NCLEX Exam Review Question Bank 2024

The nursing team consists of a nurse, an LPN/LVN, and two unlicensed assistive personnel (UAP). Which client care activity does the nurse recognize as appropriately utilizing the LPN/LVN's skill set? (Select all that apply.) - Suction a client's tracheostomy. Care for a 2-year-old client who has a systolic blood pressure of 84 mm Hg. Others here are better for hte UAP - have to pay attn to who else you have to use. They cannot administer IV meds for pain. The nurse reviews the care needs for a group of postpartum clients. Which client does the nurse identify as being the most at risk for developing a hemorrhage? - Client with a distended bladder. 1) CORRECT - A distended bladder is likely to displace the uterus to the left or the right. This will interfere with uterine contraction, which could cause a postpartum hemorrhage. A client experiencing regular contractions reports "water breaking. " Which action does the nurse take first? - Auscultate the fetal heart rate. 1) CORRECT— The priority is assessment of fetal well-being. This is completed by auscultating the fetal heart rate. This heart rate should range from 120 to 160 beats per minute. A heart rate above 160 beats per minute is an early sign of fetal hypoxia. A heart rate below 110 beats per minute is a later sign of fetal hypoxia, which could be caused by prolapse of the umbilical cord. The nurse cares for a client diagnosed with end-stage bone cancer who is newly electing hospice care. The client's spouse asks, "What can we do instead of using medications for pain?" Which response by the nurse is best? (Select all that apply.) - "Massage and heat or cold therapy are interventions that we can try."4."I'll share your concerns with the health care provider as a transcutaneous electrical stimulator may help with pain management."5."Our interdisciplinary team may have some additional treatments that would alleviate pain without medications." 6) INCORRECT- Asking a "why" question may be viewed as confrontational and is therefore non-therapeutic. Alternatively, the nurse could make an open-ended statement such as, "Tell me about your concerns with using medications." The nurse notices a client becomes confused every day in the afternoon. Which intervention by the nurse is appropriate to reduce the risk for falls when the client becomes confused? (Select all that apply.) - Offer the client pain medication to promote rest. 2.Move the client closer to the nurses' station.3.Leave one side rail down on the side of the bed where the client normally gets up. 4.Monitor the client closely during the afternoon.5.Place a rocking chair in the client's room. 3) CORRECT- It is appropriate to leave the side rail down on the side of the bed where the client normally gets up to stand. Clients who are confused often get out of bed to wander. Leaving the side rail down will allow the client to freely exit the bed without climbing over a side rail, which would increase the risk of a fall. 5) CORRECT- A rocking chair assists clients who are confused in expending energy, as the chair makes them less likely to wander and decreases the likelihood of falling. A client with a vertebral compression injury at the level of C4 to C5 is evaluated in the emergency department and receiving oxygen at 8 L/minute via nasal cannula. The client's respirations are shallow, rate is 32 breaths per minute, and oxygen saturation is 88%. Which action does the nurse take first? - Administer 100% oxygen via non-rebreather mask. 3) CORRECT- Respiratory arrest is impending, so provision of high-flow oxygen is prioritized. BEFORE contacting HCP. The nurse receives a hand-off report and four clients require venipuncture for labs to be drawn at the same time. Which client will the nurse draw labs on first? The client diagnosed with sepsis. The current blood pressure is 100/70 mm Hg, with a lactic acid lab due now.2.The client diagnosed with anemia. The previous hemoglobin was measured at 8 g/dL (80 g/L), with a complete blood count lab due now.3.The client diagnosed with respiratory failure on continuous bilevel positive airway pressure (BiPAP) therapy. The arterial blood gas lab due now.4.The client diagnosed with angina. The electrocardiogram (ECG) showed no ST elevation, and a troponin lab is due now. - 1) INCORRECT- The client is hemodynamically stable at this time with a mean arterial pressure (MAP) of 80 mm Hg. To calculate MAP, the formulate is: 2(diastolic pressure) + systolic pressure ÷ 3. For example, 2 × 70 mm Hg + 100 mm Hg ÷ 3 = 80 mm Hg. 2) INCORRECT- The client has a stable hemoglobin at this time and does not need to be drawn first. 