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A client is using aromatherapy to treat stress. Which assessment data indicates an allergic reaction in a client who has received an aromatherapy session?
A client is taking chlorpromazine. Based on the route of metabolism of this prescribed medication, the nurse is not surprised to learn the client uses which herb?
The preoperative waiting area has soft instrumental music playing in the background. What purpose should the nurse recognize in regard to this utilization of music? Select all that apply.
Which therapeutic change in laboratory values would the nurse anticipate in the client taking garlic?
A client tells the nurse that walking causes right leg pain. The pain is described as muscle cramping or burning that subsides with rest. Based on the symptoms, the nurse supports the use of what herb?
The nurse obtains a blood sample from a gravid client for determination of alpha-fetoprotein (AFP). What information will this laboratory value provide?
The nurse notes that an older client ‘s magnesium level is below normal.
Which client information should the nurse use to help explain the cause of
this client ‘s electrolyte imbalance?
The nurse notes that a client has a positive Chvostek’s sign. Which additional manifestation supports this finding?
The nurse notes that a client from the Hispanic culture does not eat
certain foods provided during meals. The client explains that the foods
provided are not appropriately “hot ” or “cold. ” What should the nurse do to
improve this client ‘s nutritional status?
The nurse notices that an older adult resident in a skilled nursing home facility has not been eating or drinking as much as usual. Which assessment finding by the nurse would best indicate the presence of dehydration?
Following a liver transplant the client is taking prednisone and other immunosuppressive medications to prevent organ rejection. The nurse should instruct the client to make it a priority to report which manifestation to the healthcare provider?
The nurse should place highest priority on which nursing intervention when planning to prevent atelectasis in the newly admitted postoperative client?
The nurse responds to a voice calling out from a room on the nursing unit. Upon entering the room, the nurse sees a client lying on the floor near the foot of the bed. After attending to the client and notifying the healthcare provider, which notation would be most appropriate to record on the incident/unusual occurrence report?
A client’s hemoglobin level is 14 grams/dL. Which interpretation of the laboratory value by the nurse is most accurate?
Which item should the nurse discuss when teaching home care measures to the parents of a child who has bilateral bacterial conjunctivitis?
After a client has experienced a seizure, the nurse should assist the client into which most appropriate position?
After correctly positioning a client for a wound dressing change and setting up a sterile field with supplies added, the nurse hears a page to respond to another client who has fallen in the hallway. What is the most appropriate action for the nurse to take at this time?
A client recently diagnosed with type 1 diabetes mellitus is learning to use the American Diabetes Association exchange lists. The nurse determines that the teaching has been effective if the client chooses which appropriate exchange for white rice?
The nurse is teaching a group of adults about health screenings for cancer. The nurse should include which item in the discussion? Select all that apply.
The nurse observes two unlicensed assistive personnel (UAP) in the corridor on the nursing unit arguing about how to handle a difficult client. What would be the most appropriate approach for the nurse to use to address this conflict between staff members?
The school nurse is assessing a muscular 17-year-old female who is coming to the high school health service because of edema, voice changes, and hair loss. What should be the nurse’s initial conclusion pending further assessment, based on the client’s subjective and objective data?
A 4-year-old child has been exposed to chickenpox. After providing information about chickenpox, the nurse asks the mother to repeat back the information. Which response by the mother indicates a need for additional information?
The school health nurse is planning safety education as part of back-to-school night for high school students and their parents. The nurse should plan to address which threat to safety that represents a developmental risk factor for adolescents?
When giving directions to a 24-year-old female with possible appendicitis who is about to undergo a pelvic sonogram, the nurse should make which statement to the client?
The nurse is conducting an initial interview with a 10-year-old boy who has been brought to the mental health clinic by his parents. The nurse can establish rapport and credibility with the child by asking the child which question?
The nurse is providing medication instructions to a client. The nurse informs the client that persistent gynecomastia can result from taking which newly prescribed diuretic?
As the nursing unit representative to the hospital quality management committee, the nurse has been asked to evaluate the quality of nursing services on the unit. What would be an appropriate quality improvement activity for the nurse to ask team members to participate in?
When a female client preparing for surgery suddenly bursts into tears, the preoperative holding unit nurse should take which action?
After reviewing the client’s health history, the nurse concludes that which item is the most significant factor for development of bronchogenic carcinoma for this client?
A client has severe pain and bladder distention related to urinary retention and possible obstruction. An experienced unlicensed assistive personnel (UAP) states that she received training in indwelling catheter insertion at a previous job. What task can be delegated to this UAP?
The nurse is caring for a young man with a history of substance abuse who had exploratory abdominal surgery 4 days ago for a knife wound. There is a prescription to discontinue the morphine via patient-controlled analgesia and to start oral pain medication. The client begs, “Please don’t stop the morphine. My pain is really a lot worse today than it was yesterday.” What is the best response?
The nurse is caring for a young client with type 1 diabetes who has sustained injuries when she tried to commit suicide by crashing her car. Her blood glucose (BG) level is 550 mg/dL (30.5 mmol/L), but she refuses insulin; however, she wants the pain medication. What is the best action?
A patient diagnosed with overactive bladder is prescribed oxybutynin 5 mg orally twice a day. The nurse is providing patient teaching about side effects of this drug. Which side effects would be included? Select all that apply.
The nurse is providing care for a patient with chronic kidney disease who receives hemodialysis 3 days a week. As the nurse prepares to administer the patient’s dose of epoetin alfa subcutaneously, the patient asks why the shot is necessary. What is the nurse’s best response?
The nurse caring for a patient with chronic kidney disease. The nurse is administering aluminum hydroxide suspension (Amphojel) before lunch. The patient says, “I am not having indigestion. Why do I need this?” Which statement is an appropriate response from the nurse?
A stroke patient is having difficulty eating and is coughing and choking during meals. Which actions should be included in the dietary care plan? (Select all that apply.)
A client is admitted with a pressure injury on the left hip. The nurse has entered the following goal on the standardized care plan, “skin heals by June 12.” Prior to this date, the nurse evaluates progress on reaching this goal. Which statement is the best notation of progress toward the goal?
Delirium represents a global impairment of cognitive processes and is best characterized by which findings?
Which finding is a characteristic of deep sedation?
In assessing a client who has been immobilized because of illness, the nurse would most likely document the state of the client’s muscles as which of the following?
A female client can move her right arm and leg but has hemiplegia on the left side. What should the nurse instruct the unlicensed assistant to perform on the client’s left side during care?
A surgical client returns to the nursing unit with a nephrostomy tube in place. What is an appropriate action by the nurse when caring for this client?
A nurse is assigned to a client with a nasogastric tube and is checking gastric pH to verify correct tube placement. Which pH reading should the nurse expect if the tube is properly positioned?
Which landmarks should the nurse use to correctly measure a client prior to nasogastric tube insertion? Select all that apply.
A client with a partial bowel obstruction will undergo nasoenteric tube placement later in the day. The nurse should explain to the client that which position will be used after placement to promote tube migration to the intended area?
A client has weakness of the lower extremities and uses crutches for mobility. What client behavior should indicate to the nurse that the client needs further teaching about using crutches?
A male client sustained numerous types of wounds when he lost control of his motorcycle and was thrown onto the pavement. The client asks the nurse which wounds will heal best. The nurse’s reply is based on analysis that which type of wound would generally be least likely to scar?
A postoperative client tells the nurse that he developed dehiscence after his last surgery and wants to make sure it doesn’t happen this time. Which nursing intervention should the nurse implement that would be most effective in preventing dehiscence in a postoperative client?