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The nurse is communicating with a 12-year-old who is hearing impaired. What action is best for the nurse to use when attempting to communicate with this child?
Although a client initially wanted to breastfeed, she has now decided to bottle-feed her newborn. The nurse concludes that teaching about breast care for this client has been effective when the client makes which statement?
The nurse is caring for a one-year-old child following surgical correction of hypospadias. What nursing action has the highest priority?
The nurse is caring for a client with chest trauma sustained from a motor vehicle crash. Which arterial blood gas result indicates that the client’s respiratory acidosis is compensated?
The nurse is caring for a client who is 24 hours post-operative amputation of a gangrenous limb. In which position should the nurse place the client’s limb?
The nurse is assessing an older client at the community clinic. The client asks if there are any medication samples that can be provided considering an estranged son has returned and is spending all of the client’s money that has been set aside for medications and food. What does this client’s situation suggest to the nurse?
The nurse is assessing a newborn infant. Which assessment finding is an early indication of a possible cardiac problem?
The nurse is assessing a client’s central venous pressure (CVP) via a pulmonary artery (PA) catheter port. The client is in a supine position with the head of the bed at a 45 degree angle. The CVP reading is 6 mmHg higher than the previous reading. To evaluate the reading, what action should the nurse take first?
The nurse is assessing a client for testing to diagnose meningitis. Which finding suggests to the nurse that the client is experiencing this health problem?
The nurse is applying prescribed sequential compression devices to a post-operative client. Which nursing action indicates the correct procedure when applying these devices to the client?
The nurse is applying an elastic bandage to a client? ‘s left forearm. In which direction should the nurse apply the bandage?
The nurse is admitting a client with psychosis demonstrating signs of delusions of grandeur. Which client statement supports this type of delusion?
When teaching a new mother how to breastfeed, the nurse should include which instruction?
The nurse should include which elements in a psychosocial assessment of the laboring client? Select all that apply.
A client scheduled for a cardiac echocardiogram at 9:00 a.m. the next day asks whether eating breakfast before the test is allowed. What response by the nurse is appropriate?
The nurse finds a client with a T4 spinal cord injury lying in bed sweating profusely. The client’s blood pressure is 180/120 mm Hg. Which action should the nurse take first to help this client?
The nurse feels a shock when plugging in an intravenous pump. After unplugging the pump, what action should the nurse implement?
The nurse enters a male client’s room to administer a subcutaneous dose of enoxaparin sodium (Lovenox), a low molecular weight heparin. The client is lying supine in bed. What action should the nurse implement?
Eighteen hours after surgery, the urine output of a client who underwent removal of a pituitary tumor is markedly increased, and the urine specific gravity is 1.002. Does the nurse expect to note which corresponding findings when reviewing the results of laboratory tests? Select all that apply.
The nurse determines that a client with type 1 diabetes mellitus is at risk for foot complications. What did the nurse assess in this client? Select all that apply.
The nurse is assisting a client who has methicillin-resistant Staphylococcus aureus in the urine to collect a clean-catch urine specimen. Which protective equipment is unnecessary?
The nurse determines that a client has an abnormality in cranial nerve XI. What did the nurse assess in this client?
The nurse calls the healthcare provider because a client diagnosed with an abdominal aortic aneurysm (AAA) is complaining of low back pain. What additional information about the client would be important for the nurse to impart to the healthcare provider?
The nurse assigns a Glasgow Coma Scale (GCS) of 7 to a 2-year old who was admitted after a head injury to the left occipital area. What description should the nurse use in the narrative documentation of this child’s level of consciousness?
The nurse assesses an adult client who has a sigmoid colostomy following a bowel exploration performed yesterday. Which assessment finding should be reported to the surgeon immediately?
The nurse assesses a newborn who experienced shoulder dystocia. Asymmetric response to which developmental reflex could indicate clavicular fracture?
The nurse is caring for a client with hepatitis A. Which client statements indicate that teaching conducted by the nurse about disease transmission was effective? Select all that apply.
A client exposed to Mycobacterium tuberculosis starts on chemoprophylaxis. The nurse provides which instruction to the client?
The nurse delegates an unlicensed assistive person (UAP) to assist a client with a clean urinary catheterization procedure. The client was formerly able to perform the procedure alone but because of arthritis, he is no longer able to do so. Although the UAP has done this procedure before, which direction is most important for the nurse to emphasize to the UAP?
The surgical unit nurse is assigned to the care of a client who returned from surgery 8 hours ago. Which assessment is of highest priority at this time?
The clinic nurse is conducting health screenings. Which client assessment findings indicate the need for health education about reducing risk factors for stroke? Select all that apply.
Which action should the nurse take to maintain medical asepsis when caring for a hospitalized client with diabetes mellitus who requires irrigation of a leg ulcer and insulin injections? Select all that apply.
Hematologic laboratory test results indicate a client with cancer is in the nadir period following the latest round of chemotherapy. Which drug should the nurse avoid administering to this client at this time?
The newborn nursery has recently formed a unit operations committee. The nurse who wishes to exert situational leadership in this committee should exhibit which behavior?
The nurse places highest priority on taking which action to reduce the spread of microorganisms when caring for a client at risk for infection?
The nurse should report to the healthcare provider which abnormal laboratory values for a 58-year-old client newly hospitalized with fever and diarrhea? Select all that apply.
A confused client who keeps trying to pull out a central venous access device has been prescribed to have a wrist restraint applied for safety reasons. Which action should the nurse take to apply the restraint correctly?
A postoperative client who will receive enoxaparin subcutaneously wants to know why this drug is being prescribed. What would be the best response by the nurse?
The emergency department has experienced a 20% increase in client visits from the same period last year. In an effort to empower staff to reduce staff stress and burnout, the charge nurse should use which approach to demonstrate shared leadership?
While providing a nursing history, a 65-year-old client reports that his sleep patterns are different than when he was younger. The nurse explains to the client that which changes in sleep can occur because of the aging process?
A labor and delivery nurse notes a pattern of late decelerations on the fetal monitor. Which priority action should the nurse take at this time?
The surgical unit nurse reassesses the condition of a postoperative client who was transferred to the unit 2 hours ago. Which data obtained at this time is of concern to the nurse? Select all that apply.
After defibrillation, the client continues to be in a pulseless ventricular tachycardia. After administration of procainamide, the nurse should expect to see which therapeutic response?
The nurse is assigned to a client diagnosed with head and neck cancer who is receiving enteral feedings via gastrostomy tube. When the nurse is called away to care for another client, which task for this client could most appropriately be delegated to the unlicensed assistive person (UAP)?
A client with uncompensated metabolic acidosis is admitted to the hospital for observation and treatment. Which values should the nurse anticipate when laboratory test results are communicated to the nursing unit?
A client has a BUN of 68 mg/dL and a creatinine level of 6.0 mg/dL. An IV solution of 5% dextrose in 0.9% NaCl with 40 mEq potassium chloride is infusing at 100 mL/hour. Which action would be most appropriate for the nurse to take?
The emergency department (ED) nurse is notified that a train travelling through the community has derailed and several casualties will be transported to the ED. What should be the first action taken by the nurse?