3) INCORRECT- Although respiratory failure is serious, the client is getting oxygen support therapy. An arterial blood gas (ABG) will determine if the intervention on BiPAP is working. 4) CORRECT- An elevated troponin, despite lack of ST elevation on the ECG, could signify a non-ST-elevation myocardial infarction (NSTEMI). If NSTEMI is diagnosed, the client will require an urgent cardiac catheterization to determine the degree of blockage. Nurses on a newborn nursery unit are developing security measures to prevent infant abductions. Which method is likely to be effective in preventing abductions? (Select all that apply.) - Parents and staff will use a daily password whenever an infant is removed from the room.2.Staff will be trained to identify a "typical" abductor.4.Staff will compare identification bands on both infant and parents.5.Parents will be taught not to use the bathroom when the infant is in the room alone. 1) CORRECT- Daily passwords help eliminate fraudulent use of an identification (ID) badge or unauthorized personnel from removing the infant. 2) CORRECT- Infant abductions are often taken by females between 12 and 55 years old. Staff should be alert to visitors fitting this profile and without a specific client they are visiting. 3) INCORRECT- Parents can choose whom they want to visit. Limiting who can visit would not prevent abductions. 4) CORRECT- Matching ID bands help prevent abductions and accidental mix-ups of infants by staff. 5) CORRECT- Parents should never leave an infant unattended in the room. Leaving an infant unsupervised is a risk for abduction. A novice nurse is completing an incident report after a client fell while getting out of bed. The nurse's preceptor reviews the nurse's proposed documentation for the electronic health record (EHR) and the incident report. Which information should the preceptor guide the nurse to exclude from the documentation? - Notation in EHR that an incident report was completed. 3) CORRECT- The nurse should not record in the EHR that an incident report was filed. The EHR is a record of the client's health. An incident report is a form used by the facility for tracking variances and improving quality and safety. The hospice nurse visits a client at home. The spouse meets the nurse at the door and says, "I just hate to see my spouse this way. I don't know that I can handle this much longer." Which response by the nurse is appropriate? (Select all that apply.) - "In times of stress, what gives you strength and hope?"2."What questions do you have about the care your spouse is receiving?"3."What cultural needs may I assist you with?"4."Do you have any spiritual or religious support?"5."Tell me what you understand about the pain relief and comfort your spouse is receiving." ALL OF THEM While making hourly rounds, the nurse notices a fire in a trash can in a client's room. Upon inspection, the client is not in the room. Which intervention does the nurse initiate first to manage the fire? (Select all that apply.) - Activate the fire alarm. Close door to the room The nurse provides care for an older adult client who had a stroke. Assessment findings include right-sided weakness, facial drooping, difficulty swallowing, and limited mobility. The nurse recognizes which sites are appropriate for use when assessing the client's temperature? (Select all that apply.) - Axillary. Tympanic membrane. Temporal artery. NOT oral or rectal. 4) INCORRECT - Rectal temperature measurement is not ideal for the client who demonstrates limited mobility (including the client whose mobility is impaired due to a stroke), as maintaining a side-lying position may be challenging. Rectal temperature assessment provides no significant advantages over other routes of temperature assessment. The nurse provides care for a client with a history of heart failure. The health care provider writes prescriptions for the client. Which prescription does the nurse question? - Verapamil 120 mg orally three times daily. 