a nurse is giving a change of shift report about a client they admitted earlier that day who has pneumonia. which of the the following piece of info is the priority fo rthe nurse to proive
breath sounds
a nurse is caring for a client who has an NG tube and is recieing intm feedings through an open system. Which of the following actions should the nurse take first
Tell the client to keep the head of the bed elevated at least 30�
A nurse is caring for a client who has tuberculosis. Which of the following actions should the nurse take? Select all that apply
Place the client in a room with negative pressure airflow. Wear gloves when assisting the client with oral care. Use anti-microbial sanitizer for hand hygiene.
A nurse is performing a Romberg test during the physical assessment of a client. Which of the following techniques should the nurse use?
Have the client stand with their arms at their sides and their feet together
A nurse is preparing to obtain a lower extremity blood pressure from a client and no longer palpates the popliteal pulse after 92 MMHG. Which of the following images displays the measurement and MMHG to which the nurse should inflate the cuff when obtaini
To 120
A nurse has excepted a verbal prescription for 3/10 of a milligram of levothyroxine IV stat for a client who has myxedema coma. How should the nurse transcribe the dosage of this medication in the clients medical record?
0.3 mg
A nurse is discussing the use of herbal supplements for healthcare promotion with a client which of the following statements indicates an understanding of herbal supplement use?
I can take echinacea to improve my immune system
A nurse is caring for a client who has decreased mobility. Which of the following actions should the nurse take to decrease the clients risk of developing plantar flexion contractures
The nurse should apply an ankle-foot orthotic device to the clients feet
A nurse is reviewing practice guidelines with a group of newly licensed nurses which of the following interventions should the nurse include that is within the are in scope of practice
Initiate and Intero feeding through a gastrostomy tube
A nurse is planning care for a client who has vision loss. Which of the following interventions should the nurse include in the plan of care to assist the client with feeding?
Arrange food in a consistent pattern on the clients plate
A charge nurse is observing and newly licensed nurse prepare a sterile field for a dressing change. Which of the following actions by the newly licensed nurse requires intervention by the charge nurse
The newly licensed nurse places the Of a bottle of sterile Celine solution on the sterile field
A nurse is reviewing protocol in preparation for suctioning secretions from a client who has a new tracheostomy. Which of the following actions should the nurse plan to take
Select a suction catheter that is half the size of the lumen
The nurse in the clinic is caring for a middle adult client who states "the doctor says that, since I am at an average risk for colon cancer, I should have a routine screening. What does that involve?" Which of the following responses should the nurse mak
You should have a fecal occult blood test every year
A nurse is just inserted an NG tube for a client which of the following findings should the nurse expect to confirm correct tube placement?
An x-ray shows the end of the tube above the pylorus
A nurse is preparing to administer 0.5 ML of oral single-dose liquid medication to a client. Which of the following actions should the nurse take??
Gently shake the container of medication prior to administration
A nurse is admitting a client who has rubella. Which of the following types of transmission based precautions should the nurse initiate?
Droplet
A nurse is reviewing a clients medication prescription that reads the digoxin 0.25 by mouth every day. Which of the following components of the prescription should the nurse verify with the provider
Medication does
A nurse manager is overseeing the care activities on the unit. for which of the following situation should the nurse manager intervene due to a violation of hipaa guidelines?
A nurse asks a nurse from another unit to assist with documentation for a client
A nurse is teaching an older client who is at risk for osteoporosis About beginning a program of regular physical activity. Which of the following types of activities should the nurse recommend?
Walking briskly
The nurse is caring for a client who requires an informed consent for surgical procedure. Which of the following actions is the nurses responsibility?
Witness the clients signature on the consent form
A nurse on a medical unit is preparing to discharge her clients at home. Which of the following actions should the nurse take as a part of the medication reconciliation process?
Compare prescriptions with medications the client received while at the facility
A nurse is teaching a group of staff nurses about the use of essential oil's for aromatherapy. The nurse should include in the teaching that this therapy might be contra indicated for which of the following clients
A client who has asthma
A nurse is caring for a client was recently started using a behind the ear hearing aid. Which of the following statements is the nurse identify as an indication that the client understands the use of this assistive device?
I will be sure to remove my hearing aid before taking a shower
A nurse is caring for a client is receiving pain medication through a patient controlled analgesia pump. Which of the following actions should the nurse take
Instruct the family to refrain from pushing the button for the client while she is asleep
A nurse is caring for a client who is refusing a blood transfusion for religious reasons. The clients partner wants the client to have the blood transfusion. Which of the following actions should the nurse take
Withhold the blood transfusion
A nurse is planning care for a client who has tuberculosis the nurse should use which of the following pieces of personal protective equipment when providing care for the client
N 95 respirator
A nurse is performing a peripheral vascular assessment for a client when placing the bell of the stethoscope on the clients neck the nurse here's the following sound this sound indicates which of the following? (It's a bruit)
Narrowed arterial lumen
A middle adult client tells the nurse "I feel so useless now that my children do not need me anymore." Which of the following responses should the nurse make?
People in middle adulthood often find satisfaction in nurturing and guiding young people" (Erik Erickson)
Nurse enters a clients room and finds her on the floor. The clients roommate reports of the client was trying to get out of bed and fell over the side rail onto the floor. Which of the following statements should the nurse document about this incident?
