PN COMPREHENSIVE

PN COMPREHENSIVE A charge nurse in a long-term care facility notices an assistants repeated failure to provide oral care for clients. Which of the following actions should the nurse take? *Discuss the unacceptable behavior with the AP while reinforcing expectations. A client who is diagnosed with Parkinson's disease verbalizes frustration due to increase difficulty with ambulation. Which of the responses should the nurse take? *Perform active ROM with your arms and legs two times a day. A community health nurse is helping to reinforce teaching about hepatitis A with a group of employees at a childcare facility. Which of the following characteristics should the nurse identify as an external factor that can impede learning for the participants? *Poor lighting in the learning setting A licensed practical nurse on a medical surgical unit is working with an RN and an Assistive personnel. Which of the following assignments should the LPN expect to receive? *Administering an NG tube feeding to a client who had a stroke A nurse assisting with a childbirth class is discussing non pharmacological strategies used during labor. Which of the following statements by a client indicates an understanding of cutaneous stimulation? *"I should use counterpressure for back pain during labor." A nurse at a clinic is performing vision testing for a client following a head injury. Which of the following findings should the nurse identify as a problem with pupil accommodation? *Lack of change in pupil size when the client looks from a far to a near object. A nurse at a long term care facility is part of a team preparing a report on the quality of care at the facility. Which of the following information should the nurse recommend including in the report to demonstrate improvement in care quality? *The facility had 12% fewer urinary tract infections over the past 6 months. A nurse at a long term care facility is transcribing new prescriptions for 4 clients. Which of the following prescriptions is accurately transcribed by the nurse? *Potassium chloride 20 mEq PO every morning A nurse delegates the collection of a sputum specimen from a client who has tuberculosis to an assistive personnel. At which of the following times should the nurse instruct the ap to collect the specimen? *As soon as the client wakes up. A nurse has administer medications to a group of clients. For which of the following client situations should the nurse complete and incident report? *The nurse administered insulin lispro to a client who has diabetes mellitus and is NPO. A nurse is caring for a client who has expressive aphasia following a stroke. Which of the following communication methods should the nurse use? *Provide a picture board. A nurse in a long-term care facility is assisting with an in-service for newly hired assistive personnel about legal issues within the facility. Which of the ff should the nurse include as an example of assault? *Informing a client the nurse is going to administer an injection even though the client refuses. A nurse in a long-term care facility is assisting with the admission of a client who requires oropharyngeal suctioning. Which of the following supplies does the nurse need to perform this task? *Yankauer catheter A nurse in a long term care facility is contributing to the plan of care for a client who has a new ostomy. Which of the following actions should the nurse plan include? *Change the appliance two times each week. A nurse in a long term care facility is reviewing information about health care associated infection with a newly licensed nurse. Which of the following information should the nurse include? *Prolonged use of corticosteroids is a risk factor for infection. A nurse in a long term care facility is serving on the ethics committee, which is addressing a client care dilemma. Which of the following strategies will facilitate resolving the dilemma? *Determine the facts related to the dilemma. *Identify possible solutions. *Consider the client's wishes. A nurse in a long term care facility is using validation therapy with a client who has dementia. The client becomes agitated and asks why his wife who died several years ago has not visited him. Which of the following responses should the nurse make? *You must miss your wife. Let's take a walk and you can tell me about her. A nurse in an acute mental health facility is caring for a client who has borderline personality disorder and reports. "I am going to kill my girlfriend when I get out of here." Which of the ff actions should the nurse take? *Notify the client's care team of the threats against the partner A nurse in a provider's office is collecting data from a preschooler. Which of the following findings should the nurse report to the provider? Heart rate 146/min A nurse in a provider's office is reinforcing teaching with a client who has a new prescription for ferrous sulfate elixir. Which of the following statements by the client should indicate to the nurse an understanding of the teaching? *I will rinse my mouth after taking this medication. A Nurse in maintaining droplet precautions for a client who has meningitis. Which of the following actions should the nurse take? *Wear a surgical mask within 3 feet of the client. A nurse in reinforcing teaching about weight loss with a female older adult client who is overweight. Which of the following statements should the nurse include in teaching? *keep fat intake to no more that 30% of daily caloric intake. A nurse in reinforcing teaching with a client about cancer prevention. The nurse should include that frequent consumption of which of the following foods increases the risk of cancer? *Lamb A nurse is administering lorazepam to a client who is scheduled for surgery within 1 yr. Which of the ff actions should the nurse take after administering the medication ? *Instruct the client not to get out of bed. A nurse is admitting a client who is at high risk for suicide. Which of the ff actions is the nurse's priority? *Search the client's personal belongings A nurse is assisting in teaching a group of staff nurses about hepatitis A. Which of the following modes should the nurse include as a method of transmitting hepatitis A? *Consumption of contaminated food. A nurse is assisting in the plan of care for a female client who is to undergo a 12-lead ECG. Which of th off actions should the nurse include in the plan of care? *Instruct the client to remain still while the test is performed. A nurse is assisting with admitting a client who has colorectal cancer. When Collecting data from the client, which of the following manifestations should the nurse expect? *Abdominal cramps A nurse is assisting with a presentation at a community center about personal disaster