injuries inconsistent with the reported cause. A nurse suspects physical abuse. Which of the following actions should the nurse take? Interview the child with the parents in the room Ask the provider to talk to the child and parents Make a note in the chart to check the child during the next visit Report the suspected abuse to the appropriate agency **A nurse is reviewing discharge instructions with a client who has undergone a lumbar laminectomy. Which of the following should the nurse include? Use a soft mattress for sleeping Practice bending from the waist several times daily Sit in a straight backed chair Wear shoes with a slightly raised heel to promote body alignment **A nurse is reinforcing teaching with a client about cancer prevention, the nurse should instruct that frequent consumption of which of the following foods increases the risk of cancer? Tuna Lamb Chicken Turkey ** A nurse is reinforcing teaching to a client who is scheduled for a lumbar puncture. Which of the following should the nurse include in the teaching? Nausea is common adverse effect after this procedure You should increase your fluid intake after this procedure You will be instructed to remain in an upright position for the first 4 hours after the procedure The provider will apply a pressure bandage to the puncture site **A newborn is scheduled to have a heel stick for blood glucose testing every 4hr. The newborn’s blood glucose on admission was less than 40 mg/dL. Which of to the following additional clinical manifestations should the nurse observe for in this newborn? Jitteriness Bradycardia Inconsolability Insomnia **A nurse is contributing to the plan of care for a client who has a prescription for range of motion exercise of the shoulder. To promote shoulder hyperextension, which of the following exercises should the nurse recommend? Move his arm behind his body with his elbow straight Move his arm in a full circle Raise his arm out to the side and reach it above his head with his palm facing away from his head Raise his arm from his side straight forward and then up above his head. **A nurse is receiving change-of-shit report for four clients. Which of the following clients should the nurse attend to first? A client who requests to be moved to a room closer to the nurse’s station A client who is postoperative and had received morphine twice during the last 8hrs A client whose urinary output was 100 mL for the past 12hr A client who insists on speaking with the provider prior to discharge **A nurse is reinforcing teaching regarding home safety to a client who has diabetes mellitus and is being discharged after an admission for hepatitis B. Which of the following client statements indicates an understanding of the teaching? I will recap my used syringes and throw them away in a plastic bag I will take Tylenol for aches and pains I will use my own eating utensils and dishes at home Houseguest will need to wear masks when they come to visit me **A nurse in a long-term care facility is transcribing new prescriptions for four clients. Which of the following prescription is accurately transcribed by the nurse? Alprazolam (Xanax) 0.5 mg PO QHS for sleep Regular insulin (Humulin R) 10 U SC at 0800 Docusate sodium (Colace) 250 mg PO QOD Potassium chloride (Micro-K) 20mEq PO every morning **A nurse is caring for a client who has altered mental status and has become increasing belligerent. Which of the following medications prescriptions, if written for this client, should the nurse question? Haloperidol (Haldol) Lorazepam (Ativan) Zolpidem (Ambien) Alprazolam (Xanax) **A nurse is caring for a client who is experiencing acute kidney failure. The nurse should monitor the client for which of the following acid-base imbalances? Metabolic alkalosis Metabolic acidosis Respiratory alkalosis Respiratory acidosis **A nurse in an urgent care clinic is collecting data from four clients. Which of the following clients should the nurse recommend for treatment first? A client who has a fever and abdominal pain in the upper aspect of the right lower quadrant A client who has shortness of breath after taking a dose of amoxicillin (Amoxil) A client who has hemoptysis and has taken medication for tuberculosis (TB) for 2 months A client who has a purple stoma following an open colon resection with a colostomy 2 weeks ago. **A nurse on a medical unit is preforming an audit on his client assisgnment. For which of the following should the client have a separate signed informed consent form. Chest radiography Echocardiogram Indwelling urinary catheter Lumbar puncture ** A nurse in an acute care hospital is planning to discharge an adult client who is immunocompromised. Which of the following immunizations should the nurse plan to administer before discharge. Measles, mumps, and rubella (MMR) immunization Pneumococcal polysaccharide (PPSV) immunization Varicella immunization Herpes zoster immunization ** A nurse is reinforcing teaching to a client regarding care of her newborn. The nurse determines that the teaching is effective when the client points to which part of the newborn’s head and states it will take 12 to 18 months for the soft stop to close. (top of the head near face) **A parent of a 3yr old child tells the nurse that he cannot get his child to sit at the table to eat a full meal. Which of the following responses by the nurse is appropriate? Provide the child with foods of the same texture rather than a variety of unfamiliar foods Engage the child in conversation during meals to encourage him to eat like the rest of the family Encourage active play prior to meals to increase the child’s appetite Offer the child heathful snacks frequently, rather than expecting him to fully eat at mealtimes **A nurse in a providers office is caring for four clients. Which of the following should the nurse see first. A client who is at 38 weeks gestation and reports urgency and frequency of urination A client who is at 37 weeks gestation and reports edema of the ankles A client who is at 36 weeks