Client found lying on floor
A nurse is caring for a client who has a prescription for wound irrigation. Which of the following actions should the nurse take
Cleanse the wound from the center outward
A nurse is preparing to delegate client care tasks to an assistive personnel. Which of the following tasks should the nurse delegate
Ambulating a client who is postoperative
A nurse is planning to teach a group of adolescents who each recently had a surgical placement of an ostomy. Which of the following methods should the nurse use as a psycho motor approach to learning
Practice sessions
A nurse is caring for a client who has a prescription for five units of regular insulin and 10 units of NPH insulin to mix together and administer subcutaneously. Determine the correct order of steps for this procedure.
The nurse should first inject air into the vile of NPH insulin without touching the needle to the solution. Next, the nurse should inject air into the vile of regular insulin and withdraw the correct amount of regular insulin. Finally, the nurse should in
Nurse is caring for a client who reports difficulty falling asleep. Which of the following recommendations to the nurse make?
Maintain a consistent time to wake up each day
A nurse is caring for a client who has terminal liver cancer. Which of the following statements should the nurse identify as an indication that the client is experiencing spiritual distress?
What could I have done to deserve this illness?
A nurse is assisting a client who received IV fluid bolus for dehydration. Which of the following findings should the nurse identify as an indication of fluid volume excess?
Distended neck veins
A nurse is completing an admission assessment for a client who reports vomiting and diarrhea for the past three days. Which of the following findings should the nurse expect?
Rapid heart rate (fluid deficit)
A nurse is caring for a client who reports pain. I'm documenting the quality of the clients pain on an initial pain assessment, the nurse should record which of the following client statements?
The pain is like a dull ache in my stomach
A nurse is teaching a client whose left leg is in a cast about using crutches. Which of the following statements should the nurse identify as an indication that the client understands the teaching?
When descending stairs, I will first shift my weight to my right leg
A nurse is caring for a group of clients on a MedSurg unit. In which of the following situations does the nurse demonstrate the ethical principle of veracity?
A client who is unaware of her recent cancer diagnosis ask the nurse if she has cancer and the nurse responds affirmatively
A nurse is caring for a client who has an indwelling urinary catheter. Which of the following findings indicate that the catheter requires irrigation
Bladder scan shows 525 ML of urine
A nurse is providing discharge teaching for a client who has a new prescription for a home oxygen concentrator which of the following instructions should the nurse provide to the client and his family? Select all that apply
Check the cord routinely for phrase or tearing. Consider purchasing a generator for power back up. Observe for signs of hypoxia.
A nurse is caring for a client who requires 24 hour urine collection. Which of the following statements by the client indicates an understanding of the teaching?
I flushed what I urinated at 7 AM and I've saved all urine since. (For a 24 hour urine collection, the client should discard the first voiding and save all subsequent voidings)
A nurse is caring for a client who is receiving fluid through a peripheral IV catheter. Which of the following findings at the IV site should the nurse identify as indicating infiltration?
Skin blanching
A charge nurse is discussing the responsibility of nurse is caring for a client to have a C diff infection. Which of the following information should the nurse include in the teaching?
Have family members wear a gown and gloves from visiting
A nurse is preparing to transfer a client who can bear weight on one leg from the bed to a chair. After securing a safe environment which of the following actions should the nurse take next
Assess the client for orthostatic hypotension
A nurse calculating a clients fluid intake over the past eight hours which of the following items should the nurse plan to document on the client intake and output record as 120 ML of fluid
8 oz ice chips (=4oz = 120 mL)
The nurse is admitting a client who has been having frequent tonic clonic seizures. Which of the following actions should the nurse add to the clients plan of care?
Wrap blankets around all four sides of the bed
A home health nurse is completing an admission assessment of an older adult client who has their caregiver present. Which of the following findings should the nurse identify as a potential indication of elder abuse
The caregiver insists on remaining in the room
The nurse is preparing to administer multiple medications to a client who has an in Terrell feeding tube. Which of the following actions should the nurse plan to take?
Flush the tube with 15 ML of sterile water
A nurse is assessing an adult client who has been in Mobile for the past three weeks. For which of the following findings should the nurse intervene?
Erythema on pressure points
A client who is non-ambulatory notifies the nurse that his trashcan is on fire. After the nurse confirms the presence of the fire which of the following actions should the nurse take next
Evacuate the client
A nurse is caring for a client who has a terminal diagnosis and whose health is declining. The client request information about advanced directives. Which of the following responses to the nurse make
We can talk about advance directives, and I can give you some brochures about them
The nurse is caring for a client who has limited mobility in his lower extremities. Which of the following actions should the nurse take to prevent skin breakdown
Have the client use a trapeze bar when changing position
A nurse and an acute care facility is preparing a discharge summary for a client who is transferring to a long-term care facility. Which of the following documentation should the nurse include
Current medications
A nurse is preparing heparin infusion for a client who was admitted to the facility with DVT. The prescription reads 25,000 units of heparin in 0.9% sodium chloride to 50 ML to infuse at 800 units an hour. At what rate should the nurse set the infusion pu
8mL/hr
A nurse is planning an educational program for a group of older adults at a senior living center. Which of the following recommendations should the nurse include
You should receive a pneumococcal vaccine when you are 65 years old
A nurse in a surgical suite notes documentation on a client medical record that he has a latex allergy. In preparation for a clients procedure which of the following precautions should the nurse take
Wrap monitoring cords with stockinette and tape them in place
A nurse is in ministry IV fluids to a client. With monitoring for adverse effects which of the following assessments should the nurse identify as the priority
Auscultate lung sounds
A community health nurse is checking blood pressures for a group of clients at a community health screening. Which of the following clients is at an increased risk for hypertension
A client who smokes one pack of cigarettes each day