A nurse is assisting a group of staff nurses about hepatits A. Which of the following modes should the nurse include as a method of transmitting hepatitis A?
Consumption of contaminated food
A nurse is reinforcing teaching with a client who is bottle feeding her full-term newborn with formula. Which of the following instructions should the nurse include in the teaching?
Feed the newborn at least every 3 to 4 hr
A nurse is assisting with the plan of care for a client following a TURP. Which of the following interventions should the nurse include in the plan of care?
Irrigate the bladder using sterile technique
A nurse is reviewing a client's EMR and finds that an AP recorded the client's temperature as 95.5 F 2 hours earlier. Which of the following actions should the nurse take first?
Check the client's temperature
A nurse is reinforcing teaching with a male client who is uncircumcised about obtaining a clean-catch midstream urine specimen. Identify the sequence.
Expose the glans of the penis
- Cleanse the penis using antiseptic swab
-Begin urination
- Pass the cup into the urine stream
- Move the cup out of the urine steam
- Replace the foreskin
A nurse is receiving change of shift report for four clients. Which of the following clients should the nurse see first?
A client whose urinary output was 100 mL for the past 12 hr
A nurse is reinforcing teaching about weight loss with a female older adult client who is overweight. Which of the following statements should the nurse include in the teaching?
Keep fat intake to no more than 30 % of daily caloric intake
A nurse is collecting data from a client who has iron deficiency anemia. Which of the following findings should the nurse expect?
Difficulty concentrating
A nurse is collecting data from an older adult client who is 48 hr post op following abdominal surgery. The provider writes a prescription to advance to the client to a regular diet. For which of the following findings should the nurse notify the provider
The client has absent bowel sounds
A nurse is reinforcing discharge teaching with a client who is post op following TURP. which of the following instructions should the nurse include in the teaching?
Perform Kegal exercises daily
A nurse is reinforcing teaching about ways to reduce solid fat consumption with a client who has an elevated cholesterol level. Which of the following strategies should the nurse include in the teaching?
Purchase beef that is a loin cut
A nurse is reinforcing teaching with a client who has a new prescription for prednisone for the treatment of Addison's disease. Which of the following instructions should the nurse include in the teaching?
You will need to schedule a bone density test
A nurse is collecting data from a client who has T2DM and is concerned about weight gain during pregnancy. Which of the following responses should the nurse make?
Your wight gain should be the same as for someone without diabetes
A nurse is reinforcing teaching with the parent of a preschooler who has lactose intolerance. Which of the following statements by the parent indicates an understanding of the teaching?
I should offer my child yogurt that has a probiotic as a snack
A parent brings her adolescent son to an urgent care center and states, "he is high on something and needs help" The client is exhibiting agitation and paranoia and reports visual hallucinations. The nurse should suspect intoxication with which of the fol
Methamphetamines
A nurse notices an AP taking a nap in the break room during her meal time. The AP appears drowsy while performing routine tasks. which of the following actions should the nurse take?
Report the observations about the AP to the unit's nurse manager
A nurse is reinforcing teaching with a client who has a fluid volume deficit about selecting foods that have a high water content. The nurse should include that which of the following raw foods contains the highest amount of water per 1 cup serving.
Cherry tomatoes
The nurse is postioning a client who is scheduled for a lumbar puncture. The nurse should assist the client into which of the following positions?
lateral recumbent
A nurse is talking with a client whose son died in a motor vehicle crash 2 weeks ago. The client states, I really thought I'd be back to my usual routines by now, but I can't think of anything else except that my son i gone. Which of the following respons
Grieving for your son is hard work. It will take as much time as you need to come to terms with your loss
A nurse is instructing an AP on the use of proper body mechanics when moving a client. Which of the following statements by the AP should the nurse identify as an understanding of the teaching?
I will use a pull sheet to help slide the client toward me
A nurse is maintaining droplet precautions for a client who has meningitis. which of the following actions should the nurse take.
Wear a surgical mask within 3 feet of the client
A nurse is collecting data from a female client who has a new diagnosis of genital herpes. Which of the following findings should the nurse expect?