gestation and reports painless vaginal bleeding A client who is at 34 weeks gestation and reports abundant amounts of odorless vaginal mucus **A nurse and an assistive personnel (AP) are caring for four clients in a long-term-care facility. For which of the following situations is it necessary to complete an incident report? A client throws an object across the dinning room A client refuses his morning medications A client who is prescribed full liquid diet receives a clear liquid diet A client who is confused walks into another client’s room ** A nurse working in the clinic receives a phone call from a mother whose child has just ingested the contents of a bottle of acetaminophen (Tylenol). Which of the following is an appropriate response by the nures? Adminster syrup of ipecac to the child to induce vomiting Take the child to the emergency department Give the child a glass of milk to drink Monitor the child’s level of consciousness **A client is scheduled for colon cancer surgery in the morning. The night nurse learns that the client has decided not to have the surgery, even through he has already signed the informed consent form. Which of the following actions should the nurse take? Inform the client that a signed consent form is legally in effect for 24hr Report the situation to the surgeon who obtained the informed consent Reinforce client teaching about the purpose of the procedure Notify the client’s family about the refusal of treatment **A nurse is caring for a newborn who is 1hr old. The mother received fentanyle (Sublimaze) 30 min before delivery. For which of the following should the nurse monitor for in the newborn? Hyperbillrubinemia Hypoglycemia Respiratory depression Increased heart rate **A nurse is reinforcing discharge teaching with the parent of a school-age child who had a tonsillectomy. Which of the following statements by the parent indicates an understandin of the instructions? I will encourage my child to drink 4 ounces of orange juice twice a day I will allow my child to chew gum to prevent throat pain I will ensure my child uses a straw to drink fluids I will give my child chocolate ice cream ** A nurse is reviewing the laboratory results for an infant receiving gentamicin intermittent IV bolus twice daily and notes the serum creatinine is 0.9 mg/dL. The nurse is aware that this result can indicate an adverse effect on which of the following systems? Hepatic Renal Gastrointestinal Endocrine **A is reinforcing teaching with an adolescent client about a scheduled blood draw of HbA1c. The nurse knows that the client understands the purpose for this test when the client states that this test will measure his average blood glucose level over the past 2 to 3 days 6 weeks 2 to 3 months 6 months **A nurse is caring for a client in Buck’s traction. Which of the following interventions should the nurse perform while the client is in this traction? Allow the weights to hang freely Inspect the skin every 24hr Remove the weights every 24hr Let the client use the bedside commode **A nurse is caring for a client who has a head injury. Using the Glasgow Coma Scale to collect data, the nurse should obtain which of the following? Motor response Vital signs Short-term memory Gait **A nurse is reinforcing teaching to a client who has a new prescription for atorvastatin (Lipitor). For which of the following shold the nurse tell the client to monitor and report to the provider? Anorexia Muscle tenderness Facial flushing Insomnia **A nurse working in a clinic is collecting data on a toddler. Which of the following findings should the nurse identify as suggestive of physical neglect? The toddler is inadequately dressed for the weather The toddler has irriation to the external genitalla The toddler has symmetrical burns to both legs The toddler does not react when the nurse adminsters an injection **A parent of a 2month old infant asks the nurse how she will know if her baby is growing appropriately. Which of the following is an appropriate response by the nurse? Your baby should weigh 2.5 time his height by 6 months Your baby should gain 1 pound per month during the first 6 months Your baby’s weight should be double his birth weight by 4 to 6 months Your baby should grow half an inch per month during the first 6 months **A nurse is contributine to a teaching plan for a group of male adolescents regarding use of anabolic steroids. Which of the following should the nurse include in the teaching as risk of using anabolic steroids? Decreased appetite Reduced height potential Increased dental caries Impaired vision **A client who is 1 day postoperative is unable to ambulate. The nurse should recognize that which of the following will promote venous return? Encouraging the client to cough and deep breathe Maintaining a sequential compression device Elevating the head of the bed Massaging the clients legs **A nurse reinforces the use of a mask prior to a family entering the room of a client who has tuberculosis (TB). Which of the following information should the nurse include? Prior to entering the room, make sure the client puts on a mask If you leave the client’s room for a break, you can reuse your mask upon returning Wearing a mask will help protect you from the client’s illness Masks are part of the hospital protocol, but family members do not have to wear them **A nurse is caring for a client recently diagnosed with adenocarcinoma of the lung. While discussing teatment option with the client, the family asks the nurse about the use of herbal medications for treatment. The nurse should respond by stating, Herbal medicines Are untested for both safety and efficacy Will protect against progression of your cancer Are frequently cheaper than conventional medications Must be prescribed by a provider **A client who is pregnant presents to the emergency department with a broken arm. The client appears anxious and gives conflicting stories about how the injury occurred. The client’s spouse is hovering over her and answering questions for her. What should