A nurse is assisting with the care of a client who has a terminal illness. The client practices Orthodox Judaism. Which of the following actions should the nurse take?
ANS: Assure the client that a family member will stay with the body after death
RAT: The nurse should assure the client that a family member will remain with the body until burial
A nurse is caring for a client who is receiving telemetry. which of the following ECG findings should the nurse report to the charge nurse?
PR interval 0.24 seconds.
A nurse in an urgent care clinic is collecting data from four clients. which of the following clients should the nurse recommend for treatment?
a client who is experiencing shortness of breath after taking amoxicillin.
A nurse is assisting with the transfer of a client to a long term care facility. the nurse should review which of the following sections of the electronic medical record to locate information about the clients personal health insurance?
admission sheet.
A nurse is reinforcing teaching with a client who is scheduled for a lumbar punture. which of the following statements should the nurse make?
you should increase your fluid intake after this procedure.
A nurse is reinforcing teaching about puberty with a group of prepubescent female clients. Which of the following information should the nurse include in the teaching?
you will likely gain weight before you start to get taller.
A nurse is assisting with a discussion about STI's with a group of adolescents at a health fair. which of the following statements should the nurse make?
an infection with gonorrhea may result in infertility.
A nurse in a providers office is caring for client who is at 34 weeks of gestation. Which of the following instructions should the nurse anticipate providing to the client?
monitor your blood pressure using your right arm daily.
A nurse is preparing to administer amoxicillin 875 mg PO every 12 hours. The amount available is amoxicillin oral suspension 400 mg/5mL. How many mL should the nurse administer per dose?
11.
A nurse is collecting data from a client who has chronic hepatitis. In which of the following locations should the nurse expect the client to point to indicate hepatic tenderness?
B.
A nurse is monitoring a client who is receiving lactated ringers 500 mL over 4 hr. the drop factor of the manual IV tubing is 10gtt/mL. The nurse should check that the manual IV infusion is delivered at how many gtt/min?
21.
A nurse is reinforcing teaching with a client who has osteoarthritis. Which of the following instructions should the nurse include?
apply capsaicin cream four times a day.
A nurse is reviewing a client's medication record and notices that a double dose of oral digoxin was administered 1 hr ago. Which of the following actions should the nurse take first?
ANS: Obtain a set of the client's vital signs
RAT: The first action the nurse should take when using the nursing process is to collect data from the client. Digoxin can cause bradycardia. By obtaining the client's vital signs, the nurse can identify the n
A nurse is instructing an assistive personnel (AP) about caring for a client who has hepatitis A and is incontinent of stool. Which of the following infection control precautions should the nurse instruct the AP to use?
ANS: Contact
RAT: Hepatitis A is spread by the fecal-oral route. Standard precautions are usually sufficient to prevent the spread of infection. However, if the client who has hepatitis A is also incontinent of stool, then contact precautions are indicate
A nurse is assisting with the transfer of a client to a long-term care facility. The nurse should review which of the following sections of the electronic health record to locate information about the client's personal health insurance?
ANS: Admission sheet
RAT: The nurse will find client data, such as date of birth, occupation, and the client's source of health insurance, on the client's admission sheet
A nurse is inspecting the skin of a newborn. Which of the following findings should the nurse report to the provider?
ANS: Generalized petechiae
RAT: Petechiae are an expected finding over the presenting part of the newborn, such as on the forehead in a brow presentation, and also anywhere on the head of the newborns who has a nuchal cord, which is an umbilical cord arou
A nurse in a provider's office is obtaining the health history from a client who is scheduled to undergo a cardiac catheterization in 2 days. Which of the following questions is the priority for the nurse to ask?
ANS: "Do you know if you're allergic to iodine?"
RAT: The greatest risk to the client is an allergic reaction to the contrast agent, which contains iodine. Therefore, the priority question is to identify the client's allergies
A nurse is reviewing the medical record of a client who is receiving warfarin and has atrial fibrillation. Which of the following laboratory values should the nurse report to the provider?