3) CORRECT - Verapamil is contraindicated in clients diagnosed with heart failure and in clients taking digoxin, because it can cause severe bradycardia. The emergency department (ED) charge nurse is notified that a city bus has overturned on the road. Several casualties are expected to be transported to the ED. Which nursing action is appropriate? (Select all that apply.) - Activate the hospital emergency response plan.2.Instruct assistive personnel to stock treatment areas.Assign increased numbers of staff to the triage area. DO NOT call off-duty nurses to come in. 3) INCORRECT- The command center team will assign the most appropriate person to begin calling in extra staff. A client diagnosed with a head injury is being prepared for a lumbar puncture. Which action will the nurse take first? - Measure pre-procedure vital signs. Before education or implementation. The nurse provides care for a client diagnosed with systemic lupus erythematosus (SLE). Which clinical manifestation does the nurse anticipate when completing a physical assessment? - Red rash. 1) CORRECT — The nurse can anticipate seeing a red rash, especially on the face, for this is a clinical manifestation associated with systemic lupus erythematosus. Will also see ulcerrs in the mouth but not dry mouth. The nurse provides care for a client who underwent a lumbar puncture. Which action by the nurse is priority? - Encourage increased fluid intake following the procedure. 1) CORRECT- Extra fluid helps the body replace any lost cerebrospinal fluid and may decrease the risk for headache. The nurse provides care for a client receiving a blood transfusion. Ten minutes after the transfusion is started, the client reports a headache, chest pain, low back pain, chills, and nausea. Which action by the nurse is appropriate? (Select all that apply.) - Notify the blood bank.4.Assess the client's vital signs.5.Obtain a sample of the client's blood.6.Obtain a sample of the client's urine. DO NOT DC the peripheral IV or administer aspirin. THe infusion should be stopped but the IV should not be DC'd. Aspirin is unsafe because it is antiplatelet. The LPN/LVN delegates tasks to the unlicensed assistive personnel (UAP). The nurse intervenes if which action is observed? (Select all that apply.) - The UAP administers prescribed eye ointment. This is a prescription. The UAP delegates client ambulation to another UAP.3) CORRECT - It is not within the UAP's scope of practice to re-delegate tasks.4.The UAP takes a phone prescription from a health care provider. The UAP listens to breath sounds. The nurse provides care for a client who had an above the knee amputation. Which intervention reduces phantom limb sensation? - Mirror therapy. 2) CORRECT— The mirror is thought to provide visual information to the brain, replacing sensory feedback expected from the missing limb. The nurse provides care for a client who is experiencing cancer-related chronic pain. Which non-pharmacological comfort intervention should be included in the plan of care? (Select all that apply.) - Guided imagery. Meditation. Diaphragmatic breathing. NOT Application of heat or cold, this is for acute. NOT therpautic touch because research does not say it is effective. The nurse monitors a client receiving 1 unit of packed red blood cells intravenously. Which action is appropriate when the client states "I can't catch my breath!"? (Select all that apply.) - Notify the health care provider. Follow facility protocol. Applying oxygen is 3) INCORRECT- While oxygen may be needed, the client's pulse oximeter reading should be obtained first. The nurse admits a client with severe, persistent headaches. Which question is appropriate to ask when assessing the client's orientation? (Select all that apply.) - "What is your health care provider's name?"2."What is the name of this health care facility?" "What year and month is it currently?" The nurse provides care for a client at 28 weeks' gestation. The nurse teaches the client how to perform fetal kick counts. Which client statement indicates to the nurse that the client understands the teaching? - "I should feel my baby move more than five times in one hour." Should try to count at the same time each day- not various times. The nurse receives a report on clients who reside on the psychiatric unit. Which actions, if performed by the off-going nurse, require follow-up by the nurse? (Select all that apply.) - The nurse assessed a suicidal client every 15 minutes. 1) CORRECT - The suicidal client must have one-on-one supervision at all times. The client could attempt suicide in a 15-minute interval. The nurse placed a client in a dimly lit room after the client did not eat all of the provided meal. 4. The nurse allowed a suicidal client to remain in street clothes. 5. The nurse initiated a signed PRN prescription for physical restraints. The nurse supervises the staff providing care to four clients receiving blood transfusions. Which client will the nurse see first? - Experiencing emesis. 