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A depressed client in an assisted living facility tells the nurse that "life isn’t worth living anymore." What is the best response to this statement?
A client, recovering from alcoholism, asks the nurse, "What can I do when I start recognizing relapse triggers within myself?" How might the nurse best respond?
A client with paranoid delusions stares at the nurse over a period of several days. The client suddenly walks up to the nurse and shouts "You think you? ‘re so perfect and pure and good." An appropriate response for the nurse is
A client with moderate persistent asthma is admitted for a minor surgical procedure. On admission the peak flow meter is measured at 480 liters/minute. Post-operatively the client is complaining of chest tightness. The peak flow has dropped to 200 liters/minute. What should the nurse do first?
A client with Guillain Barre is in a nonresponsive state, yet vital signs are stable and breathing is independent. What should the nurse document to most accurately describe the client’s condition?
A client with anorexia is hospitalized on a medical unit due to electrolyte imbalance and cardiac dysrhythmias. Additional assessment findings that the nurse would expect to observe are
A client with a documented pulmonary embolism has the following arterial blood gases: PO2 – 70 mm hg, PCO2 – 32 mm hg, pH – 7.45, SaO2 – 87%, HCO3 – 22. Based on these data, what is the first nursing action?
A client with a diagnosis of Methicillin resistant Staphylococcus aureus (MRSA) has died. Which type of precautions is appropriate to use when performing postmortem care?
A client who is a former actress enters the day room wearing a sheer nightgown, high heels, numerous bracelets, bright red lipstick and heavily rouged cheeks. Which nursing action is the best in response to the client? ‘s attire?
A client was admitted to the eating disorder unit with bulimia nervosa. The nurse assessing for a history of complications of this disorder expects
A client tells the nurse, "I have something very important to tell you if you promise not to tell." The best response by the nurse is
A client receiving chlorpromazine HCL (Thorazine) is in psychiatric home care. During a home visit the nurse observes the client smacking her lips alternately with grinding her teeth. The nurse recognizes this assessment finding as what?
A client is scheduled for an intravenous pyelogram (IVP). Which of the following data from the client? ‘s history indicate a potential hazard for this test?
A client is recovering from a thyroidectomy. While monitoring the client’s initial post-operative condition, which of the following should the nurse report immediately?
A client is being treated for paranoid schizophrenia. When the client became loud and boisterous, the nurse immediately placed him in seclusion as a precautionary measure. The client willingly complied. The nurse? ‘s action
A client is admitted with infective endocarditis (IE). Which finding would alert the nurse to a complication of this condition?
A client is admitted to the rehabilitation unit following a cerebral vascular accident (CVA) and mild dysphagia. The most appropriate intervention for this client is to
A client is admitted to the emergency room following an acute asthma attack. Which of the following assessments would be expected by the nurse?
A client is admitted to a voluntary hospital mental health unit due to suicidal ideation. The client has been on the unit for 2 days and now states ? “I demand to be released now!? ” The appropriate from the nurse is
A client is admitted to a psychiatric unit with delusions. What findings could the nurse observe that would be consistent with delusional thought patterns?
A client is admitted for treatment of a right upper lobe infiltrate and to rule out tuberculosis. Which of these would be the most appropriate self-protective action by the nurse ?
A client has returned to the unit following a renal biopsy. Which of the following nursing interventions is appropriate?
A client has been tentatively diagnosed with Graves’ disease (hyperthyroidism). Which of these findings noted on the initial nursing assessment requires quick intervention by the nurse?
A client has been hospitalized after an automobile accident. A full leg cast was applied in the emergency room. The most important reason for the nurse to elevate the casted leg is to
A client has been admitted with a fractured femur and has been placed in skeletal traction. Which of the following nursing interventions should receive priority?
A client has been admitted to the coronary care unit with a myocardial infarction. Which nursing diagnosis should have priority?
A client has an order for 1000 ml of D5W over an 8 hour period. The nurse discovers that 800 ml has been infused after 4 hours. What is the priority nursing action?
A client has a nasogastric tube after colon surgery. Which one of these tasks can be safely delegated to an unlicensed assistive personnel (UAP)?
A client had 20 mg of Lasix (furosemide) PO at 10 AM. Which would be essential for the nurse to include at the change of shift report?
A client enters the emergency department unconscious via ambulance. What document should be given priority to guide the direction of care for this client?
A client diagnosed with hepatitis C discusses his health history with the admitting nurse. The nurse should recognize which statement by the client as the most important?
A 72 year-old client with osteomyelitis requires a 6 week course of intravenous antibiotics. In planning for home care, what is the most important action by the nurse?
A 42 year-old male client refuses to take propranolol hydrochloride (Inderal) as prescribed. Which client statement from the assessment data is likely to explain his noncompliance?
A 16 year-old enters the emergency department. The triage nurse identifies that this teenager is legally married and signs the consent form for treatment. What would be the appropriate action by the nurse?
You are the charge nurse on the 3 P.M. to 11 P.M. shift. The nurses on this shift range from novice to competent. What response would be expected in the beginner stage of clinical competence development when the nurse is assigned a patient on beta-blockers and scheduled for a stress test?
When studying for the NCLEX-RN exam, the new graduate should be able to determine which tasks to delegate to which employee. Which tasks are appropriately delegated to the LPN?