ANS: INR 5.0
RAT: The international normalized ratio (INR) is a measurement of the body's blood clotting ability. A client receiving warfarin to prevent clot formation related to atrial fibrillation should have an INR of 2.0 to 3.0. An INR of 5.0 or great
A nurse is evaluating the safe use of electrical equipment by a newly hired assistive personnel (AP). Which of the following actions by the AP demonstrates an understanding of the proper use of electrical equipment?
ANS: Grasps the plug of a device in the client's room to pull it straight out from the wall
RAT: The nurse should recognize that by grasping the plug, rather than the cord, the AP is demonstrating an understanding of proper equipment use and preventing ri
A nurse is reinforcing discharge teaching with the parents of a school-age child who has severe hemophilia A. Which of the following statements by the parents indicates an understanding of the teaching?
ANS: "I will soak my child's toothbrush in warm water to soften it before my child uses it."
RAT: The nurse should instruct the parents to soften their child's toothbrush in warm water before they use it or allow them to use a sponge-tipped disposable too
A nurse is assisting with the development of an in-service for newly licensed nurses about seclusion. In which of the following situations should the nurse identify the need to request a prescription for seclusion?
ANS: A client hits another client because they thought the other client was talking about them
RAT: The nurse should request a prescription for seclusion for a client who hits another client to protect the client and others from physical injury
A nurse in a provider's office is reviewing the medical record of a client who requests a prescription for an oral contraceptive. Which of the following findings should the nurse identify as a contraindication for oral contraceptive use?
ANS: Coronary artery disease
RAT: Coronary artery disease is a contraindication to oral contraceptive use because it increases the client's risk for myocardial infarction. Other contraindications for receiving oral contraceptives include gallbladder disea
A nurse is assisting with the care of a school-age child immediately following surgery. The child weights 21.8 kg (48 lb) and has a chest tube applied to suction. Which of the following findings should the nurse report to the provider?
ANS: 250 mL of sanguineous drainage over the last 3 hr
RAT: The nurse should recognize that if more than 3 mL/kg/her of sanguineous drainage occurs for more than 3 consecutive hours following surgery, it can indicate active hemorrhaging. Therefore, 250 mL
A nurse is collecting data from a client who is at 30 weeks of gestation and has gestational diabetes. Which of the following findings should the nurse report to the provider as an indication of hyperglycemia?
ANS: Polyuria
RAT: The nurse should identify polypuria as an expected finding of hyperglycemia and report this finding to the provider
A nurse is discussing home safety with a group of clients who have type 1 diabetes mellitus. Which of the following client statements indicates an understanding of the teaching?
ANS: "I will dispose of my needles in a plastic laundry detergent container."
RAT: The nurse should instruct the client to dispose of needles in a puncture-proof container, such as a plastic laundry detergent container.
A nurse is caring for a client who has Alzheimer's disease. Which of the following actions should the nurse take?
ANS: Encourage the client to reminisce about the past
RAT: The client who has Alzheimer's disease has progressive loss of short-term memory and might not be able to recall recent happenings and events. This can lead to increased frustration. However, remo
A nurse is monitoring a client who is receiving telemetry. Which of the following ECG findings should the nurse report to the provider?
ANS: PR interval 0.24 seconds
RAT: An expected PR interval is 0.12 to 0.20 seconds. A prolonged PR interval can indicate a heart block; therefore, the nurse should report this finding provider
A nurse on a medical unit is reviewing a client's medical record. Which of the following procedures should the nurse identify requires the client to sign a separate informed consent form?
ANS: Lumbar puncture
RAT: The nurse should identify that a client needs to provide consent for general treatment as well as a separate written informed consent for any treatment that has an element of risk, such as a lumbar puncture
A nurse is reviewing the techniques for transferring a client from a bed to a chair with a group of assistive personnel (AP). Which of the following instructions should the nurse include?
ANS: Use lower-body strength
RAT: The nurse should instruct the AP to use lower-body strength when lifting a client to reduce stress on the back
A nurse is participating in a quality improvement study about the effectiveness of client pain management on the unit. Which of the following strategies should the nurse use to collect data?