2) CORRECT- Emesis is a symptom of a hemolytic reaction, which is the most dangerous type of transfusion reaction. Symptoms include nausea, vomiting, pain in lower back, and hematuria. Treatment is to the stop blood transfusion, obtain a urine specimen, and maintain blood volume and renal perfusion. The nurse instructs the client who is diagnosed with mastitis of the left breast about breastfeeding the client's infant. Which statement by the client best indicates understanding of the instructions? - "Everyone in my family should use good handwashing techniques at all times." 3) CORRECT— Anyone who is in contact with the infant should use good handwashing techniques to prevent the spread of infection. 1) INCORRECT - It is not necessary to discontinue breastfeeding on the affected breast and is not desired, as discontinuing breastfeeding will increase breast engorgement and exacerbate pain. 4) INCORRECT - A tight bra will reduce milk production. This will not improve the mastitis. The nurse should advise the client to wear a bra that is as supportive as possible and still comfortable. Constrictive clothing should be avoided. The nurse is assigned to care for a client diagnosed with methicillin-resistant Staphylococcus aureus (MRSA) of a draining wound. Which personal protective equipment (PPE) does the nurse wear when measuring vital signs? (Select all that apply.) - Plastic gown Gloves NOT face mask - not needed The nurse provides care to several hospitalized clients. Which clients does the nurse monitor closely for the development of pneumonia? (Select all that apply.) - NOT someone with addison's - not a risk factor A client diagnosed with cystic fibrosis. A client with a fractured rib due to an auto accident.6.A client in Buck traction due to a fractured hip. The nurse is made aware of a client's situation during hand-off of care via the Situation-Background-Assessment-Recommendation (SBAR) report. Which detail about the client should the nurse address with the off-going nurse? (Select all that apply.) - The client has a troponin level of 1.5 ng/mL (1.5 mcg/L).2.The client has a newly placed nasogastric tube in the right nare.3.The client is on a 1.5-liter fluid restriction.4.The nurse noticed blood in the client's stool.5.The client's temperature reached a peak of 101.2°F (38.4°C) during the past 12 hours. ALL OF THESE . A client diagnosed with a severe sprain of the right ankle must avoid all weight- bearing on the right foot. Which demonstration by the client indicates proper use of the crutches? (Select all that apply.) - 5) INCORRECT- Crutches should be kept 8 to 10 inches out to side. NOT 14 to 16 inches out to the side. Also elbows should be flexed 20-30 degrees. Ensure rubber tips are on both crutches. The nurse speaks to the spouse of a client who has concerns about the client's sleeping pattern. The spouse states, "I am having a hard time getting a good night's rest because of my spouse's noisy breathing." Which response by the nurse will help to further evaluate the problem? (Select all that apply.) - "Does your spouse report feeling drowsy during the day?" "How many times does your spouse awaken at night?"5."What is your spouse's current weight?"6."Describe the types of sounds your spouse makes at night." The health care provider prescribed 40 mg of furosemide IV for a client. The electronic medication dispensary has 40 mg vials of furosemide available and the screen reads, "Take 2 vials." The nurse realizes that the 40 mg vials are in the designated 20 mg vial cubicle. Which action does the nurse take? (Select all that apply.) - Report the error to the pharmacy and wait to remove medication from the cubicle. DO NOT put up a sign in the med room and do not administer a 40 mg vial. The sign will not help, couldf fall down, etc., The nurse prepares to remove a central venous access device in a hemodynamically stable client. Which action by the nurse will help prevent the development of embolism during the procedure? - Ask the client to hold breath during removal. 