Painful erythematous vesicles
A school nurse is having a conversation with the parents of an adolescent. The nurse should identify which of the following situations as an ethical dilemma for the parents?
We can't decide whether to try to homeschool our child or move her to a private school
A nurse is preparing to administer a rectal suppository to a school-age child. which of the following actions should the nurse plan to take?
Use one finger to insert the suppository past the anal sphincters
A nurse is assisting with monitoring a client who is at 40 weeks of gestation and is in active labor. The nurse recognizes late decelerations on the fetal monitor tracing. Which of the following actions should the nurse take
Place the client in lateral position
Lung sound auscultation
fine crackles
A nurse manage is providing an in-service on hand hygiene to AP. which of the following information should the nurse manager include in the in-service?
Remove rings when washing hands with soap and water
A nurse is reinforcing home safety instructions with the parent of a newborn. Which of the following statements should the nurse include in the instructions?
Place your baby's crib away from heat vents.
A nurse is preparing to administer a clients morning medications. Which of the following actions should the nurse take to verify the client's identity
Scan the facility identification band
A nurse is caring for a client following a bronchosopy procedure. Which of the following actions should the nurse perform first?
check for a gag reflex
While administering medication to a client, a nurse notices a frayed electrical cord connecting the clients continuous passive motion machine to the electrical outlet. Which of the following actions should the nurse take?
Remove the device from the client's room
A nurse is caring for a client who requests information about advance directives. which of the following responses should the nurse make?
Advance directives are written instructions regarding end-of-life care
A nurse is contributing to the plan of care for a client who is at risk of developing pressure ulcers. Which of the following actions should the nurse include in the plan of care?
Place the client in a 30 degree lateral position
A nurse is assisting with performing a nonstresss test for a client who is at 39 weeks of gestation. which of the following instructions should the nurse reinforce with the client?
You should depress the button on the handheld marker when you feel your baby move
A nurse is reinforcing discharge teaching with a client following cataract surgery. which of the following instructions should the nurse include in the teaching?
Sleep on the nonoperative side for 2 weeks
A nurse manager is preparing to complete a performance analysis for a group of AP. The manager asks a staff nurse for feedback on each APs abilities. Which of the following actions should the staff nurse take?
Discuss how each APs actions measures against the job description
A nurse is preparing to administer a medication when the client states, Im sick of all these medications I'm not taking any more today. Which of the following actions should the nurse take?
Inform the client of the possible consequences of the medication refusal
A nurse is contributing to the plan of care for a client who is on suicide precautions. Which of the following interventions should the nurse recommend?
Encourage the client to sign a no-harm contract
A nurse is reinforcing teaching for a perioperative client on how to use an incentive spirometer. Which of the following actions by the client indicates an understanding of the teaching?
the client attempts to elevate the cylinder by inhaling deeply
A nurse at a long term care facility is part of a team preparing a report on the quality of care at the facility. Which of the following information should the nurse recommend including in the report to demonstrate improvement in care quality?
The facility had 12% fewer UTI over the past 6 months
A nurse is reviewing lab reports for a client who has an E. coli infection and is receiving gentamicin. Which of the following results should the nurse report to the provider before administering the next dose?
Creatinine 2.5
A nurse working in a community clinic is caring for an adolescent who has infectious mononucleosis. The client asks the nurse to explain how the disease was aquired. The nurse should explain that an individual acquires this disease by which of the followi
sharing eating utensils with an infected person
A nurse is reinforcing teaching with a client who has hypothyroidism and a prescription for levothyroxine. Which of the following instructions should the nurse include in the teaching?
You will need to take the medication for the rest of your life
A nurse is collecting data from a postpartum client who had a vaginal birth 2 days ago. Which of the following findings is the nurse's priority to report to the provider?
Client reports burning with urination
A nurse is reinforcing teaching with a client about a planned thoracentesis. Which of the following information should the nurse include in the teaching
you will need to be monitored for 1 hour after the procedure
A nurse is contributing to the plan of care for an older adult cllient who has difficulty sleeping. Which of the following interventions should the nurse include in the plan?
establish a regular exercise routine 2 hr or more before bedtime
A nurse in a provider's office is reinforcing teaching with a client who has a new prescription fo ferrous sulfate elixir. Which of the following statements by the client should indicate to the nurse an understanding of the teaching?