the nurse do to handle this situation? Disregard the spouse’s remarks while continuing with data collection Request that the spouse go to the waiting room Bring a second nurse into the examination room Ask the client’s spouse to refrain from answering for the client. **A nurse is caring for a client who has a history of long-term alcohol use disorder. The client has a prescription for disulfiram (Antabuse). The nurse should recognize that the use of this medication is a form of which of the following types of therapy? Operant conditioning Systemtic desensitization Aversion therapy Cognitive therapy **A nurse is caring for a client who has impaired vision. Which of the following strategies should the nurse include in the plan of care? Keep the door to the client’s bathroom slightly ajar Hold the client’s arm while standing even with the client’s shoulders while ambulating During ambulation, the nurse should stand just ahead of the client and offer his arm for guidance Place frequently used items on the bedside table **A nurse has administerd lorazepam (Ativan) to a client who is scheduled for surgery within the next hour. Which of the following actions should the nurse take? Instruct the client to remain in bed Ensure that the informed consent form has been signed Assist the client to the bathroom to void Reinforce teaching about deep breathing and coughing exericses **A nurse is preparing to insert a nasogastric tube for a client. Identify the sequence the nurse should follow after performing proper hand hygiene and preparing equipment at the bedside Place the client in high-Fowler’s position Determine which naris has the greatest airflow Measure the distance to insert the tube Lubricate 7.5 to 10 cm (3-4 in) of the end of the tube Instruct the client to hyperextend her neck **A nurse is reinforcing teaching about pancrelipase (Pancreaze) with the parent of a child who has cystic fibrosis. Which of the following instructions should the nurse include in the teaching? Place the medicine under the tongue Take the medication after a meal Sprinkle the contents of the capsule on food Chew each capsule thoroughly **A nurse brings her adolescent son to an urgent care center, stating that “he is high on something and needs help.” The client is exhibiting agitation and paranola, and reports visual hallucinations. The nurse should suspect intoxication with which of the following substances? Methamphetamines Opioids Anbolic steroids Alcohol **A nurse enters the room of a client who had a bone marrow transplant 3 days ago for treatment of leukemia. Which of the following observations warrents intervention? The client’s meal tray contains stewed tomatoes A visitor brought the client a bouquest of flowers The client is using an electric razor to shave An assistive personnel is removing a bag of biohazardous materials **A nurse is collecting data from a client who is primigravida and at 25 weeks of gestation. The client is tearful and tells the nurse, “I’m sorry, I’m just nervous and emotional today.” Which of the following actions should the nurse take first? Help the client identify a support person to talk to Recoomend the client join a support group for first time mothers Assist the client to schedule childbirth classes Explore the client’s underlying concerns **A nurse is caring for a client who has expressive aphasia following a cerbrovascular accident. Which of the following communication methods is appropriate for the nurse to use with this client? Ask open-ended questions Speak slowly with a raised voice Provide a picture board Limit the use of gestures **A nurse is caring for a client who is postoperative following an open reduction with internal fixation of the ankle. The client reports pain, and the nurse notes that the affected extremity is cool, pale, and has a weak pulse. The nurse calls the surgical resident, who responds, “It has always been like that.” Which of the following actions should the nurse take first? Notify the nursing supervisor Administer the prescribed pain medication Recheck the client in 30 min Reposition the client to improve anatomical alignment **A nurse is reinforcing teaching to a client about the adverse effects of propranolol (Inderal). For which of the following effects should the nurse instruct the client to observe? Bradycardia Cough Paresthesias Urinary retention **A nurse is caring for a postpartum client who is breastfeeding. Which of the following is appropirate for the nurse to reinforce about breastfeeding? Look for slowed suck/swallow pattern as a sign that the newborn is finished eating Ensure that the newborn has the entire areola in the mouth during feeding Begin feeding the newborn on the same breast each time Push the back of the newborn’s head toward the nipple **A nurse is reinforcing teaching for a client who has a new prescription for metronidazole (Flagyl), The nurses should instruct the client to expect which of the following adverse effects while taking this medication? Reddish brown urine Increased saliva production Photophobia Peripheral edema **A nurse is admitting a client who is at risk for suicide. Which of the following is the nurse’s highest priority? Search the client’s personal belongings. Place the client in a room close to the nurses’ station Ask the client to sign a no-suicide contract Review the client’s SAD PERSONS scale assessment **A nures enters the room of an adolescent client and observes him on the floor experiencing a tonic-clonic seizure. Which of the following actions should the nurse take when the seizure subsides? Insert a tongue blade in the client’s mouth Assist the client to an upright posiiton Offer clear fluids through a straw Keep the client in a side-lying position **A nurse is reinforcing discharge teaching for a client who has a new prescription for digoxin (Lanoxin). Which of the following should the nurse include in the instructions as an indication of digoxin toxicity? Visual changes Skin irritation Fever Angina **A female client presents to an outpatient