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While interviewing a new admission, the nurse notices that the client is shifting positions, wringing her hands, and avoiding eye contact. It is important for the nurse to:
The new graduate (GN) working on a medical unit night shift is concerned that the RN charge nurse is drinking alcohol on duty. On more than one occasion, the new graduate has smelled alcohol when the charge nurse returns from a break. Which action should the new graduate nurse implement first?
Which statement made by a client indicates to the nurse that the client may have a thought disorder?
Which statement best describes time management strategies applied to the role of a nurse manager?
The client is in the cardiac intensive care unit on dopamine and BP increases to 210/130. Which intervention should the intensive care nurse implement first?
Which of the following times is a depressed client at the highest risk for attempting suicide?
Which of the following findings contraindicates the use of haloperidol and warrant withholding the dose?
The RN charge nurse is making client assignments in the cardiac critical care unit. Which client should be assigned to the most experienced nurse?
Which intervention best demonstrates the nurse’s sensitivity to a 16 year-old? ‘s appropriate need for autonomy?
Which blood serum finding in a client with diabetic ketoacidosis alerts the nurse that immediate action is required?
The nurse is preparing to administer medications to clients on a vascular unit. Which medication should the nurse question administering?
When teaching suicide prevention to the parents of a 15 year-old who recently attempted suicide, the nurse describes the following behavioral cue as indicating a need for intervention.
When caring for a client receiving warfarin sodium (Coumadin), which lab test would the nurse monitor to determine therapeutic response to the drug?
When admitting a client to an acute care facility, an identification bracelet is sent up with the admission form. In the event these do not match, the nurse? ‘s best action is to
Upon completing the admission documents, the nurse learns that the 87 year-old client does not have an advance directive. What action should the nurse take?
Therapeutic nurse-client interaction occurs when the nurse
The unlicensed assistive personnel (UAP) reports a sudden increase in temperature to 101 degrees Fahrenheit for a post surgical client. The nurse checks on the client? ‘s condition and observes a cup of steaming coffee at the bedside. What instructions are appropriate to give to the UAP?
The provisions of the law for the Americans with Disabilities Act require nurse managers to
The pediatric clinic nurse examines a toddler with a tentative diagnosis of neuroblastoma. Findings observed by the nurse that is associated with this problem include which of these?
The nurse’s primary intervention for a client who is experiencing a panic attack is to
The nurse receives a report on an older adult client with middle stage dementia. What information suggests the nurse should do immediate follow up rather than delegate care to the nursing assistant? The client
The nurse notes in the patient’s history that the patient has persistent, malignant pain. What is the meaning of this type of pain?
The nurse manager hears a provider loudly criticize one of the staff nurses within the hearing range of others. The nurse manager’s next action should be to
The nurse manager has been using a block scheduling plan to staff the nursing unit. However, staff have asked for many changes and exceptions to the schedule over the past few months. The manager considers self-scheduling knowing that this method will
The nurse is teaching an elderly client how to use MDI’s (multi-dose inhalers). The nurse is concerned that the client is unable to coordinate the release of the medication with the inhalation phase. What is the nurse’s best recommendation to improve delivery of the medication?
The nurse is teaching a newly diagnosed asthma client on how to use a peak flow meter. The nurse explains that this should be used to
The nurse is teaching a client with non-insulin dependent diabetes mellitus about the prescribed diet. The nurse should teach the client to
The nurse is teaching a client newly diagnosed with asthma how to use the metered-dose inhaler (MDI). The client asks when they will know the canister is empty. The best response is
The nurse is teaching a class on HIV prevention. Which of the following should be emphasized as increasing risk?
The nurse is reviewing with a client how to collect a clean catch urine specimen. What is the appropriate sequence to teach the client?
The nurse is reinforcing teaching to a 24 year-old woman receiving acyclovir (Zovirax) for a Herpes Simplex Virus type 2 infection. Which of these instructions should the nurse give the client?
The nurse is providing instructions for a client with asthma. Which of the following should the client monitor on a daily basis?
The nurse is preparing the teaching plan for a group of parents about risks to toddlers and is including the proper communication in the event of accidental poisoning. The nurse should tell the parents to first state what substance was ingested and then what information should be the priority for the parents to communicate?
The nurse is preparing a client with a deep vein thrombosis (DVT) for a Venous Doppler evaluation. Which of the following would be necessary for preparing the client for this test?
The nurse is planning discharge for a 90 year-old client with musculo-skeletal weakness. Which intervention should be included in the plan that would be most effective for the prevention of falls?
The nurse is observing a client with an obsessive-compulsive disorder in an inpatient setting. Which behavior is consistent with this diagnosis?
The nurse is having difficulty reading the health care provider’s written order that was left just before the shift change. What action should be taken?
The nurse is caring for a client with sickle cell disease who is scheduled to receive a unit of packed red blood cells. Which of the following is an appropriate action for the nurse when administering the infusion?
The nurse is caring for a client with a distal tibia fracture. The client has had a closed reduction and application of a toe to groin cast. 36 hours after surgery, the client suddenly becomes confused, short of breath and spikes a temperature of 103 degrees Fahrenheit. The first assessment the nurse should perform is
The nurse is caring for a client with a colostomy pouch. During a teaching session, the nurse appropriately recommends that the pouch be emptied
The nurse is caring for a client who was successfully resuscitated from a pulseless dysrhythmia. Which of the following assessments is critical for the nurse to include in the plan of care?
The nurse is caring for a client who is post-op following a thoracotomy. The client has 2 chest tubes in place, connected to 1 chest drain. The nursing assessment reveals bubbling in the water seal chamber when the client coughs. What is the most appropriate nursing action?
The nurse is caring for a 69 year-old client with a diagnosis of hyperglycemia. Which tasks could the nurse delegate to the unlicensed assistive personnel (UAP)?
The nurse is assigned to care for a client who had a myocardial infarction (MI) 2 days ago. The client has many questions about this condition. What area is a priority for the nurse to discuss at this time?
The nurse is assessing a client with a Stage 2 skin ulcer. Which of the following treatments is most effective to promote healing?
The nurse is assessing a 55 year-old female client who is scheduled for abdominal surgery. Which of the following information would indicate that the client is at risk for thrombus formation in the post-operative period?
The nurse is assessing a 17 year-old female client with bulimia. Which of the following laboratory reports would the nurse anticipate?
The nurse instructs the client taking dexamethasone (Decadron) to take it with food or milk. The physiological basis for this instruction is that the medication
The nurse has performed the initial assessments of 4 clients admitted with an acute episode of asthma. Which assessment finding would cause the nurse to call the provider immediately?
The nurse explains an autograft to a client scheduled for excision of a skin tumor. The nurse knows the client understands the procedure when the client says, "I will receive tissue from