I will rinse my mouth after taking this medication
A LPN on a med-surge unit is working with an RN and an AP. Which of the following assignments should the LPN expect to receive?
Administering an NG tube feeding to a client who had a stroke.
A nurse is caring for a client who has schizophrenia and is experiencing auditory hallucinations. Which of the following actions should the nurse take?
offer the client headphones to listen to music
A nurse is reinforcing teaching with a client about taking warfarin to treat A. Fib.
If i forget to take a dose, I can take it later on the same day.
A nurse is working with an interpreter to explain a diagnostic procedure to a client who doesn't speak the same language as the nurse.
Ensure the interpreter is culturally compatible with the client
A nurse is reinforcing teaching with a client who has dependent personality disorder. Which of the following instructions should the nurse include in the discharge teaching?
Demonstrate assertiveness
A nurse is contributing to the discharge plan for a client who had a knee arthroplasty. Which of the following actions should the nurse identify as the priority
check the client's mobility
A nurse in a long term care facility is assisting with the admission of a client who requires oropharyngeal suctioning. Which of the following supplies does the nurse need to perform this task?
Yankauer catheter
A nurse is collecting data from a client who is 24 hr post-op from an open resection, has a clamped NG tube, and is resuming a clear liquid diet. Which of the following findings should the nurse report to the provider?
Client reports vomiting green-tinged fluid
A nurse is caring for a client who took an overdose of acetaminophen. Which of the following medications should the nurse plan to administer to the client?
Acetylcysteine
A nurse delegates the collection of a sputum specimen from a client who has TB to an AP. At which of the following times should the nurse instruct the AP to collect the specimen?
As soon as the client wakes up
A nurse is reinforcing teaching with a client who has a new diagnosis of the type 2 DM and inquires about information concerning oral antidiabetic agents. In addition to the provider, where should the nurse refer the client for information? (Select All)
- Pharmacist
- Package inserts
- American Diabetes Association
A nurse is caring for four clients who are all scheduled for surgery on the same day. Which of the following nursing actions demonstrates that the nurse possesses effective time management skills? (Select All)
- Gathers all needed supplies and equipment before entering client rooms
- Completes one task before beginning a new task
- Document the client's pre-op vital signs
- Delegate tasks to the AP that are within range of function
A nurse in a long-term care facility is using validation therapy with a client who has dementia. The client becomes agitated and ask why his wife who died several years ago has not visited him. Which of the following responses should the nurse make?
You must misss your wife. Let's take a walk and you can tell me about her.
A nurse is reinforcing teaching with a client who has a prescription for nitroglycerin sublingual tablets. Which of the following instructions should the nurse include in the teaching?
Take up to three tablets during a single angina episode
A nurse is caring for a client who is post-op following an open reduction with internal fixation of the ankle. The client reports pain and the nurse notes that the affected extremity is cool, pale, and has a weak pulse. The nurse calls the surgical reside
Notify the nursing supervisor
A nurse is collecting data from a client who has Tourette syndrome. The client reports taking halperidol 0.5 mL orally three times a day at home. Which of the following components of the prescription should the nurse question?
dosage
A nurse is caring for a female client who has an indwelling urinary catheter. Which of the following actions should the nurse take?
Wipe the drainage port with an antiseptic wipe after emptying urine from bag.
A nurse is reinforcing teaching with a newborn's parents about umbilical cord care. Which of the following statements by a parent indicates an understanding of the instructions?
I will give our baby sponge baths until the cord falls off.
A nurse who is facilitating a support group notices that one client in the group is extremely talkative, to the point where others in the group have difficulty sharing their own ideas. Which of the following strategies should the nurse use to facilitate t
Speak privately to the client about this behavior
A nurse at a clinic is performing vision testing for a client following a head injury. Which of the following finding should the nurse identify as a problem with pupil accommodation?
Lack of change in pupil size when the client looks from a far to a near object
A nurse is reinforcing teaching with a client who has cancer and a new prescription for fentanyl transdermal patches. Which of the following statements by the client indicates an understanding of the teaching?