clinic. Which of the following findings place the client at risk for coronary artery disease? The client’s LDL level The client’s daily alcohol consumption The client’s weight for her height The client’s blood pressure **A nurse is caring for an infant who is receiving IV fluids for dehydration. Which of the following should the nurse recognize as a positive response to the therapy? Bulging fontanel Capillary refill 6 seconds Moist mucous membranes Urine specific gravity 1.031 **A nurse is reinforcing teaching for a clientwho has a new prescription for sublinguail nitroglycerin (Nitrostat). Which of the following statements indicates client understanding? I will take half a tablet before I exercise I can take up to four tablets to relieve my pain I will put the tablets in a medication container for easy acess I may develop a headache after taking this medication **A nurse is caring for a client who has a new diagnosis of HIV. The client states, “I don’t want anyone else to know that I have HIV.” Based on the recommendations of the Centers for Disease Control and Prevention, which of the following is an appropriate response by the nurse? Your HIV status will be protected by HIPPA regulations Your HIV status needs to be reported to the state health department We must report your HIV status to your employer Your HIV status is protected under the Patient Care Partnership **A nurse is reinforcing discharge teaching with a client regarding self-administration of epid insulin (Humulin R). Which of the following instructions should the nurse include? Shake the insulin vial before administering Administer insulin at room temperature Administer insulin 15 min prior to each meal Dissolve solid deposits by warming the insulin before administering **A nurse is reinforcing teaching to a client who has schizophrenia and his family regarding treatment options. Which of the following statements by the nurse is appropriate? Family therapy can assist clients and their families to learn effective coping skills Cognitive remediation therapy is used to solve longstanding family problems resulting from the disease Use of medication is considered short-term therapy until symptoms are stabilized Day treatment programs are the desired choice for achieving acute symptom stabilization **A nurse notices an assistive personnel (AP) of the unit taking naps in the break room instead of having a meal or a snack. She appears drowsy while performing routine tasks. Which of the following actions should the nurse take? Keep a record of the AP’s behavior over a period of time Report the observations about the AP to the unit’s nurse manager Ask other unit staff if they have observed the same behavior Determine if the AP is having problems at home **A nurse is assisting with the plan of care for a client following a transurethral resection of the prostate (TURP) surgery. Which of the following is appropriate to include in the plan of care Discontinue the urinary catheter 24hr after surgery Adjust the bladder irrigation to keep the urine a bright yellow color Use 50 mL sterile water to clear the urinary catheter of obstruction Irrigate the bladder using sterile technique **A nurse is collecting a urine specimen from a client with diabetes insipidus. The nurse should expect which of the following findings? Proteinuria Creatinine clearance of 100 mL/min/m Urine specific gravity of 1.002 Hematuria **A nurse is reinforcing teaching with a newborn’s parents about umbilical cord care. Which of the following statements by a parent indicates an understanding of the instructions? I will give our baby sponge baths until the cord falls off I will remove the cord clamp after 5 days I will wrap the cord in petroleum jelly gauze I will keep the cord protected by covering it with the diaper **A nurse is preparing to administer a dose of furosemide (Lasix) 30 min past the scheduled time. The nurse notes that there is a new potassium value alert on the client’s electronic record. The nurse should Review the laboratory value prior to preparing the medication Administer the medication, and then review the client’s laboratory values Hold the dose of medication until the provider makes rounds Administer the medication, and notify the provider that new laboratory values are available **A nurse is assisting in the plan of care for a female client who is to undergo a 12-lead electrocardiogram (ECG). Which of the following actions should the nurse include in the plan of care? Place the client in Sims’ position Put chest electrodes on the client’s breast Instruct the client to remain still while the ECG is performed Cleanse the skin with providone-iodine prior to electrode placement **A nurse is caring for an older adult client who is 48hr postoperative following abdominal surgery. The provider writes a prescription to advance the client to a regular diet. After evaluating the client, the nurse should notify the provider about which of the following findings? The client has absent bowel sounds The client is unable to sit for long periodsof time The clients incision is draining serous fluid The client reports loss ofappetite due to pain **A nurse is collecting data from an older client who has a hip fracture. Which of the following findings should the nurse expect? External rotation Muscle flaccidity Leg lengthening Hyperreflexia **A nurse is supevising an assistive personnel (AP) who is preparing to remove his personal protective equipment (PPE) after providing direct care to a client who requires airborne and contact precautions. The nurse identifies understandingof the procedure when the AP removes which of the following items first? Goggles Gloves Gown Respirator **A nurse is reinforcing newborn care to a client whose newborn underwent clamp circumcision procedure. Which of the following statements made by the client indicates to the nurse a need for further teaching? I should apply petroieum jelly each time I change the diaper I will apply gentle pressure if bleeding occurs I will be sure to wipe off any