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A nurse is assessing a client who received 2 units of packed RBCs 48 hrs ago. Which of the following findings should indicate to the nurse that the therapy has been effective? - ANSWER-hemoglobin 14.9 g/dL a nurse working in an emergency department is triaging four clients. which of the following clients should the nurse recommend for treatment first? - ANSWER-a middle adult client who has unstable vital signs a nurse is caring for a client who has fluid volume overload. which of the following tasks should the nurse delegate to an assistive personnel? - ANSWER-measure the client's daily weight a nurse is preparing to administer mannitol 0.2 g/kg IV bolus over 5 min as a test dose to a client who has severe oliguria. The client weighs 198 lb. what is the amount in grams the nurse should administer? - ANSWER-18 g a nurse is conducting a physical examination for an adolescent and is assessing the rang of motion of the legs, which of the following images indicates the adolescent is abducting the hip joint? - ANSWER-Moving the leg away from the midline of the body (off to the side, not to the front) a nurse is caring for a client who has hyperthyroidism. which of the following findings should the nurse expect? - ANSWER-tremors tachycardia, diaphoresis, weight loss, insomnia, exopthalmia hypothyroidism has dry corase hair, bradycardia, and periorbital edema a nurse is assessing a school age child who has bacterial meningitis. which of the following findings should the nurse expect? - ANSWER-nuchal rigidity also weight loss a nurse is assessing a newborn's heart rate. which of the following actions should the nurse take? - ANSWER-auscultate the apical pulse at least 1 min a nurse is preparing to assist with a thoracentesis for a client who has pleurisy. the nurse should plan to perform which of the following actions? - ANSWER-instruct the client to avoid coughing during the procedure a nurse is the emergency department is assessing a preschooler who has a facial laceration. the nurse should identify which of the following findings as a potential indication of child sexual abuse? - ANSWER-the child exhibits discomfort while walking a nurse is preparing to teach about dietary management to a client who has crohn's disease and an enteroenteric fistula. which of the following nutrients should the nurse instruct the client to decrease in their diet? - ANSWER-fiber - reduce diarrhea and inflammation a nurse is caring for a client who has a prescription for a continuous passive motion CPM machine following a total knee arthroplasty. which of the following actions should the nurse take? - ANSWER-Turn off the CPM machine during mealtime promote client comfort and dietary intake a nurse is preparing to initiate IV access for an older adult client. Which of the following sites should the nurse select when initiating the IV for this client? - ANSWER-radial vein of the inner arm a nurse is developing a client education program about osteoporosis for older adult clients. the nurse should include which of the following variables as a risk factor for osteoporosis? - ANSWER-sedentary lifestyle also, small framed body with a thin build, estrogen deficiency a nurse in an emergency department is caring for a child who has a fever and fluid filled vesicles on the trunk and extremities. which of the following interventions should the nurse identify as the priority? - ANSWER-initiate transmission based precautions a nurse is caring for a client who has a clogged percutaneous gastrostomy feeding tube. which of the following actions should the nurse take first? - ANSWER-change the position of the client a home health care nurse is developing a teaching plan for a client who has a new ileostomy. which of the following instructions should the nurse include? - ANSWER￾empty the appliance when it is one third to one half full a nurse is reviewing the laboratory report of a client who has end stage kidney disease and received hemodialysis 24 hr ago. Which of the following laboratory values should the nurse report to the provider? - ANSWER-sodium 148 mEq/L a nurse is caring for four clients. which of the following tasks should the nurse delegate to an assistive personnel? - ANSWER-Arrange the lunch tray for a client who has a hip fracture a nurse is preparing a client for a paracentesis. which of the following actions should the nurse take? - ANSWER-instruct the client to void a nurse has received change of shift report on four assigned clients. for which of the following clients should the nurse intervene to prevent a potential food and medication interaction? - ANSWER-a client who is receiving an MAOI and is requesting a cheeseburger for dinner a nurse is planning care for a client who has rheumatoid arthritis and has moderate to severe pain in multiple joints. which of the following actions should the nurse plan to take? - ANSWER-allow for frequent rest periods throughout the day a nurse is caring for a client who is receiving continuous bladder irrigation following a transurethral resection of the prostate. the client reports bladder spasms, and the nurse observes a decreased urinary output. which of the following actions should the nurse take? - ANSWER-irrigate the catheter with 0.9% sodium chloride irrigation a nurse is assessing a client who has COPD. which of the following findings should the nurse expect? - ANSWER-pH 7.31 a nurse in a community center is providing an educational session to a group of client about ovarian cancer. which of the following manifestations of ovarian cancer should the nurse include in the teaching? - ANSWER-abdominal bloating increase in abdominal girth, pelvic