I will fold the patch with the adhesive sides inward before discarding it
A nurse is contributing to the plan of care for a client who had a vaginal delivery 4 hr ago and has a 4th degree perineal laceration. Which of the following actions should the nurse recommend?
Instruct the client to use a sitz bath at least twice a day
A nurse is collecting data from a client who sustained spinal cord injuries from fractures to the T1 and T2 vertebrae. Which of the following outcomes should the nurse expect?
Flexes and extends the shoulders
A nurse is preparing to administer an influenza virus immunization to a client by the intradermal route. Which of the following actions should the nurse take?
Avoid massaging the site after injecting the vaccine
A nurse assisting with a childbirth class is discussing nonpharmacological strategies used during labor. Which of the following statements by a client indicates an understanding of cutaneous stimulation
I should use counterpressure for back pain during labor
A nurse is assisting with the admission of a client who has major depressive disorder. Which of the following communication techniques should the nurse use to establish a trusting relationship with the client?
Offering general leads
A nurse is preparing to administer medications to a client who is NPO and is receiving enteral feedings through an NG tube. Which of the following prescriptions should the nurse clarify with the provider?
Metoprolol ER 50 mg per NG tube BID
A nurse is contributing to the plan of care for a client who is newly diagnosed with iron deficiency anemia. Which of the following foods should the nurse include in the plan as having the highest amount of iron?
Boiled spinach
A nurse is administering lorazepam to a client who is scheduled for surgery within 1 hour. Which of the following actions should the nurse take after administering the medication.
Instruct the client not to get out of bed
A nurse is observing an AP caring for a client. For which of the following actions should the nurse intervene
The AP reports client information to the oncoming AP in the hallway
A nurse is observing a stable preterm newborn who develops apnea for longer than 20 seconds, with a decrease in heart rate of 20/min. Which of the following actions should the nurse take first?
Flick the sole of the newborns foot
A nurse is assisting in the plan of care for a female client who is to undergo a 12-lead ECG. Which of the following actions should the nurse include in the plan of care?
Instruct the client to remain still while the test is preformed
A nurse is caring for a client who is 4 hr post-op followingg a total thyroidectomy. Which of the following manifestations should the nurse report to the provider as indicating possible hypocalcemia.
Tingling of fingers
A nurse in a long-term care facility is assisting with an in-service for newly hired assistive personnel about legal issues within the facility. Which of the following should the nurse include as an example of assult?
Informing a client the nurse is going to administer an injection even though the client refuses
A nurse is collecting data from a client who is in severe pain. Which of the following questions should the nurse ask first?
Where is your pain located?
A nurse is reviewing the laboratory results for a client who is at 29 weeks of gestation. For which of the following results should the nurse notify the provider?
Platelet count 95,000
A nurse is preforming a dressing change for a client who had abdominal surgery 5 days ago. The nurse notes organs protruding from the incision. Which of the following actions should the nurse take?
Cover the exposed area with sterile, saline-soaked dressings
A nurse is speaking with the adult daughter of a client who has Alzheimer's disease. The daughter states, "I love my dad, but caring for him is wearing me out." Which of the following responses should the nurse make?
Let's discuss how caring for your father is affecting your health
A nurse is contributing to the plan of care for a client who has a chest tube connected to a closed drainage system. Which of the following actions should the nurse include in the plan of care?
Maintain the drainage system below the level of the client's chest
A nurse in an acute mental health facility is caring for a client who has borderline personality disorder and reports, "I am going to kill my girlfriend when i get out of here." Which of the following actions should the nurse take?
Notify the client's care team of the threats against his partner
A nurse is admitting a client who is at a high risk for suicide. Which of the following actions is the nurse's priority?
Search the client's personal belongings
A nurse is caring for a client who is 1 day postoperative and is unable to ambulate. Which of the following actions should the nurse take to promote the client's venous return?
Maintain a sequential compression device
A nurse in a pediatric clinic is collecting data from a school-age child whose injuries are inconsistent with the parent's stated cause. Which of the following actions should the nurse take?
Report the suspected abuse to the appropriate agency
A nurse is collecting data from a middle adult female client who is taking melatonin. Which of the following responses to the medication should the nurse expect?
