A nurse is admitting a client who has schizophrenia. The client
states, “I’m hearing voices.” Which of the following responses is the
priority for the nurse to state?
Answer: “What are the voices telling you?”
A nurse is reviewing the laboratory levels of a client who is having
elective surgery. Which of the following levels should the nurse
report to the provider?
Answer: Potassium 3.2 mEq/L 3.5 - 5.0 is normal
A nurse is preparing to catheterize a toddler for a urine culture.
Which of the following is an appropriate action for the nurse to
take?
Answer: Don sterile gloves prior to the procedure.
A nurse is providing a preoperative teaching about patient-
controlled analgesia (PCA) to a client. Which of the following
statements should the nurse include in the teaching?
Answer: “You should push the button before physical activity to allow
maximum pain control.”
A nurse is assessing a client who is prescribed valproic acid. Which
of the following laboratory tests should the nurse monitor?
Answer: Liver function test
A nurse is interviewing the partner of a client who was admitted in
the manic phase of bipolar disorder. The partner states, “I don’t
know what to do. Everything has been happening so quickly.” Which
of the following responses by the nurse is therapeutic?
Answer: “Can you talk about what was happening with your partner at
home?”
A nurse is caring for a client who is in active labor and notes the
FHR baselines has been 100/min for the past 15 min. The nurse
should the identify which of the following conditions as a possible
cause of fetal bradycardia?
Maternal hypoglycemia
This study source was downloaded by 100000898062787 from CourseHero.com on 09-30-2025 11:52:58 GMT -05:00
https://www.coursehero.com/file/250985038/A-nurse-is-admitting-a-client-who-has-schizophreniadocx/
, A nurse is planning care for a client who is scheduled to have a
paracentesis. Which of the following actions should the nurse
include in the plan of care?
Answer: Instruct the client to empty her bladder prior to the procedure
A nurse on an antepartum unit is prioritizing care for multiple
clients. Which of the following clients should the nurse see first?
Answer: A client who has preeclampsia and reports a persistent headache
A nurse is assessing a client who requests an oral contraceptive.
Which of the following findings in the client’s medical history should
the nurse identify as a contraindication for the use of a combination
oral contraceptive?
Answer: Migraines with aura
A client’s partner tells a staff nurse that he overhears laboratory
staff discussing the result of the client’s biopsy report while on the
elevator. Which of the following actions should the nurse take?
Answer: Report the information to the charge nurse
A nurse is assessing a client's respirations which of the following
actions should the nurse take?
Answer: Count respirations for 1 minute if the rhythm is irregular
A nurse is teaching a newly licensed nurse about therapeutic
techniques to use when leading a group on a mental health unit.
which of the following group facilitation techniques should the nurse
include in the teaching?
Answer: Use modeling to help the clients improve their interpersonal skills
A nurse is observing a newly licensed nurse who is administering
Total parenteral Nutrition tpn to a client. Which of the following
actions by the newly licensed nurse indicates a need for the nurse to
intervene?
Answer: Uses the tpn IV tubing to administer the clients next dose of
antibiotic
A nurse is assessing a client Telemetry strip. Which of the following
This study source was downloaded by 100000898062787 from CourseHero.com on 09-30-2025 11:52:58 GMT -05:00
https://www.coursehero.com/file/250985038/A-nurse-is-admitting-a-client-who-has-schizophreniadocx/
states, “I’m hearing voices.” Which of the following responses is the
priority for the nurse to state?
Answer: “What are the voices telling you?”
A nurse is reviewing the laboratory levels of a client who is having
elective surgery. Which of the following levels should the nurse
report to the provider?
Answer: Potassium 3.2 mEq/L 3.5 - 5.0 is normal
A nurse is preparing to catheterize a toddler for a urine culture.
Which of the following is an appropriate action for the nurse to
take?
Answer: Don sterile gloves prior to the procedure.
A nurse is providing a preoperative teaching about patient-
controlled analgesia (PCA) to a client. Which of the following
statements should the nurse include in the teaching?
Answer: “You should push the button before physical activity to allow
maximum pain control.”
A nurse is assessing a client who is prescribed valproic acid. Which
of the following laboratory tests should the nurse monitor?
Answer: Liver function test
A nurse is interviewing the partner of a client who was admitted in
the manic phase of bipolar disorder. The partner states, “I don’t
know what to do. Everything has been happening so quickly.” Which
of the following responses by the nurse is therapeutic?
Answer: “Can you talk about what was happening with your partner at
home?”
A nurse is caring for a client who is in active labor and notes the
FHR baselines has been 100/min for the past 15 min. The nurse
should the identify which of the following conditions as a possible
cause of fetal bradycardia?
Maternal hypoglycemia
This study source was downloaded by 100000898062787 from CourseHero.com on 09-30-2025 11:52:58 GMT -05:00
https://www.coursehero.com/file/250985038/A-nurse-is-admitting-a-client-who-has-schizophreniadocx/
, A nurse is planning care for a client who is scheduled to have a
paracentesis. Which of the following actions should the nurse
include in the plan of care?
Answer: Instruct the client to empty her bladder prior to the procedure
A nurse on an antepartum unit is prioritizing care for multiple
clients. Which of the following clients should the nurse see first?
Answer: A client who has preeclampsia and reports a persistent headache
A nurse is assessing a client who requests an oral contraceptive.
Which of the following findings in the client’s medical history should
the nurse identify as a contraindication for the use of a combination
oral contraceptive?
Answer: Migraines with aura
A client’s partner tells a staff nurse that he overhears laboratory
staff discussing the result of the client’s biopsy report while on the
elevator. Which of the following actions should the nurse take?
Answer: Report the information to the charge nurse
A nurse is assessing a client's respirations which of the following
actions should the nurse take?
Answer: Count respirations for 1 minute if the rhythm is irregular
A nurse is teaching a newly licensed nurse about therapeutic
techniques to use when leading a group on a mental health unit.
which of the following group facilitation techniques should the nurse
include in the teaching?
Answer: Use modeling to help the clients improve their interpersonal skills
A nurse is observing a newly licensed nurse who is administering
Total parenteral Nutrition tpn to a client. Which of the following
actions by the newly licensed nurse indicates a need for the nurse to
intervene?
Answer: Uses the tpn IV tubing to administer the clients next dose of
antibiotic
A nurse is assessing a client Telemetry strip. Which of the following
This study source was downloaded by 100000898062787 from CourseHero.com on 09-30-2025 11:52:58 GMT -05:00
https://www.coursehero.com/file/250985038/A-nurse-is-admitting-a-client-who-has-schizophreniadocx/