or abdominal pain, early satiety, urinary frequency of urgency a nurse is caring for a client who has active tuberculosis TB. which of the following actions should the nurse plan to take to prevent the transmission of the disease? - ANSWER-Have the client wear a surgical mask while being transported outside the room a nurse is caring for a group of clients. which of the following clients should the nurse attend to first? - ANSWER-an older adult client who is anxious and attempting to pull out an IV line an RN is observing a licensed practical nurse LPN and an assistive personnel AP move a client up in bed. for which of the following situations should the nurse intervene? - ANSWER-The LPN and the AP grasp the client under his arms to lift him up in bed a nurse is preparing to administer insulin to a client via a pen device. which of the following actions should the nurse take? - ANSWER-hold the insulin pen device perpendicular to the client's skin to inject the medication a nurse is caring for a client who has immunosuppression and a continuous IV infusion. which of the following actions should the nurse take? - ANSWER-monitor the client's mouth every 8 hours a nurse is providing teaching about advance directives to a middle adult client. which of the following client responses indicates an understanding of the teaching? - ANSWER-"I can designate my partner as my health care surrogate" a nurse is assessing a client following a vaginal delivery and notes heavy lochia and a boggy fundus. which of the following medications should the nurse expect to administer? - ANSWER-oxytocin a nurse manager is planning to use a democratic leadership style with the nurses on the unit. Which of the following actions by the nurse manager demonstrates a democratic leadership style? - ANSWER-seeks input from the other nurses a nurse is assigning task roles for a group of clients in a community mental health clinic. which of the following tasks should the nurse assign to the member of the group functioning as the orienteer? - ANSWER-noting the progress of the group toward assigned goals a nurse is creating a plan of care for a newly admitted child. which of the following actions should the nurse include in the plan? - ANSWER-Administer high dose antibiotic therapy cystic fibrosis kid with lung infection a nurse is caring for a newborn immediately after delivery. which of the following interventions should the nurse implement to prevent heat loss by conduction? - ANSWER-use a protective cover on the scale when weighing the infant a nurse is caring for a client who has abdominal surgery 24 hr ago. which of the following actions is the nurse's priority? - ANSWER-assist with deep breathing and coughing a nurse in an outpatient mental health clinic is caring for four clients. the nurse should recognize that which of the following clients is effectively using sublimation as a defense mechanism? - ANSWER-a client who channels their energy into a new hobby following the loss of their job a nurse is assessing for correct placement of a client's NG feeding tube prior to administering a bolus feeding. which of the following actions should the nurse take? - ANSWER-aspirate contents from the tube and verify the pH level an antepartum nurse is caring for four clients. for which of the following clients should the nurse initiate seizure precautions? - ANSWER-a client who is at 33 weeks of gestation and has severe gestational hypertension a nurse is providing discharge teaching to a client who is to receive home oxygen therapy. which of the following instructions should the nurse include in the teaching? - ANSWER-wear clothing made with cotton fabrics while oxygen is in use use water soluble lubricant not petroleum based lubricant a nurse is providing teaching for a client who has a fracture of the right fibula with a short leg cast in place a new prescription for crutches. The client is non weight bearing for 6 weeks. which of the following instructions should the nurse include in the teaching? - ANSWER-use a three point gait a nurse is preparing to transfer a client from the ICU to the medical floor. The client was recently weaned from mechanical ventilation following a pneumonectomy. which of the following information should the nurse include in the change of shift report? - ANSWERThe time of the client's last dose of pain medication a nurse is assessing an infant who has hydrocephalus and is 6 hr postoperative following placement of a ventriculoperitoneal VP shunt. Which of the following findings should the nurse report to the provider? - ANSWER-irritability when being held - increased intracranial pressure a nurse is caring for a client who has a prescription for chlorpromazine. which of the following findings should the nurse identify as an indication that the medication is effective? - ANSWER-decreased hallucinations a nurse is providing teaching about lithium to a client who has bipolar disorder. which of the following statements should the nurse include in the teaching? - ANSWER-"Notify your provider if you experience increased thirst" a nurse is caring for a client who has a fecal impaction. which of the following actions should the nurse take when digitally evacuating the stool? - ANSWER-insert a lubricated gloved finger and advance along the rectal wall a nurse is planning to delegate client care tasks to an assistive personnel AP. which of the following tasks should the nurse plan to delegate to the AP? - ANSWER-perform gastrostomy feedings through a client's established gastrostomy tube a nurse manager is preparing an educational session for nursing staff about how to provide cost effective care. which of the following methods