Improved sleep
A nurse on a pediatric unit is collecting data from four newly admitted clients. Which of the following clients should the nurse identify as being at risk for urinary retention?
A school-age child who has allergic rhinitis and is taking diphenhydramine
A nurse is preparing to administer PPD to a client who has suspected TB. Which of the following actions should the nurse plan to take?
Ensure the injection produces a wheal on the skin
A client who is diagnosed with Parkinson's disease verbalizes frustration due to increased difficulty with ambulation. Which of the following responses should the nurse make?
Perform active range-of-motion with your arms and legs two times a day.
A nurse is collecting data from a client who has multiple fractures following a motor-vehicle crash. For which of the following client statements should the nurse recommend a referral to an occupational therapist?
I am so frustrated. I cannot even open my milk carton for breakfast
A nurse on an acute care unit is collecting data from a school-age child who has cystic fibrosis (CF). Which of the following findings is the priority for the nurse to report to the provider?
Reports lack of appetite
A nurse is working in a provider's office receives a phone call from the parent of a school-age child who has varicella. The parent asks the nurse when the child can return to school. Which of the following responses should the nurse make?
When the lesions have scabbed over.
A nurse is caring for a client who has a Penrose drain. To ensure proper placement and functioning of the drain, which of the following should the nurse expect to observe?
The safety pin is present at the distal end of the drain
A community health nurse is helping to reinforce teaching about hepatitis A with a group of employees at a childcare facility. Which of the following characteristics should the nurse identify as an external factor that can impede learning for the particip
Poor lighting in the learning setting
A nurse is observing a newly licensed nurse who is providing trach care for a client. The nurse identifies proper performance of the procedure when the newly licensed nurse selects which of the following solutions to clean the inner cannula?
Hydrogen peroxide
A nurse is caring for a client who has right-sided heart failure. The client's partner expresses concern that the client will die. Which of the following responses should the nurse make?
It is difficult to see someone so sick. What have you been told about your partner's prognosis?
A nurse is reinforcing discharge instructions with the parent of an infant who has rotavirus. Which of the following statements by the parent indicates an understanding of the teaching?
I will apply diaper cream to my baby's skin during each diaper change
A nurse is caring for a client who is scheduled for surgery in the morning. The nurse learns that the client has decided not to have surgery even though he has already signed the informed consent form. Which of the following actions should the nurse take?
Report the situation to the provider who obtained the informed consent
A nurse has administered medications to a group of clients. For which of the following client situations should the nurse complete an incident report?
The nurse administered insulin lispro to a client who has DM and is NPO
A nurse is collecting data from a client who is experiencing a situational crisis following the loss of a job. The client states, I don't think i can go through this again. Which of the following actions is the nurse's priority?
Determine if the client is experiencing psychotic thinking
A nurse is reinforcing discharge teaching with a client who is 48 hr post-op from a mastectomy. Which of the following statements by the client indicates an understanding of the teaching?
I will wear rubber gloves whenever i wash dishes or do yard work
A nurse is reinforcing teaching about home care for conjunctivits with the parent of a school-age child. Which of the following information should the nurse include?
Separate the child's used washcloth from those of others
A nurse is collecting data from an older adult client during a routine physical exam. Which of the following client statements should the nurse identify as a possible indication of abuse?
My son took my wallet so he can keep track of what I'm spending
A nurse is assisting with a presentation at a community center about personal disaster preparedness. Which of the following strategies should the nurse recommend for preparing a home disaster supply kit?
Have a supply of prescribed medications
A nurse is reinforcing teaching on food selection with a client who has a moderate burn injury. Which of the following foods should the nurse recommend as being high in vitamin C?
Tomatoes
A nurse on a med-surg unit is delegating tasks to an AP. Which of the following tasks should the nurse delegate to the AP?
Obtaining a client's vital signs prior to discharge
A nurse is caring for a client in Buck's traction. Which of the following actions should the nurse take?
Allow the weights to hang freely
A nurse in a long-term care facility is contributing to the plan of care for a client who has a new ostomy. Which of the following actions should the nurse include in the plan?