preparedness. which of the following strategies should the nurse recommend for preparing a home disaster supply kit? *Have a supply of prescribed medications. A nurse is assisting with monitoring a client who is at 40 weeks of gestation and is in active labor. The nurse recognizes late deceleration on the fetal monitor tracing. Which of the following actions should the nurse take? *Place the client in the lateral position. A nurse is assisting with monitoring a client who is in labor and has spontaneous rupture of membranes following a vaginal examination. The provider reports the client's cervix is dilated to 1 cm with an unengaged presenting part. Which of the following actions should the nurse take? *Apply the external fetal heart rate monitor. A nurse is assisting with performing a non stress test for a client who is at 39 weeks of gestation which of the following instructions should the nurse reinforce with the client? *"You should depress the button on the handheld marker when you feel your baby move." A nurse is assisting with the admission of a client who has major depressive disorder. Which of the ff communication technique should the nurse use to establish a trusting relationship with the client? *Offering general leads A nurse is assisting with the plan of care for a client following a transurethral resection of the prostate. Which of the following interventions should the nurse include in the plan of care? *The nurse should irrigate the bladder using strict sterile technique and maintain closed catheter drainage system to minimize the rick of infection. A nurse is caring for a client following a bronchoscopy procedure. Which of the following actions should the nurse perform first? *Check for a gag reflex. A Nurse is caring for a client in Buck's Traction. Which of the following actions should the nurse take? *Allow the weights to hang freely. A nurse is caring for a client who had a bone marrow transplant 3 days ago for treatment for leukemia. Which of the following findings should the nurse identify as a safety hazard? *A visitor brought the client a bouquet of flowers. 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 expect to observe? *The safety pin is present at the distal end of the drain. A nurse is caring for a client who has multiple sclerosis. Which of the following manifestations should the nurse expect? *Ataxia A nurse is caring for a client who has right sided heart failure. The client's partner expresses concern the the client will die. Which of the following responses should the nurse make? *"It is difficult to see someone so sick. What have you been told about your partner's prognosis?" A nurse is caring for a client who has schizophrenia and is experiencing auditory hallucinations. Which of the following actions should the nurse take? *Offer the client headphones to listen to music. A nurse is caring for a client who is 1 day postoperative and is unable to ambulate. Which of the ff actions should the nurse take to promote the client's venous return? Maintain the sequential compression device. A nurse is caring for a client who is 4 hr postoperative ff a total thyroidectomy. Which of the ff manifestations should the nurse report to the provider as indicating possible hypocalcemia? *Tingling of fingers A nurse is caring for a client who is 16 hr postoperative following a total hip arthroplasty. the client reports numbness, pain, and tingling in the affected leg. Which of the following actions should the nurse take first? *compare capillary refill in toes bilateraly A nurse is caring for a client who is NPO and has an NG tube attached to suction for gastric decompression. Which of the following actions should the nurse take if the client experiences abdominal distention? *Irrigate the tube with normal saline. A Nurse is caring for a client who is post op following an open reduction with internal fixation of the ankle. The client report pain and the nurse notes that the affected extremity is cool, pale, and has a weak pulse. The nurse calls the surgical assistant who responds "it has always been like that" Which of the following actions should the nurse take first? *Notify the nursing supervisor. A nurse is caring for a client who is scheduled for surgery in the morning. The nurse learns that the client has decided not to have surgery even though he has already signed the informed consent form. Which of the following actions should the nurse take? *Report the situation to the provider who obtained the informed consent. A nurse is caring for a client who requests information bout advance directives. Which of the following responses should the nurse make? *"Advance directives are written instructions regarding end-of-life care." A nurse is caring for a client who took an overdose of acetaminophen. Which of the following medications should the nurse plan to administer to the client? *Acetylcysteine a nurse is caring for a female client during an outpatient clinic visit. Which of the following findings places the client at risk for coronary artery disease? *The client's LDL level A nurse is caring for a female client who has an indwelling urinary catheter. which of the following actions should the nurse take? *Wipe the drainage port with an antiseptic wipe after emptying urine from bag. 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 therapy? *Moist mucous membranes A nurse is caring for four clients who are all scheduled for surgery on the same day. Which of the following nursing actions demonstrates that the nurse possesses effective time management skills? *Gathers all needed supplies and equipment before entering client rooms Completes one task before beginning a new task Documents the clients' preoperative vital signs when they are taken Delegates tasks to an assistive personnel (AP) that are within his range of function A nurse is checking a newborn's vital signs. Which of the following methods of temperature measurement should the nurse use? *Axillary A nurse is collecting data from a client who has an unprepared femur fracture and rates his pain as 8 on a scale of 0 to 10. The client is talking and caught with a visitor. Which of the following of the prescribed medication should the nurse administer? *Hydromorphone 5 mg orally. A Nurse is collecting data from a client who has bipolar disorder and is experiencing acute mania. Which of the following findings is the nurse's priority? *lack of sleep A nurse is collecting data from a client who has iron deficiency anemia. Which of the following findings should the nurse expect? *Difficulty concentrating. a Nurse is collecting data from a client who has multiple fractures following a motor- vehicle crash. For which of the following client statements *"I am so frustrated. I cannot eve