ANS: Review clients' charts for their rating of pain before pain medication was administered and 1 hr after administration
RAT: The nurse should collect data from clients' charts about pain ratings before and after pain management interventions
A nurse is reinforcing teaching about confidentiality with a client who has a new diagnosis of HIV. Which of the following information should the nurse include in the teaching?
ANS: "Your HIV status will be shared with members of your health care team."
RAT: The diagnosis of HIV or AIDS is shared with every member of the health care team who provides direct care for the client, just like any other diagnosis
A nurse is planning care for a client who has a history of seizures. Which of the following pieces of equipment should the nurse place in the client's room?
ANS: Suction catheter
RAT: The nurse should place suction equipment in the room of a client who has a history of seizures. During a seizure, the client might have excessive oral secretions or might vomit. If the client's airway becomes occluded, then the
A licensed practical nurse (LPN) is reviewing client assignments for the upcoming shift. Which of the following clients should the LPN ask the charge nurse to reassign to a registered nurse (RN)?
ANS: A client who has a new colostomy and requires the development of a teaching plan
RAT: Developing a client teaching plan is not within the scope of practice for an LPN. The nurse should contact the nursing supervisor to inform them of the client's nee
A nurse is caring for a client who is recovering from a stroke and is experiencing difficulty using eating utensils. The nurse should identify the need for a referral to which of the following interprofessional team members?
ANS: Occupational therapist
RAT: The nurse should identify the need for a referral to an occupational therapist to teach the client how to use special eating utensils
A nurse is preparing to perform blood glucose monitoring for a client who has type 1 diabetes mellitus. Which of the following actions should the nurse take first?
ANS: Hold the finger for testing in a dependent position
RAT: Evidence-based practice indicates that the nurse should first position the testing site to enhance blood flow, which improves the ability to collect an adequate specimen
A home health nurse is reinforcing teaching with a client about the use of elastic stockings to decrease peripheral edema. Which of the following instructions should the nurse include?
ANS: Apply the stockings in the morning
RAT: The nurse should instruct the client to apply the elastic stockings in the morning and remove them at the end of the day before bedtime
A nurse in a provider's office is reviewing pediculosis capitis management and prevention strategies with the parent of a school-age child. Which of the following strategies should the nurse include? (Select all that apply.)
ANS:
Store the child's clothing in a separate cubicle when at school.
Boil brushes and combs in water for 10 min.
Dry bed linens and clothing in a hot dryer for at least 20 min.
RAT:
Transmission of lice occurs via contact with personal items.
Boiling hai
A nurse is contributing to the plan of care for a client who has a continent urinary diversion. Which of the following interventions should the nurse plan to implement to facilitate urinary elimination?
ANS: Use intermittent urinary catheterization for the client at regular intervals
RAT: A continent urinary diversion contains valves that prevent urine from exiting the pouch; therefore, the nurse should plan to insert a urinary catheter at regular interv
A nurse is preparing to perform a bladder scan for a client. Which of the following actions should the nurse take?
ANS: Tell the client they should not experience any discomfort
RAT: The nurse applies the handheld scanner over the area of the bladder when performing a bladder scan. This noninvasive procedure should not cause the client any discomfort
A nurse is caring for a client who is crying and states that their provider informed them that they have a tumor and will need a biopsy. Which of the following responses should the nurse make?
ANS: "What have you done to help yourself get through stressful situations before?"
RAT: This is a therapeutic response. The nurse is aware that the client is under stress and encourages comparison to investigate whether they have experience dealing with
A nurse is caring for a newborn who is 12 hr old. The nurse should expect the newborn's stool to have which of the following characteristics within the first 24 hr following birth?
ANS: Dark greenish-black and viscous
RAT: The first stool passed by a newborn is the meconium that develops in utero. It is dark greenish-black and viscous, containing of amniotic fluid, cells, intestinal secretions, and blood
A licensed practical nurse is assisting with preparation of client for insertion of a peripherally inserted central venous catheter (PICC). Which of the following actions should the nurse take?
ANS: Witness the client's signature on the informed consent form.