2) CORRECT- Valsalva maneuver increases intrathoracic pressure, which prevents air from entering through the opening of the skin. The nurse prepares to administer newly prescribed clonazepam and meloxicam to the client. Upon assessment, the client reports hives and difficulty breathing after taking midazolam and oxycodone years ago. Which actions will the nurse implement? (Select all that apply.) - 1) CORRECT— The nurse should hold the clonazepam because of the client's previous allergic reaction. A client could develop an allergic reaction to midazolam if clonazepam is administered, as both medications are benzodiazepine medications. A client could also develop an allergic reaction if clonazepam is administered. Can still give the melloxicam which is an NSAID. HCP should also be notified. The nurse provides care for four newborn clients. Which client does the nurse assess first? - The newborn who has not voided since having a circumcision 7 hours ago. 3) CORRECT - Noting the first urination after circumcision is important because edema could cause an obstruction. If the infant goes home before voiding, the mother is instructed to call the health care provider if there is no urinary output within 6 to 8 hours. The nurse assigns a client prescribed a continuous bladder irrigation to an unlicensed assistive personnel (UAP). Which tasks can be delegated to the UAP? (Select all that apply.) - Do perineal care and clean around the catheter.4.Report pain and bladder spasms to the nurse.5.Record the intake and output as prescribed. CANNOT manually irrigate the catheter if outflow is decreased. The nurse in the emergency department assists forensic investigators with evidence preservation and collection after a client's sudden death. Which actions by the nurse are considered professionally negligent? (Select all that apply.) - The nurse cuts holes through fabric to remove client's shirt. The nurse gives the client's clothing to the family.5.The nurse places any evidence in a plastic bag. They retain moisture wich could promote mold and mildew formation, destroying evidence. 6.The nurse removes intravenous lines before the medical examiner arrives. The nurse teaches a client about the correct use of the transdermal nicotine patch. The client states, "Using the patch will help me cut down on smoking." Which response does the nurse provide to this client? - "If you smoke while you are using the nicotine patch, then you are at risk of having a heart attack." The nurse has been assigned to evaluate the occurrence of nursing errors on a telemetry unit. Which action will be reported to the supervisor? (Select all that apply.) - When administering medications, the nurse asks clients their names and then administers the medications.2.The health care provider prescribes "5.0 mg metoprolol IV push now" for a client with new onset atrial fibrillation.3.The unit is short-staffed and nurses are regularly requested to work 16-hour shifts.4.The nurse is unable to read a prescription due to poor handwriting and requests another nurse to verify what is written.5.The nurse completes a client's initial fall risk assessment 36 hours after admission. The nurse provides care for a client who had abdominal surgery 2 days ago. The nurse notes a moderate amount of green-tinged drainage with the dressing change. Which action does the nurse take? - Check the client's morning white blood cell count. 3) CORRECT- Green-tinged wound drainage is an indication of infection. The nurse should check the white blood cell count, as well as the client's temperature. The charge nurse is reviewing medical records. The charge nurse follows up as a result of which documentation entry? (Select all that apply.) - Ferrous sulfate 60 mg given orally. Client reported GI discomfort because of medication; calcium carbonate chewable tablets given.v1) CORRECT - This documentation entry requires follow up by the charge nurse. Calcium decreases iron absorption and should not be administered with iron replacement. Iron is administered separately from foods and other medications to ensure absorption. Carvedilol 12.5 mg orally administered as prescribed. Temperature 99.1oF (37.3oC), pulse 54 bpm, respirations 18 breaths/min, BP 146/86 mm Hg. 4) CORRECT - This documentation entry requires follow up by the charge nurse. The beta-blocker should be held if the client's heart rate is less than 55 to 60 bpm, as this medication will further decrease the heart rate. Oxycodone 10 mg prescribed orally every 6 hours as needed for pain. Medication was administered at 0400, 0800, 1200, 1600, and 2000. 