yellow drainage I should make sure my baby has at least six wet diapers in 24hrs **A client newly diagnosed with diabetes mellitus inquires about information concerning oral antidiabetic agents. In addition to the provider, where should the nurse refer the client for information? (select all) Local pharmacist Personal tesimonial web sites Package inserts Other clients in a diabetes support group American Diabetes Association **A nurse in an urgent care facility is reinforing teaching to a client about the safe use of crutches. Which of the following statements indicates the client understands the teaching? I will wear leather-soled shoes when walking with my crutches I will ensure the pad of the crutch fits snugly in my armpit I will hold both crutches on the side opposite my injured leg when sitting I will switch to using only one crutch when I regain some strength **A nurse is reinforcing teaching on food selection for a client who has a moderate burn injury. Which of the following foods should the nurse recommend as being high in vitamin C? Tomatoes Apricots Avocados Carrots **A nurse is caring for an adolescent who has meningitis. To prevent the adolescent from experiencing increase intracranial pressure, which of the following actions should the nurse take? Keep the head of the bed flat Withhold pain medication until the client is in severe pain Suction the airway when necessary Keep the client’s door open for visual observation **A nurse is preparing to administer purified protein derivative (PPD) to a client who has suspected tuberculosis, Which of the following actions should the nurse plan to take? Inject 0.5 mL of medication Insert the needle at a 10degree angle Ensure that the bevel of the needle is pointing down during administration Aspirate the syringe prior to injecting the medication ** A nurse is reinforcing discharge teaching with a client about adverse effects of prescribed medications. The nurse should tell the client that if black, tarry stools are noted, the client should stop taking which oft eh following medications and notify the provider? Acetaminophen (Tylenol) Aspirin (Ecotrin) Guaifenesin (Robitussin) Loratadine (Claritin) **A nurse in a clinic is reinforcing discharge teaching with a client who has a sprained ankle. The nurse should instruct the client to rewrap the compression dressing if she experiences which of the following manifestations? Warm toes Erythema of the ankle Swollen toes Increased ankle stiffness **A nurse is observing an assistive personnel (AP) caring for a client. For which of the following actions should the nurse intervene? The AP documents morningcare in the client’s electronic health care record at the bedside The AP writes his own name on the client’s message board in the room The AP instructs the client to void prior to obtaining a daily weight The AP reports client information to the oncoming AP in the hallway **A nurse in the rehabilitation unit is assisting in the development of a plan of care for a client who had a knee arthroplasty. Which of the following should the nurse include first in the plan of care? Discuss with the client the need for family support Assist the client to develop attainable goals Evaluate the clients repsonse to therapy Check the client’s mobility **A providerf prescribes levothyroxine (Synthroid) 0.3 mg PO daily for a client. Available is levothyroxine 150 mcg/tablet. How many tablets does the patient get? 2 tablets **A client is being discharge home after experiencing a cerbrovascular accident. Which of the following documents should the nurse plan to include with the discharge instructions? Physician progress notes Physical therapy record Medication adminstration record List of symptoms to report **Which of the following findings in a client who is postpartum should indicate to a nurse to contact the provider? Temperature of 37.8C (100.2F) after delivery Redness and tenderness of the right calf Breast discomfort on postpartum day 3 Increased lochia after breastfeeding **A nurse is assisting with admitting a client who has colorectal cancer. When collecting data from the client, which of the following clinical manifestations should the nurse expect to find? Abdominal cramps Hematuria Weight gain Epigastfic pain **A client who is crying tells a nurse that his provider informed him that he has a tumor and will need a biopsy. Which of the following is an appropriate response by the nurse? Try to relax as much as possible, because most tumors are benign What have you done to help yourself get through stressful situations before Perhaps you should wait to get your biopsy results before you become overly concerned I will keep you in my thought and check on your results the next time I work **A nurse is reinforcing teaching about defense mechanisms with an adolescent who is angry that her parents won’t let her go to a party. Which of the following statements by the client should the nurse recognize as sublimation? I guess I’ll just go to the mall with friends instead People who go to parties are stupid They’ll probably all get into trouble I’ll just quit cleaning my room and mowing the grass that’ll teach them My parents are just afraid I will get into trouble **A nurse is contributing to the plan of care for a client who is at risk of developing pressure ulcers. Which of the following actions should the nurse recommend to include in the plan of care? Place the client in a 30degree lateral position Limit time spent sitting in a chair to 4hr daily Cleanse the client’s skin twice daily with soap and hot water Massage reddened areas over bony prominences every 2hrs **While making rounds, a nurse smells cigarette smoke in the unit. Upon entering the client’s room, the nurse observes a pack of cigarettes on the bedside table. Which of the following actions should the nurse take first? Provide the client with smoking cessation information Report the finding to the charge nurse Remove the cigarettes from the clients room Notify the provider of the clients behavior **A nurse