RAT: The insertion of a PICC is an invasive procedure with risks and benefits. The nurse should witness the client's signature on the consent form after ensuring the client has an understan
A nurse is caring for a client who adheres to a kosher diet. Which of the following food selections should the nurse expect to see on the client's meal tray?
ANS: Spaghetti noodles with red sauce
RAT: The nurse should identify that spaghetti noodles with red sauce is appropriate for a client who adheres to a kosher diet.
A nurse is contributing to the plan of care for a client who is receiving continuous bladder irrigation following a transurethral resection of the prostate (TURP). Which of the following interventions should the nurse include?
ANS: Maintain a drainage flow rate to keep the urine diluted to a reddish-pink color
RAT: The nurse should maintain the flow rate of the bladder irrigation to keep the urine diluted to a reddish-pink color and the tubing free of clots and bleeding
A nurse is assisting with the care of a client who is postpartum and has a deep-vein thrombosis. The client has been receiving heparin IV infusion. Which of the following medications should the nurse ensure is readily available?
ANS: Protamine sulfate
RAT: The nurse should ensure that protamine sulfate is readily available. Protamine sulfate is the antidote used to reverse the anticoagulant effects of heparin
A nurse is reinforcing teaching with a client about how to replace their two-piece ostomy pouching system. The client tells the nurse that removing the skin barrier is painful. Which of the following strategies should the nurse suggest?
ANS: Hold the skin taut while removing the barrier
RAT: Gently and gradually peeling the skin barrier away while holding the skin taut minimizes discomfort and trauma to the peristomal skin
A nurse in an inpatient mental health facility is caring for a newly admitted client who has alcohol use disorder. During a therapy session, the client asks about Alcoholics Anonymous (AA). Which of the following resposes should the nurse make?
ANS: "What is your current understanding about the purpose of AA?"
RAT: The nurse should identify the client's understanding about the purpose of AA to provide further information about the program and meetings and to facilitate a referral if needed. For
A nurse is performing a dressing change for a client who is 3 days postoperative. Which of the following findings should the nurse report to the provider?
ANS: Yellow-green drainage at the incision line
RAT: Yellow-green, purulent, or odorous drainage indicates the wound is infected. The nurse should report this finding to the provider
A nurse is providing comfort to the partner of a client who has died. Which of the following statements should the nurse make?
ANS: "Journaling about your relationship might help with the grieving process."
RAT: Journaling provides a means for the client to identify thoughts and feelings and to recognize and come to terms with the positive and negative aspects the client's relati
A nurse is assisting with an educational session for newly licensed nurses about partner violence. Which of the following characteristics should the nurse include as placing a vulnerable person at risk for partner violence?
ANS: Recent confirmation of pregnancy
RAT: The nurse should include pregnancy as a characteristic placing a vulnerable person at risk for partner violence. The perpetrator might view the pregnancy as a threat to the relationship due to the attention the c
A nurse is reinforcing teaching for a client who is preparing to return to work after a back injury. Which of the following instructions for safe lifting technique should the nurse include?
ANS: "You should hold a box close to your body when lifting it up."
RAT: The client should hold the box as close to their body as possible to maintain balance and prevent injury
A nurse is reinforcing discharge teaching with a client who has a prescription for home oxygen therapy via nasal cannula. Which of the following instructions should the nurse include?
ANS: "Apply a water-based lubricant around the nostrils to prevent irritation."
RAT: The client should protect their nares with a water-based lubricant to prevent irritation from the nasal cannula. Petroleum and oil-based products are combustible and shou
A nurse is caring for a client who is in an inpatient mental health facility and has dependent personality disorder. Which of the following client behaviors should the nurse expect?
ANS: The client calls their partner to ask what they should wear each day
RAT: Clients who have dependent personality disorder have problems making everyday decisions without input from others
A nurse is caring for a client who is scheduled for a mastectomy the following day. The client is tearful and tells the nurse that they are not ready to have this procedure done at this time. Which of the following responses should the nurse make?
ANS: "Would you like for me to talk to the surgeon with you?"
