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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 clinical elements found by the nurse 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.
During an intravenous (IV) push administration of doxorubicin peripherally into the client’s left forearm, the nurse becomes unable to obtain a blood return. The client reports no discomfort at the site and no swelling is noted. What is the appropriate action by the nurse?
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
A nurse giving an intramuscular injection places the hand’s heel on the client’s greater trochanter, with the fingers pointing toward the client’s head. The nurse places the index finger on the client’s anterior-superior iliac spine, while the middle finger is stretched dorsally, palpating the iliac crest. After giving the injection in the triangle formed, the nurse documents the injection as given in which intramuscular injection site?
A 3 1 / 2 -month-old 312-month-old infant has an order for acetaminophen suspension 45 mg by mouth q4h prn. The product label lists a concentration of 500 mg/5 mL. After determining that the dosage is safe, the nurse should administer how many mL? Record your answer, rounding to two decimal places. Fill in your answer below: Answer: ______mL
The home health nurse is monitoring a client who performs self-care of a central line. The nurse observes the client doing all of the following activities. Which activity indicates the need for further education?
The nurse is preparing to enter the room of a client with pneumonia caused by penicillin-resistant Streptococcus pneumoniae (PRSP). The client has a tracheostomy and requires suctioning. Put the following personal protective equipment in order of donning.
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 determines a new mother is in greatest need of more education about infant care and safety when the mother makes which statement?
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
A patient who has sickle cell disease is admitted with vaso-occlusive crisis and reports severe abdominal and flank pain. Which of the analgesic medications on the pain treatment protocol will be best for the nurse to administer initially?
A patient with sickle cell disease is admitted with splenic sequestration. The blood pressure is 86/40 mm Hg, and heart rate is 124 beats/min. Which of these actions will the nurse take first?
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 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 is caring for a postoperative client who reports pain. Based on recent evidence-based guidelines, which approach would be best?
The charge nurse is reviewing the records of clients who were assigned to a newly graduated RN. The RN has correctly documented dose and time of medication, but there is no documentation regarding nonpharmaceutical measures. What action should the charge nurse take first?
Which clients must be assigned to an experienced RN? Select all that apply.
A patient diagnosed with hypertension has received the first dose of lisinopril. Which interventions will the RN delegate to the unlicensed assistive personnel (UAP)? Select all that apply.
An older patient with chronic obstructive pulmonary disease (COPD) is to be discharged with prescriptions for albuterol, a short-acting beta agonist (SABA), and salmeterol, a long-acting beta agonist (LABA) bronchodilator. Which statement by the patient indicates to the nurse that the patient requires additional teaching?
A nurse has been having difficulty sleeping since the death of a patient who had a stressful family situation involving a DNR (do not resuscitate) order. She is arguing with her husband and coworker and is complaining about working conditions. The nurse’s symptoms could be signs of what problem?
The family of a patient who is receiving mechanical ventilation for respiratory distress associated with an inoperable brain tumor asks that the patient be extubated to “allow natural death” to occur. This is an example of what situation?
The nurse observes a coworker diverting narcotics by administering normal saline to a patient in pain. By not reporting this observation, the nurse is in violation of what ethical principle concerning the patients under the care of the impaired nurse?
A nurse is explaining the difference between respiration and ventilation to a nursing student. Which statement made by the student shows that the teaching was effective?
A patient admitted after a motor vehicle crash has a spinal cord injury at C4. What is the priority nursing diagnosis for this patient?
A patient has aspirated a tooth and is undergoing a bronchoscopy for retrieval. In which lobe will the object most likely be found?
What information should the nurse provide when doing dietary teaching with a client placed on a fat-restricted diet because of significant cardiac history?
During a nursing assessment, the client states he is 70 years old and has a history of staphylococcus infections, increased intraocular pressure, and blurred vision. The nurse concludes that which item reported by the client is a risk factor for the development of cataracts?
A 92-year-old client who is very hard of hearing is hospitalized. Which action by the nurse is appropriate when conducting the admission interview and assessment of the client?
A client’s mother wants to know why she should have her daughter follow an allergy I and II diet. How would the nurse reply to this mother’s concern?
A 72-year-old client has been in the ICU for the past 2 days. Which intervention would be the most appropriate in decreasing the risk for sensory deprivation? Select all that apply.
The nurse must apply an elastic bandage to support a client’s sprained ankle. Which action should the nurse take during this procedure?
Which food item should the nurse encourage in the diet of a client diagnosed with celiac disease?
The nurse is providing care to a client who is 2 weeks postoperative for a tracheostomy. The nurse sees the tracheostomy tube come out when the client coughs. What should be the nurse’s first action?
The client has just had emergency intubation for respiratory distress. Immediately following insertion of the endotracheal tube, what action by the nurse is most appropriate?
Which food item from the lunch menu should the nurse suggest to a client taking a monoamine oxidase inhibitor (MAOI)?
Which respiratory assessment finding is of greatest concern to the nurse following endotracheal tube extubation?
Following chest tube insertion, the nurse notes continuous bubbling in the suction control chamber of the closed chest drainage system. What action should the nurse plan to take at this time?
How should the nurse best respond to a client who states, “I am always dieting, but I never seem to be losing weight.”
During routine chest tube assessment, the nurse notes the presence of continuous bubbling in the water seal chamber of the closed chest drainage system. Which conclusion should the nurse draw from this data?
The nurse should encourage the client wishing to reduce risk of cancer to maintain adequate intake of which foods?