is caring for a client who reports a sudden onset of an itchy rash after being givenciprofloxacin (Cipro) 1hr ago. Which of the following actions should the nurse take first? Check the client for wheezing Administer diphenhydramine Prepare the client for insertion of an IV catheter Obtain a set of vital signs **A nurse assigns an AP to collect a sputum specimen from a client who has tuberculosis. The nurse should instruct the AP to collect the sputum specimen at which of the following times? Immediately after the client brushes his teeth After the client ambulates When the client reports he is experiencing night sweats As soon as the client wakes up **A nurse is reinforcing discharge teaching with the family of a client who has dependent personality disorder. Which of the following instructions should the nurse include in the discharge teaching? Demonstrate assertiveness Refrain from engaging in power struggles Permit expression of rituals Avoid crowded environments **A nurse is caring for a client who is scheduled to receive hemodialysis through an arteriovenous fistual in the left arm. Which of the following actions should the nurse take prior to the procedure? Ensure the client has fasted for 6hr Obtain the client’s weight Measure the client’s blood pressure about the fistula Draw a blood sample from the fistula **A nurse is reinforcing teaching with a client about how to replace her two-piece ostomy pouching system. The client tells the nurse that removing the skin barrier is painful. Which of the following strategies should the nurse suggest? Break the seal by tugging gently on the bottom of the pouch Hold the skin taut while removing the barrier Pull one corner of the barrier quickly over the stoma Lift both sides of the skin barrier simultaneously **A nurse is caring for a client who has Alzheimer’s disease. Which of the following will help the client maintain independence in eating? Allow the client to choose foods from a menu Place the tray of food directly in front of the client Provide music or visula stimulation at mealtimes Maintain a routine for mealtimes **A nurse is caring for a client who has a penrose drain. To ensure proper placement and functioning of the drain, which of the following should the nurse observe? The safety pin is present at the distal end of the drain The suction bulb is fully compressed Wall suction is set at low-intermittent suction The evacuator unit gradulaly expands as it fills with drainage **A nurse is preparing to administer digoxin (Lanoxin) to a client. Which of the following should the nurse check prior to administration? Platelet count Liver enzymes Serum potassium Coagulation studies **A nurse is assisting with the admission of an older adult client. Which of the following actions should the nurse take first? Orient the client to the room Provide the client with nonskid footwear Complete a fall risk assessment on the client Reinforce safe ambulation techniques with the (AP) on the unit **A client who is diagnosed with Parkinson’s disease verbalize frustration due to increase difficulty with ambulation. Which of the following is an appropriate response for the nurse to make? Watch your feet when you walk to maintain balance to prevent falls We should monitor your serum blood level of levodopa monthly Perform active range of motion with your arms and legs three times a day You should consider using a wheelchair instead of trying to walk **A nurse is caring for a client and notes the IV fluid rate has slowed. Which of the following actions should the nurse take first? Repostion the tip of the catheter Check the tubing for kinks or obstructions Position the IV tubing to avoid tension on the IV catheter Tighten the IV tubin connections **A nurse administers a dose of digoxin (Lanoxin) that was prescribed to be given every other day. She discovers 1hr later that the medication had been given yesterday. Which of the following actions should the nurse take next? Obtain a set of vital signs Document the medication erro on an incident report Report the error to the appropriate hospital personnel** Perform any treatments necessary **A nurse is reinforcing teaching with a client who has a prescription for isoniazid (Laniazid) and rifampin (Rifadin) to treat tuberculosis. Which of the following should the nurse include in the teaching? You may need to take medicatons to treat tuberculosis for as long as two years You can take isoniazid with an antacid if it upsets your stomach You will need to have a tuberculin test in 3 months to determine the effectiveness of the medications You should notify the provider if your urine turns orange while taking the medication **A nurse in an outpatient surgery center is reinforcing discharge teaching with a client following a lithotripsy for uric acid stones. Which of the following should the nurse plan to include in the teaching? Limit fluid intake to 1 L per day Report the appearance of blood in the urine Strain the urine to collect stone fragments Increase dietary protein intake **A nurse is caring for a client who is expressing sorrow about the amputation of her leg 72hr ago due to trauma. The nurse must leave the room but promises to return as soon as possible. The nurse demonstrates which of the following ethical principles when he returns a promised? Autonomy Nonmaleficence Justice Fidelity **An upper airway x-ray indicates that a toddler has aspirated a bead. A nurse is reinforcing teaching about the need for a bronchoscopy to the parents. Which of the following statements given an accurate description? A bronchoscope is a device that wil help your child breathe This is a scan that will help the doctor see if the bead has done any damage This is a technique that will wash the bead out of the airway A bronchoscope is a tube that allows the doctor to see and remove the bead **A nurse is using the FLACC pain scale to determine the level of pain for an 11-month-old infant who is postoperative. Which of the following factors should the nurse consider when using this pain