5) CORRECT - This documentation entry requires follow-up by the charge nurse. The medication is prescribed every 6 hours as needed; however, the client has received the medication at 4-hour intervals. Oxycodone is an opioid analgesic that can lead to respiratory depression if taken in large doses or too frequently. The nurse conducts a class for clients in their first trimester of pregnancy. Which information is appropriate for the nurse to include? (Select all that apply.) - Quickening should occur around 16 to 20 weeks' gestation.2.The fundal height is the measurement from the top of the symphysis pubis to the top of the fundus. Nausea usually ends by 14 to 16 weeks. The nurse provides care for a client who experienced a pulmonary embolism. The client is receiving a continuous heparin infusion. Which instruction will the nurse provide to the unlicensed assistive personnel (UAP) assisting with the care? (Select all that apply.) - Use an electric razor to shave the client's face. Tell the nurse if the client reports cold, painful, or blue feet.6.When assisting the client to reposition, use a lift sheet. The nurse palpates a pregnant client's uterus. The nurse notes that the fetal position is left sacrum anterior (LSA). Which location does the nurse place the Doppler to hear the point of maximum intensity of the fetal heart tone? - Mother's left side near the level of mother's umbilicus. A client with a recent diagnosis of human immunodeficiency virus infection suddenly reports confusion and dizziness. The client's vital signs are: BP 100/70 mm Hg, P 130 beats/min, R 28 breaths/min, and T 102.2°F (39°C). Which nursing intervention is appropriate? (Select all that apply.) - Administer broad-spectrum antibiotics, as prescribed.3.Infuse normal saline solution, as prescribed.4.Coordinate with the laboratory department for a blood culture test.5.Assess BP and P every 15 minutes. NO NEED FOR AIRBORNE PRECAUTIONS The nurse provides care for a term neonate born to a client diagnosed with diabetes mellitus (DM). Which manifestation does the nurse monitor the newborn for when conducting the physical examination? - Hypoglycemia. 2) CORRECT- Neonatal hyperinsulinemia occurs after birth. The maternal glucose is no longer available, but insulin production remains high. This results in hypoglycemia. The nurse provides cares for an older adult client diagnosed with type 2 diabetes, heart failure, and mild cognitive impairment. The client is preparing for discharge to home. Which recommendation to the caregiver will the nurse include in the discharge instructions? (Select all that apply.) - "Effective management of blood glucose can improve oral health." "Encourage the client to moisturize the lips in the morning and at night to soothe and prevent cracking."5."If the client reports fatigue during oral care, the caregiver should allow the client to rest before completing the task." 2) CORRECT- Because of the diabetes mellitus, the client is more prone to develop cavities and periodontal disease. Improved blood glucose management can help prevent these complications. The nurse should recommend oral care be completed at least twice a day to prevent dental caries. The nurse begins administering packed red blood cells (PRBCs) to a client with hemophilia who has received blood twice this admission. Shortly after the nurse begins the blood transfusion, the client reports mild lower back pain and asks to stand and stretch. After standing, the client reports that the back pain is worse and now accompanied by shortness of breath. Which action does the nurse take first? - Stop the blood transfusion and remove the blood tubing. 4) CORRECT- Stopping the blood transfusion and removing the blood tubing is the priority nursing intervention when the nurse suspects the client is having a blood transfusion reaction. Dyspnea and lower back pain are signs of an acute hemolytic reaction related to ABO-incompatibility. Additional clinical manifestations include fever, hypotension, abdominal or chest pain, and hematuria. An infant with an unrepaired congenital heart defect has been prescribed digoxin for heart failure. Which assessment finding indicates the medication is having the desired effect? (Select all that apply.) - Clear breath sounds.4.Normal sinus rhythm.5.Easy work of breathing. The nurse provides care for clients in the emergency department. Which client situation most benefits from having a case manager assigned to the care plan team? (Select all that apply.) - A middle-age adult diagnosed with chronic obstructive pulmonary disease. An adolescent diagnosed with type 1 diabetic ketoacidosis. 1) CORRECT- Nurses and designated case managers understand that chronic and advanced stages of chronic illnesses require close monitoring, medication management, and exacerbation prevention. This is often done for known disease processes such as chronic obstructive pulmonary disease (COPD) to prevent emergency department visits and hospitalizations. 2) INCORRECT- A toddler with otitis media is a fairly routine visit. Case management resources traditionally are used to help link clients with resources to help manage complex, chronic, or long-term care symptoms and conditions. 