RN comprehensive online practice 2019 A Latest Update.

RN comprehensive online practice 2019 A Latest Update. A nurse is planning care for a client who is receiving heparin to treat a deep-vein thrombosis of the left lower leg. Which interventions should the nurse include in the plan of care? maintain the client on bed rest restrict the client to 1 L of fluid per day place cool compresses on the edematous area elevate the affected leg ANSWER elevate the affected leg the nurse should elevate the client's affected extremity to reduce edema and decrease the risk of chronic venous insufficiency A nurse is teaching a group of guardians about child safety measures. Which of the following statements by a guardian indicates an understanding of the teaching? I will make sure my 4 year old child wears a helmet when using a skateboard I should have my child avoid sun exposure between 10 am and 2 pm I can give my 2 year old child a whole hotdog on a bun When my infant is in the carrier, I will place it on a raised, flat surface whenever possible ANSWER I should have my child avoid sun exposure between 10 am and 2 pm To prevent sunburns, guardians should apply sunscreen, dress their child in protective clothing, and avoid sun exposure between 1000 and 1400 A home health nurse is providing teaching about infection prevention to a client who has cancer and receiving chemotherapy. Which of the following statements by the client indicates an understanding of the teaching? I will leave my drinking water out of my refrigerator for at least 1 hour so it will be room temperature I will clean my toothbrush in my dishwasher once each month I will take my temperature once each week and let my doctor know if it is high I will walk short distances throughout the day ANSWER I will walk for short distances throughout the day The client should ambulate for short distances as tolerated throughout the day. This will help reduce pulmonary stasis and prevent the development of respiratory infections A nurse is providing dietary teaching to the parents of a 6-month old infant. Which of the following instructions should the nurse include? Provide the infant with 1 cup of cereal Give the infant 240 mL (8 oz) of juice per day Introduce new foods one at a time over 5 to 7 days Give whole milk first, then small amounts of solid food ANSWER Introduce new foods one at a time over 5 to 7 days The parents should introduce new foods one at a time over 5 to 7 days to identify potential food allergies A charge nurse is planning care for a client who has mechanical restraints in place. Which of the following interventions should the nurse include in the plan? Remove the client's restraints while sleeping Document the client's status every 60 min Check for a new prescription every 6 hours Provide a staff member to stay with the client continuously ANSWER Provide a staff member to stay with the client continuously A staff member must remain continuously with a client who is in restraints or view the client via audiovisual equipment if necessary due to the risk of injury A community health nurse is assisting with the development of a disaster management plan. The nurse should include which of the following nursing responsibilities in the disaster response stage of the plan? Performing a rapid needs assessment Organizing an immunization campaign Identifying the specific roles of disaster workers Conducting home visits to identify health hazards ANSWER Performing a rapid needs assessment Disaster management includes prevention, preparedness, response, and recovery stages. The nurse should perform a rapid needs assessment during the response phase of the disaster cycle. A rapid needs assessment allows the nurse to identify the severity of the incident, the health needs of the community, and the priority actions needed during the response stage A nurse manager is assisting with the orientation of a newly licensed nurse. Which of the following actions by the nurse requires the nurse manager to intervene? Informs the provider about a client's suicide plan Notifies the health department of a client's diagnosis of chlamydia Reports suspected child maltreatment to social services Tells the hospital chaplain a client's diagnosis ANSWER Tells the hospital chaplain a client's diagnosis Discussing a client's diagnosis with the hospital chaplain is a breach of client confidentiality and a violation of HIPPA A nurse is caring for a client who is in labor at 39 weeks of gestation. During the second stage of labor, the nurse observes early decelerations on the monitor tracing. Which of the following actions should the nurse take? Continue observing the fetal heart rate Assist the client to a knee-chest position Prepare the client for continuous internal monitoring Prepare for an emergency cesarean birth ANSWER Continue observing the fetal heart rate Early decelerations indicate the progression of labor and are an expected finding. The nurse should continue to monitor the fetus by observing the fetal heart rate and tracing A nurse manager is planning to make changes to the current scheduling system on the