scale? Quality of feeding Level of activity Respiratory effort Skin color **A nurse is monitoring a client who is receiving lactated Ringer’s 500 mL IV over 4hr. The drop factor of the manual IV tubing is 10 gtt/mL. The nurse should check that the manual IV infusion is delivering how many gtt/min? 21 gtt/min **A nurse is advising a group of AP about lifting clients in prepartion for transfer from the bed to a chair. Which of the following instructions should the nurse include? Stand with feet together Use lower body strength Turn at the waist Raise the bed to a high position **A nurse is reinforcing teaching about conjunctivitis to the parent of a school-aged-child. Which of the following should the nurse reinforce? Maintain a warm compress on the affected eye at bedtime Clean the eye from the outer to the inner canthus Separate the child’s used washcloth from those of others Instill ointment in the child’s affected eye each morning **A nurse at a health fair for college students is reinforcing teaching about skin cancer prevention. Which of the following instructions should the nurse include in her presentation? Reapply sunscreen every 4hr during sun exposure Sunscreen has a shelf life of 5 years Limit sun exposure especially before noon Use sunscreen with a sun protective factor of at least 15 **A home health nurse is caring for an older adult client in his home. Which of the following should the nurse consider as an environmental risk factor? Water heater set at 37.8C (100F) Smooth shower stall floor Carpeted floor Table lamp next to the bed **A nurse is reinforcing teaching about foot care with a client who has a new diagnosis of diabetes mellitus. Which of the following should the nurse include in the teaching? Trim toenails straight across Apply lotion betwene toes daily to prevent dryness Wear open-toed footwear Use a heating pad on fee nightly to promote circulation **A nurse is reinforcing teaching with a client who is to undergo a coronary angiography at 0700. Which of the following instrustions should the nurse include? The client will receive general anestheia before the procedure The client may feel a hot flush as the dye is injected The client should report a metallic taste to the provider The client will feel chest pain during the procedure **A nurse is caring for a client who has delirium. Which of the following should the nurse expect? Difficulty using correct words Obsessive behaviors Fluctuating levels of consciousness Reports of hopelessness **A nurse is reinforcing teaching about coughing exercises to a client scheduled for surgery. Which of the following information should the nurse include ine the teaching? Take one deep breath and then cough Repeat coughing exercises twice consecutively Perform coughing exercises every 3hr after surgery Splint the incision with interlocked hands when coughing **A natural diseaster has occurred in a community. Clients who may have safely discharge need to be identified to make room for incoming casualties. Which of the following clients should the nurse recognize could be discharged in this situation? A client who was admitted with diabetic ketoacidosis whose current blood glucose readin is 350 mg/dl A client who was admitted this morning with the onset of fever severe headache and nuchal rigidity A client who has pneumonia who is currently receiving oral antibiotics A client who had a small bowel resection with a loop ileostomy 24hr ago **A nurse is reinforcing teaching with a client who is schedule for modified radical mastectomy with drainage tubes. Which of the following should the nurse include in the teaching? You should avoid exercise of the arm of the affected side Keep your arms at your sides while lying in bed Your drainage tube will be discontinued 24hr following surgery You should avoid measuring your blood pressure on the affected side **A nurse is reinforcing teaching to a client who has cholecystitis. Which of the following foods should the nurse instruct the client to avoid in her diet? Orange juice Eggs Peanut butter Wine **A nurse is caring for a client who is scheduled to undergo a thoracentesis for a left pleural effusion. In which of the following postitons should the nurse place the client? Supine with arms raised over the head Prone with arms at sides Upright with arms resting on the overbed table Left lateral side position **A client who has a chest tube drainage device asks the nurse for assistance in using the bathroom. Which of the following actions should the nurse take? Provide the client with a bedpan until the chest tube is removed Keep the collection device below the level of the client’s chest Strip the chest tube to create negative pressure Clamp the collection device **A nurse has a prescription to perform a bladder scan for a client. Which of the following actions should the nurse take? Ask the client to sign a concent form Use surgical aseptic technique Check for allergies to iodine or shellfish Tell the client she should not experience any discomfort **A nurse is assisting with the plan of care for a client who had a stroke and has dysphagia. Which of the following intervenions should the nurse include in the plan of care? Offer a drink of ice water before meals Maintain the client in an upright position for 10 mins after meals Remind the client to swallow twice with each bite of food Engage the client in conversation during the meal **A nurse is discussing the use of epidural analgesia with a newly licenesed nurse. Which of the following statements by the newly licensed nurse indicated an understanding of this method of pain control? I should instruct the client to administer a dose of medication when he feels pain I should monitor the client for hypertension when he is receiving the analgesia I should instruct the client that the medication is administered directly to the nerve I should report leaking at the insertion site to the anesthesiologist **A nurse at a mental health facility is assisting with the development of a an education program for