RAT: The nurse should advocate for the client's needs by offering to talk to the surgeon with the client. The nurse should also offer moral support and encourage the client to express their con
A nurse is documenting client care in the medical record. Which of the following entries should the nurse make?
ANS: "Client remains NPO until x-ray procedure is complete."
RAT: The nurse should use documentation that is specific and uses accepted terminology. The nurse can use the abbreviation "NPO", which is an accepted abbreviation for "nothing by mouth.
A nurse is using an interpreter to reinforce discharge teaching with a client who speaks a different language than the nurse. Which of the following actions should the nurse take?
ANS: Observe the client's facial expressions during communication
RAT: The nurse should observe the client while the interpreter is speaking to the client. Both verbal and nonverbal behaviors, such as facial expressions and body language, can indicate whe
A nurse is collecting data from a client who reports recent methamphetamine use. Which of the following manifestations should the nurse expect?
ANS: Dilated pupils
RAT: The nurse should expect a client who has stimulant intoxication to have dilated pupils. Other expected findings of stimulant intoxication include increased energy and hypervigilance
A nurse is working in an acute care facility when a natural disaster occurs. The facility must discharge clients to provide room for new admissions. Which of the following clients should the nurse recommend to the charge nurse for discharge?
ANS: A client who has pneumonia and is currently receiving oral antibiotics
RAT: The nurse should recognize that this client can continue oral antibiotics at home. Therefore, this client is a candidate for discharge in a disaster situation
A nurse is assisting with the plan of care for a client who has bipolar disorder and is in the manic phase. Which of the following activities should the nurse recommend for the client?
ANS: Walking outside with a staff member
RAT: During the manic phase of bipolar disorder, psychomotor activity is excessive. The nurse should include physical activity, such as walking, in the plan of care. Additionally, the one-on-one nature of the activ
A nurse is supervising an assistive personnel (AP) who is preparing to remove personal protective equipment (PPE) after providing direct care to a client who requires airborne and contact precautions. The nurse should recognize that the AP understands the
ANS: Gloves
RAT: The greatest risk to the AP is contamination from pathogens that might be present on the PPE. Therefore, the priority actions for the AP to take is to remove the gloves, which are considered the most contaminated of the PPE.
A nurse in an outpatient surgery center is reinforcing discharge teaching with a client following a lithotripsy for uric acid stones. Which of the following instructions should the nurse plan to include in the teaching?
ANS: Strain the urine to collect stone fragments
RAT: The client should verify passage of the stones by straining their urine. Laboratory analysis of the stones can provide information to help prevent future stone formation
A nurse is reinforcing teaching with a client who has hypercholesterolemia and a new prescription for atorvastatin. The nurse should instruct the client that which of the following findings is an adverse effect of this medication and should be reported to
ANS: Muscle pain
RAT: The nurse should instruct the client to report findings of muscle pain or tenderness to the provider. These findings can be manifestations of myopathy, or muscle injury, which is a potential serious adverse effect of atorvastatin
A nurse is caring for a client who is recovering from a motor vehicle crash. The client's employer calls to ask if the client's injuries will prevent them from returning to work. Which of the following responses should the nurse make?
ANS: "I cannot give you this information. You will need to speak with your employee."
RAT: Sharing client information with an employer is a violation of client confidentiality. HIPAA ensures that client information is kept confidential once it is disclose
A nurse is assisting a client who is scheduled for a nonstress test (NST). Which of the following actions should the nurse take?
ANS: Provide the client with a handheld event marker to record fetal activity
RAT: The nurse will provide the client with a handheld event marker for use in documenting fetal movement. The client will press the button everytime they feel the fetus move th
A nurse is reinforcing teaching with a client who is receiving radiation therapy for cancer of the larynx. Which of the following statements made by the client indicates an understanding of the teaching?
ANS: "I should wear a soft scarf around my neck when I am outside."
RAT: A client receiving radiation therapy should cover the affected area with loose, soft clothing to protect the skin from sun exposure
A nurse is reinforcing teaching with an older adult client who has severe left-sided heart failure. Which of the following statements should the nurse make?
ANS: "Rest for 15 minutes between activities."