Change the appliance two times each week
A nurse is receiving report on four clients. Which of the following clients should the nurse plan to see first?
A client who has pneumonia and a new onset of confusion
A nurse is reinforcing discharge teaching with a client who has a T-tube in place following a cholecystectomy. Which of the following instructions should the nurse include in the teaching?
Empty the drainage bag each day at the same time
a nurse in a long term care facility is serving on the ethics committee, which is addressing a client care dilemma. Which of the following strategies will facilitate resolving the dilemma. (Select all)
- determine the facts related to the dilemma
- identify possible solutions
- consider the client's wishes
A nurse is preparing to insert an indwelling urinary catheter for a female client who has urinary retention. Which of the following actions should the nurse take?
Open the outer package flap of the catheterization kit away from her body
A nurse is caring for a client who has expressive aphasia following a stroke. Which of the following communication methods should the nurse use?
Provide a picture board
A nurse is caring for a client who is NPO and has an NG tube attached to suction for gastric decompression. Which of the following actions should the nurse take if the client experiences abdominal distention?
Irrigate the tube with normal saline
A nurse is assisting with admitting a client who has colorectal cancer. When collecting data from the client, which of the following manifestations should the nurse expect?
Abdominal cramps
A nurse is preparing to administer digoxin to a client who has heart failure. Which of the following findings should indicate to the nurse that the medication has been effective?
Cardiac workload decreases
A nurse is discussing alopecia with a client who is scheduled to begin chemotherapy. Which of the following statements should the nurse make?
Your oncologist may prescribe a cold cap to wear during treatment to reduce hair loss
A nurse is reinforcing teaching about stress management techniques with a client who has moderate anxiety disorder. Which of the following responses by the client indicates an understanding of the teaching?
I will imagine myself in a calm place when I can't recognize
A nurse is caring for a female client during an outpatient clinic visit. Which of the following findings places the client at risk for coronary artery disease?
The clien'ts LDL level
A nurse is reinforcing teaching with a client who is at 20 weeks of gestation and will undergo routine abdominal ultrasonography the following day. Which of the following statements should the nurse include in the teaching
You will need to have a full bladder for the procedure
A nurse is reviewing the plan of care for a client who is 3 hr post-op following a thyroidectomy. Which of the following is the priority intervention?
Listen to the client for evidence of stridor
A nurse in a long term care facility is reviewing information about health care associated infections with a newly licensed nurse. Which of the following information should the nurse include?
Prolonged use of corticosteroids is a risk factor for infection
A nurse is collecting data from a client who has PTSD. Which of the following manifestations should the nurse expect?
Hypervigilance
A nurse is caring for a client who has MS. Which of the following manifestations should the nurse expect?
Ataxia
A nurse is checking a newborn's vital signs. Which of the following methods of temperature measurement should the nurse use?
Axillary
A nurse is in a provider's office is collecting data from a preschooler. Which of the following findings should the nurse report to the provider?
Heart rate 146/min
A nurse is preparing to discharge a middle adult client who is immunocompromised. Which of the following immunizations should the nurse plan to administer.
PPSV
a nurse is caring for a client who had a bone marrow transplant 3 days ago for treatment of leukemia. Which of the following findings should the nurse identify as a safety hazard?
A visitor brought the client a bouquet of flowers
A nurse is caring for an infant who is receiving IV fluids for dehydration. Which of the following should the nurse recognize as a positive response to the therapy?
Moist mucous membranes
A nurse is preparing a client for surgery. The client states, "i'm sure this surgery will not help me get better." Which of the following responses should the nurse make?
You're saying that you are doubtful that this procedure will benefit you
A nurse at a long-term care facility is transcribing new prescriptions for four clients. Which of the following prescriptions is accurately transcribed by the nurse?
Potassium chloride 20 mEq PO every morning
A charge nurse in a long-term facility notices an AP's repeated failure to provide oral care for clients. Which of the following actions should the nurse take?
Discuss the unacceptable behavior with the AP while reinforcing expectations
A nurse is collecting data from a client who has bipolar disorder and is experiencing acute mania. Which of the following findings is the nurse's priority?
Lack of sleep