newly licensed nurses. The nurse should include that it is approprite to obtain a prescription to place a client in seclusion in which of the following situations? A client shouts degrading statesments at a family member A client states she is going to leave the facillity in the middle of the night A client refuses to take her medication and throws the pills toward the nurse’s desk A client hits another client because she thought he was talking about her **A nurse is collecting data about health risks from a young adult client. Which of the following questions by the nurse is the priority? How many fruits and vegetables do you include in your diet How much alcohol do you consume on a regular basis What types of physical activity do you engage in Can you describe your peer relationships **A client who is diagnosed with Parkinson’s disease verbalize frustration due to increase difficulty with ambulation. Which of the following is an appropriate response for the nurse to make? Watch your feet when you walk to maintain balance to prevent falls We should monitor your serum blood level of levodopa monthly Perform active range of motion with your arms and legs three times a day You should consider using a wheelchair instead of trying to walk **A nurse is caring for a client and notes the IV fluid rate has slowed. Which of the following actions should the nurse take first? Repostion the tip of the catheter Check the tubing for kinks or obstructions Position the IV tubing to avoid tension on the IV catheter Tighten the IV tubin connections **A nurse is caring for a client who is NPO and has a NG tube attached to suction for gastric decompression. Which of the following actions is appropriate if the nurse observes abdominal distention? Provide oral hygiene Increase the suction pressure Clamp the tube for 30 min Irrigate the tube with normal saline **A nurse is caring for a client who is on telemetry. Which of the following ECG findings should the nurse report to the charge nurse? One P wave prior to each QRS complex PR interval 0.24 seconds QRS duration 0.06 seconds Ventricular rate 75/min **A nurse on an acute mental health unit observes a client who begins to speak loudly in the common room, saying that he can’t hear the TV. Which of the following is an appropriate response by the nurse? You will need to go to your room until you can calm down okay The TV is loud enough for everyone to hear it You are being inconsiderate. Please stop talking so loudly Let’s go to another room to talk about what is upsetting you **A nurse is caring for a client who is NPO and has a NG tube attached to suction for gastric decompression. Which of the following actions is appropriate if the nurse observes abdominal distention? Provide oral hygiene Increase the suction pressure Clamp the tube for 30 min Irrigate the tube with normal saline **A nurse is caring for a client who delivered a full-term newborn 16hr ago. The nures notes excessive lochia discharge. Which of the following actions should the nurse take first? Obtain a blood specimen for hematocrit Perform fundal massage Have the client empty her bladder Administer carboprost tromethamine (Hemabate) **A nurse is preparing to perform trachostomy care for a client. Which of the following actions should the nurse take first? Don sterile gloves Open sterlie packages Pour sterile solution in a bowl Replace tracheostomy ties Delegation not sure which one I get wrong **A nurse is caring for a client who has COPD. An assistive personnel (AP) reports that the client is having difficulty breathing. The nurse returns to the client’s room with the AP to check the client’s status. Which of the following tasks should the nurse delegate to the AP? Perform nasotracheal suctioning Begin low-flow oxygen via nasal cannula Obtain a provider’s prescription for a chest x-ray Place the client in high-fowler’s position **A nurse on a medical unit is deciding what task to delegate to an assistive personnel (AP). Which of the following can the nurse delegate to the AP? Administer a rectal suppository to a client Evaluating a client’s use of an assistive walking device Obtaining a client’s vital signs prior to discharge Reinforcing teaching to a client on how to perform finger stick blood glucose testing **A nurse is caring for a group of clients who are all scheduled for surgery on the same day. Which of the following nursing actions demonstrates that the nurse possessess effective time management skills? (Select all) Gathers all needed supplies and equipment before entering a client’s room Prepares all preoperative medications early and stores them for later use Completes one task before beginning a new task Documents each client’s preoperative vital signs when they are taken Delegates tasks to the assistive personnel (AP) that are within the scope of practice **A nurse is collecting data from a client who is receiving radiation therapy for throat cancer. Which of the following findings indicates an adverse effect that the nurse should report to the provider immediately? Skin irritation Black, terry stools Chest congestion I keep picking this one but I’m not sure if its correct can’t figure it out Fever Keep getting this one wrong **A nurse is involved in developing a security plan for the newborn nursery. Which of the following interventions are appropriate to include? (Select All) Provide a hospital in-service on newborn security policies for personnel Apply a neonatal safety device to each newborn Footprint newborns as soon as they are transferred to the nursery Apply identification braclets to the newborn and parents Require distinctive identification badges for personnel in the newborn nursery Wrong!!! Every time picked a, c **A nurse is preparing to perfom a venipuncture on a client. Which of the following steps by the nurse is appropriate? Shave the excess hair from the skin around the selected site Place the extremity in an elevated position Cleanse the insertion site with the tourniquet in place Select a site in the antecubital fossa