unit. To facilitate the staff's acceptance of this change, which of the following actions should the nurse manager take? Provide information about scheduling issues to the staff Ask staff members to participate in a trial of the new scheduling system Encourage staff to offer alternate scheduling solutions Develop goals to implement the new scheduling system ANSWER Provide information about scheduling issues to the staff The first stage of the change process is the unfreezing stage, when the nurse should inform the staff about the current staffing issues. This can increase their understanding of why changes are necessary A nurse is planning teaching about allowable foods for a client who has a history of uricacid based urinary calculi formation. Which of the following foods should the nurse include in the teaching? Liver Oranges Chicken Red wine ANSWER Oranges A client who is prone to uric acid calculi formation can eat citrus fruits A charge nurse is teaching a newly licensed nurse how to identify true labor. Which of the following should the nurse include in the teaching? Contractions will be felt primarily in the upper abdomen The cervix transitions to an anterior position Contraction intensity decreases with ambulation The cervix progressively thickens ANSWER The cervix transitions to an anterior position In true labor, the cervix transitions to an anterior position and begins to dilate in preparation for birth A nurse on a medical-surgical unit is caring for a client prior to a surgical procedure. Which of the following findings should indicate to the nurse that the client has the ability to sign the informed consent? The client's partner tells the nurse that the client understands the procedure The nurse locates the provider's prescription for the surgical procedure The nurse witnesses the provider's explanation of the procedure The client is able to accurately describe the upcoming procedure ANSWER The client is able to accurately describe the upcoming procedure The ability of the client to accurately describe the upcoming procedure indicates that the provider adequately informed the client and that the client is able to sign the informed consent form A charge nurse assigns a newly licensed nurse to care for a client who has a chest tube. The nurse expresses concern about having limited experience with monitoring chest tube drainage. Which of the following actions should the charge nurse take first to provide teaching about chest tubes? Refer the nurse to the procedure manual Use a diagram to explain the procedure to the nurse Demonstrate the procedure to the nurse Ask the nurse about their knowledge of the procedure ANSWER Ask the nurse about their knowledge of the procedure The first action the charge nurse should take using the nursing process is to assess the newly licensed nurse's knowledge about the procedure. By assessing the nurse's knowledge, the charge nurse can identify the nurse's learning needs A nurse is teaching a client who has a new prescription for estradiol. For which of the following adverse effects of this medication should the nurse instruct the client to monitor and report to the provider? Hypotension Headaches Bruising Oliguria ANSWER Headaches The nurse should instruct the client to monitor for and report headaches. Headaches can be an indication of a thromboembolic stroke because estradiol increases the risk for adverse cardiovascular events A nurse is preparing to administer diazepam 0.3 mg/kg IV bolus to a toddler who weighs 22 lb and is experiencing a grand mal seizure. Available is diazepam solution for injection 5 mg/mL. How many mL should the nurse administer? ANSWER 0.6 mL A nurse is caring for a client who is 12 hr postoperative, is receiving PCA for pain control, and requires a blood pressure check in 10 min. Which of the following staff members should the nurse assign to collect this information? An RN who is monitoring a client who started receiving a blood transfusion 5 min ago An assistive personnel (AP) who just began performing a bed bath A licensed practical nurse (LPN) who is reinforcing discharge instructions with a client An assistive personnel (AP) who is assisting a client to return to bed ANSWER An assistive personnel (AP) who is assisting a client to return to bed Performing a blood pressure check is within the range of function of an AP, and the AP should be available to obtain a blood pressure within the specified time A nurse is creating a plan of care for a child who has acute lymphoid leukemia and an absolute neutrophil count of 400/mm^3. Which of the following interventions should the nurse include in the plan? Encourage friends and family to visit the child Withhold administering the varicella vaccine to the child Collect a daily urine specimen from the child to check for proteinuria Provide a low-protein diet for the child ANSWER Withhold administering the varicella vaccine to the child A child who has severe immunodeficiency should not receive a lie vaccine due to the risk of developing the disease. Inactivated vaccines can be administered to children who are immunosuppressed.