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The home health aide reports that a 70-year-old client is non-compliant in taking prescribed medications. What does the nurse do to solve this problem?
A 72-year-old client admitted to the hospital for congestive heart failure has a history of a fractured hip due to a previous fall. The client is taking oxycodone-acetaminophen (Tylox) as needed for pain secondary to a recent dental procedure. Which risk factor puts this client at the greatest risk for a fall?
The nurse is teaching a class of unlicensed assistive personnel (UAP) about turning and repositioning clients in a long-term care setting. Which client requires extreme caution and is at the greatest risk for a skin tear?
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 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.
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?
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 admitting a client with psychosis demonstrating signs of delusions of grandeur. Which client statement supports this type of delusion?
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 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 is completing a hospital admission assessment on an 86-year-old client with renal impairment. The client’s daughter gives the nurse a long list of drugs that the client is taking at home, both prescription and over-the-counter. What does the nurse do next?
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 son of an older adult client states that he has noticed progressive periods of forgetfulness in his father over the past year. After noting the son’s comments and assessing the client, which cognitive problem does the nurse suspect the client may have?
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?
An older adult client who is admitted to the medical-surgical unit with a diagnosis of heart failure states to the nurse, “I am of no use to anyone. I just want to die.” What therapy does the nurse expect the provider to order to ensure this client’s safety?
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 team is providing emergency care to a client who received an excessive dose of opioid pain medication. Which task is best to assign to the LPN/LVN?
What is the best way to schedule medication for a client with constant pain?
Which clients can be appropriately assigned to an LPN/LVN who will function under the supervision of an RN or team leader? Select all that apply.
The nurse is providing patient teaching for an older adult about spironolactone. Which key points would the nurse include? Select all that apply.
The RN is preparing to administer drugs to a group of patients. Which drug is most important for the nurse to discuss with the health care provider before administration?
Many patients experience stress when they are admitted to the intensive care unit. Which statement about stress is accurate?
A patient has been admitted with the symptoms of alcohol withdrawal syndrome (AWS). The nurse would expect which finding when the patient is assessed?
A patient has been displaying apathy, anxiety, and the inability to perform basic activities of daily living. When asked the patient states “I just can’t do it.” What psychosocial problem is the patient displaying?
A nurse is assessing a patient with end-stage kidney disease (ESKD) and notices that the patient’s left cheek is twitching, the patient’s gums are bleeding, and the patient is irritable. Which electrolyte disturbance should the nurse suspect the patient is experiencing?
A patient is having an abdominal computed tomography (CT) scan with intravenous (IV) contrast in the morning. Which instructions should be included in the teaching for this procedure? (Select all that apply.)
Which nursing actions are important in the management of a patient with an arteriovenous (AV) fistula? (Select all that apply.)
The nurse is performing an abdominal assessment on a newly admitted patient and notes a bluish discoloration around the umbilicus. The nurse suspects the patient may have which problem?
The nurse is auscultating bowel sounds and notes high-pitched gurgling sounds every 10 seconds. What intervention should the nurse take?
The nurse is teaching the patient about the preparation for an esophagogastroduodenoscopy (EGD). Which statement by the patient indicates the teaching was effective?
The nurse is performing an abdominal assessment on a patient who was just admitted to the unit. In what order should the patient’s abdomen be assessed?
Which assessment data would prohibit the use of imagery with a client?
A patient is complaining of blurred vision, fatigue, and nausea. The nurse notes that the patient’s face is flushed, and he has a heart rate of 125 beats/min and blood pressure of 90/40 mm Hg. Which action should the nurse take next?
The patient has a glycosylated hemoglobin of 8. The nurse understands that this represents an average blood sugar of over what time frame?
A postoperative craniotomy patient has a serum osmolality of 260 mOsm/kg/H2O and a urine osmolality of 1500 mOsm/kg. The nurse suspects that the patient is experiencing which problem?
A patient has an elevated thyroid-stimulating hormone (TSH) level and low T4 values. The nurse suspects the patient is experiencing which disorder?
A patient’s serum cortisol level is 7 mcg/dL. After administration of 250 mcg of cosyntropin, the cortisol level is 9 mcg/dL. The nurse suspects the patient is experiencing which disorder?
A nurse is teaching the diabetic patient about insulin therapy. Which statement by the patient indicates the teaching was effective?
Which patient with a fasting blood sugar of 110 mg/dL has the highest risk for development of metabolic syndrome?