RAT: The nurse should instruct the client to increase activity gradually and to rest for a period of 15 min if fatigue occurs. Clients who have heart failure should balance activity with rest to reduce cardia
A nurse is caring for a client who is scheduled to undergo a thoracentesis for a left pleural effusion. In which of the following positions should the nurse plan to place the client durign the procedure?
ANS: Upright with arms resting on the overbed table
RAT: The nurse should position the client upright with arms resting on the overbed table to widen the intercostal spaces and improve access to the pleural fluid
A nurse is talking with a client who says the provider agreed to initiate a do-not-resuscitate (DNR) prescription. After leaving the client's room, which of the following actions should the nurse take first?
ANS: Check for documentation that the provider spoke with the client about the DNR
RAT: The first action the nruse should take when using the nursing process is to determine whether the provider documented the conversation appropriately. The nurse must en
A nurse is observing a client who is in the first stage of labor. Which of the following interventions should the nurse recommend for this client? (Select all that apply.)
ANS: Squatting using an exercise ball.
Counterpressure to the sacral area.
Pelvic rocking.
RAT: Squatting using an exercise ball can help relax the pelvis and perineal area and can relieve pain during contractions.
Counterpressure to the sacral area can h
A nurse is caring for a group of clients. The nurse should fill out an incident report for which of the following situations?
ANS: A visitor who develops a bruise on their head following a syncopal episode
RAT: The nurse should complete an incident report for an injury involving a client or visitor
A client is requesting information from a nurse about creating a health care proxy. Which of the following statements should the nurse make?
ANS: "The person you appoint will make health care decisions for you if you cannot do so yourself."
RAT: The nurse should instruct the client that a health care proxy designates a surrogate to make health care decisions when the client is no longer able t
A client in a mental health facility unjustly accuses a nurse of stealing money from their room. Which of the following therapeutic responses should the nurse make?
ANS: "Tell me how you decided who took your money."
RAT: This response by the nurse is an example of therapeutic communication, in which the nurse validates the client's concern by encouraging them to describe their perception
A nurse is preparing to administer a dose of digoxin to a client who is receiving continuous tube feedings. Which of the following actions should the nurse take?
ANS: Flush the feeding tube with water before and after administering the medication
RAT: To maintain patency of the feeding tube and to ensure that the client receives all of the medication, the nurse should flush the tubing before and after administrati
A nurse is planning care for a 5-year-old child who is 8 hr postoperative following a tonsillectomy. Which of the following interventions should the nurse include in the plan of care?
ANS: Administer PRN analgesics regularly for the first 24 hr.
RAT: The nurse should administer analgesics for the first 24 hr even if they are ordered on an as-needed basis. It is necessary to control pain postoperatively. Giving the analgesics regularly
A nurse is reinforcing preoperative teaching with a client who will receive morphine through a PCA pump after surgery. Which of the following information should the nurse include?
ANS: "You should increase your fluid intake while receiving this medication through the PCA pump."
RAT: The client should increase their fluid intake to prevent or relieve the adverse effect of constipation while receiving morphine through the PCA pump
A nurse is using the FLACC scale to determine the pain level of an 11-month-old infant who is postoperative. Which of the following factors should the nurse consider when using this pain scale?
ANS: Level of activity
RAT: The nurse should consider the infant's activity level when using the FLACC pain scale. The FLACC score is determined by five categories of behavior: facial expression (F), leg movement (L), activity (A), cry (C), and consolabil
A nurse is receiving change-of-shift report for four clients. The nurse should plan to collect data from which of the following clients first?
ANS: A client who has asthma and had frequent exacerbations on the previous shift
RAT: When using the airway, breathing, circulation (ABC) approach to client care, the nurse should prioritize data collection from a client who has asthma. The client experi
A nurse is caring for a newborn who is 1 hr old. The mother received fentanyl 30 min before birth. For which of the following adverse effects should the nurse monitor the newborn?
ANS: Respiratory depression
RAT: Fentanyl, an opioid agonist, rapidly crosses the placenta, and it is present in fetal blood within 1 min. The nurse should monitor the newborn for respiratory depression, which is an adverse effect of fentanyl
A nurse is caring for a client who has asthma and has been taking montelukast for 1 month. Which of the following findings should indicate to the nurse that the client is complying with this medication regimen?