3) INCORRECT- A client with acute symptoms that are life-threatening is a traditional and appropriate case for the emergency department. Case management resources traditionally are used to help link clients with resources to help manage chronic or long-term care symptoms and conditions. 4) CORRECT- In this case, the growing emotional, developmental, and hormonal changes in an adolescent can make them at risk for frequent blood glucose fluctuations. A nurse case manager can assist in educating for prevention of exacerbation of diseases such as diabetes and asthma. They also can help clients understand how to cope with their disease and provide symptom management to help clients manage the disease and reduce or prevent the occurrence of emergency department visits. 5) INCORRECT- Case management resources traditionally are used to help link clients with resources to help manage chronic or long-term care symptoms and conditions. This client will require assessment of knowledge related to STIs and routine education on prevention. 6) INCORRECT- A client with routine infant symptoms and illnesses with no other extenuating ci The health care provider prescribes doxorubicin for a client diagnosed with bladder cancer. Which vein is most appropriate to administer doxorubicin therapy? - A central venous access device (CVAD) subclavian catheter with a double lumen. 3) CORRECT- Infusion administration of vesicant antineoplastic agents frequently is done through a CVAD to minimize the likelihood of venous injury and the consequences of any subcutaneous extravasation. The public health nurse assesses a client reporting a persistent cough with blood- tinged sputum and night sweats. Which action does the nurse take first? - Assist the client in putting on a mask. 3) CORRECT — A cough with bloody sputum and night sweats are classic symptoms of tuberculosis. The nurse's priority is preventing the potential spread of disease. The nurse plans staff assignments. Which clients are appropriate to assign to the LPN/LVN? (Select all that apply.) - A client diagnosed with herpes zoster ophthalmicus and dementia. A client following L-4 to L-5 laminectomy with a history of breast cancer.3.A client diagnosed with multiple sclerosis with increased bilateral leg weakness. 2) CORRECT— A client who had a laminectomy is a stable client with predictable outcomes. This client can be safely assigned to the LPN/LVN. The nurse observes the unlicensed assistive personnel (UAP) perform mouth care on an older adult client admitted to the hospital with fever of unknown origin. Which action performed by the UAP requires an intervention by the nurse? - Rinsing the client's mouth with a glycerin-based mouthwash. 3) CORRECT - A mouthwash with glycerin causes dehydration and irritation of the oral tissues. The nurse should intervene and provide the UAP and client with a non-glycerin mouthwash. The nurse prepares a teaching plan for a client who is prescribed captopril for hypertension. Which information does the nurse include in the teaching plan? (Select all that apply.) - Avoid using salt substitutes.2.Do not stop the medication abruptly. Avoid using salt substitutes.2.Do not stop the medication abruptly. The charge nurse must rearrange client room assignments to accommodate a new admission. Each client is currently in a private room. Which client can be safely cohorted with another client from this list? (Select all that apply.) - A 58-year-old female client with alcohol-induced pancreatitis. A 47-year-old female client who is receiving IV opioids to treat renal calculi. The nurse performs teaching for a client being discharged on dexamethasone 0.75 mg PO daily. Which statement by a client helps the nurse to determine teaching is successful? - "I will take my medication with breakfast. " A client's spouse of 45 years died 6 months ago. Which client statement indicates the client is adequately coping with the loss? (Select all that apply.) - "My friends have been trying to keep me busy." 5) CORRECT- It is a good sign that the client still engages with friends and recognizes that continued activity is an important part of the grieving process. The nurse reviews the medical record under the prescription tab. Which prescription documented in the medical record should the nurse address with the health care provider regarding appropriate abbreviations and standard terminology when documenting care? (Select all that apply.) - "Aspirin 81 mg q.d." "MS 4 mg PRN"