When studying for the NCLEX-RN exam, the new graduate should be able to determine which tasks to delegate to which employee. Which task would require an intervention if performed by the UAP?
When studying for the NCLEX-RN exam, the new graduate should be able to determine which tasks to delegate to which employee. Which tasks would require an intervention if performed by the LPN?
When taking the NCLEX-RN exam, the new graduate realizes that most of the questions will address nursing in which unit?
When using the DMAIC acronym of the Six Sigma quality process improvement model, the nurse understands that the M (measure) refers to:
When using the DMAIC acronym of the Six Sigma quality process improvement model, the nurse understands that the I (improve) refers to:
When leading a team, a low performing leader is seen as having which abilities?
When leading a team, a high performing leader is seen as which type of leader?
When interviewing with the nurse manager, the new nurse should be prepared to ask about:
When interviewing for a position at a new facility, the nurse managers ask to review the mission, vision, and values statements because they understand that these statements provide information about the organization’s:
When identifying the objectives in an organization’s action plan, what would be an essential tool to use to improve performance?
When healthy, a patient had requested that all life-sustaining measures be implemented. Now the patient has Alzheimer’s and had a deterioration in health that severely limits quality of life. The patient’s only child is petitioning that the parent not be placed on life support again and be given only palliative care. The nurse assessing this ethical situation following the procedure would place the steps in what order?
a. Discuss with the ethics committee possible alternatives that would be acceptable to the family while considering the patient’s wishes.
b. After the family presents two alternatives, work with the committee and family to agree on one alternative.
c. Provide rationale for the selection made.
d. Carefully assess the situation to identify the ethical issue and concerns.
When following up with a thank-you letter to the nurse manager after an interview, the new nurse should include:
When establishing a unit action plan, the nurse manager identifies steps to be taken to accomplish the goal. What is most important for achieving the goal?
When eligible, the new nurse is encouraged to sit for a certification exam in their specialty area. What is the best reason for “going this extra mile”?
In application of the principles of pain treatment, what is the first consideration?
The nurse is considering seeking clarification for several prescriptions of pain medication. Which client circumstance is the priority concern?
Which client has the most immediate need for IV access to deliver immediate analgesia with rapid titration?
Which patient care action could the nurse delegate to unlicensed assistive personnel (UAP) after administering an inhaled anti-inflammatory drug to a patient with chronic obstructive pulmonary disease (COPD)?
A patient with familial hypercholesterolemia is prescribed atorvastatin 10 mg once a day. Which finding will the nurse immediately report to the health care provider?
The nurse is concerned that the physician is ignoring the wishes of the patient and family in the care of a patient. The nurse should take these concerns to: (Select all that apply.)
A patient with metastatic cancer tells the nurse, “I am tired and do not want to be put on a breathing machine.” The patient’s out-of-town son wants “everything done for my mother” when his mother later develops respiratory distress. Which ethical principles are involved in this dilemma? (Select all that apply.)
A nurse is reviewing the pulmonary function test results for a patient with emphysema. The nurse expects the test to show that the patient has which condition?
A nurse is waiting for the results of arterial blood gas analysis on a patient with a neuromuscular disease and is reviewing the purpose of the chemoreceptors. Which statements are true? (Select all that apply.)
A patient has a history of respiratory problems. The nurse is assessing the patient’s chest and notes that the sternum and lower ribs are displaced posteriorly, creating a pit-shaped depression in the chest. What is this finding called?
A nurse is performing an assessment on a patient’s lungs. While performing percussion on the left lung, the nurse notes a low-pitched resonant sound. This is compatible with what disease process?
A nurse notes that a patient’s trachea is deviated to the left side. What condition could cause this to occur? (Select all that apply.)
A patient has bronchial breath sounds over the peripheral lung fields. What condition could cause this? (Select all that apply.)
The nurse is teaching an adolescent client who is preparing for a long-distance running event about eating for competition. The nurse explains that which type of meal is most appropriate before the competition?
The nurse who has completed an assessment of a Hispanic client determines that some cultural food practices place the client at risk for cardiovascular disease. Which suggestion by the nurse is appropriate?
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 client is scheduled for removal of a chest tube at 0900. At approximately 0830, what action should the nurse take?
The nurse concludes that which behavior by the client is consistent with adherence to a 2-gram sodium-restricted diet?
The nurse determines that a hypertensive client understands the DASH diet (Dietary Approaches to Stop Hypertension) when the client chooses which items from a sample menu used in dietary teaching?
A client who is recovering from partial- and full-thickness burns has been advanced to a general diet. Which foods should the nurse encourage the client to eat most often?
A client on complete bedrest is at risk for disuse syndrome. The nurse should consider which client goal as appropriate?
An older adult client who was hospitalized 3 days ago is having trouble sleeping with some periods of confusion during waking hours. What is the best interpretation by the nurse regarding this client data?
The nurse is planning discharge teaching for the client with gastroesophageal reflux disease (GERD). What dietary modification should be included?
An 80-year-old client has been admitted to the nursing unit with Parkinson’s disease. Which action by the nurse would be most appropriate in preventing disuse syndrome?
Which dietary recommendation should the nurse include in discharge instructions for a client diagnosed with coronary heart disease?