ANS: The client takes the medication once daily at bedtime
RAT: Montelukast, a leukotriene modifier, is taken once a day for maintenance at bedtime
A nurse is assisting with planning palliative care for a client who has stage IV cancer and is in the active stage of dying. Which of the following interventions should the nurse include in the plan of care?
ANS: Administer atropine to reduce the client's respiratory secretions
RAT: The nurse should administer atropine to reduce terminal respiratory secretions and reduce noisy ventilations called "the death rattle.
A nurse in a pediactric clinic is collecting data from a toddler. Which of the following findings should the nurse identify as a possible indication of physical neglect?
ANS: The toddler is inadequately dressed for the weather
RAT: Inappropriate dress is a suggestive finding of physical neglect. The nurse should collect further data for other indicators of physical neglect
A nurse enters the room of an adolescent client and finds them on the floor experiencing a tonic-clonic seizure. Which of the following actions should the nurse take when the seizure subsides?
ANS: Keep the client in a side-lying position
RAT: The nurse should keep the client in a side-lying position to facilitate drainage of any secretions and prevent aspiration
A nurse is contributing to the plan of care for a client who has a prescription for range-of-motion exercises of the shoulder. Which of the following exercises should the nurse recommend to promote shoulder hyperextension?
ANS: Move the arm behind the body with the elbow straight
RAT: Hyperextension of the shoulder involves the deltoid, teres major, and latissimus dorsi muscles. The client performs this motion by moving their arm behind their body while keeping the elbow st
A nurse is reviewing various defense mechanisms with a newly licensed nurse. Which of the following client statements should the nurse use as an example of rationalization?
ANS: "I didn't get a good grade because my teacher does not like me."
RAT: The nurse should recognize this statement as the use of rationalization by a client. Rationalization is used as a means of justifying unreasonable feelings, thoughts, or actions
A nurse is caring for an older adult client who is experiencing difficulty sleeping. Which of the following actions should the nurse take?
ANS: Offer the client a snack of whole grain crackers before bedtime
RAT: The nurse should provide the client a light carbohydrate snack, such as whole grain crackers, before bedtime
A nurse is preparing a client for an enternal feeding and notices that the pump at the client's bedside is warm to the touch. Which of the following actions should the nurse take?
ANS: Unplug the equipment and remove it from the room
RAT: If the nurse identifies a potential safety hazard with the equipment, the nurse should remove the pump from the client's room to prevent injury to the client. The nurse should then follow facility
A nurse is collecting data from a 5-year-old child at a well-child visit. The parent reports that the child is having frequent nightmares. Which of the following statements by the parent indicates to the nurse that the child is experiencing sleep terrors
ANS: "My child goes back to sleep right away."
RAT: The nurse should realize that going back to sleep quickly is an indication of sleep terrors, rather than nightmares. A child who is experiencing nightmares has difficulty returning to sleep because of co
A nurse is assisting with the admission of an older adult client. Which of the following actions should the nurse take first?
ANS: Complete a fall risk assessment on the client
RAT: The first action the nurse should take when using the nursing process is to collect data from the client. By completing a fall risk assessment, the nurse can identify the client's risk for falls and
A nurse is reinforcing teaching about a high-protein diet with a client who has HIV. Which of the following foods should the nurse recommend as containing the highest amount of protein per serving?
ANS: 2 Tbsp peanut butter
RAT: The nurse should recommend 2 Tbsp of peanut butter because it contains approximately 7 g of proteins
A nurse is caring for a client who has a phobia of elevators. Which of the following should the nurse recognize as an indication of a positive client response to systematic desensitization?
ANS: The client remains relaxed when thinking of the phobia
RAT: The purpose of desensitization therapy is to teach the client to use relaxation techinques to overcome the anxiety caused by the phobia. The nurse should recognize the client's lack of anxie
A nurse is assisting with the admission of a client who has rubeola. Which of the following transmission-based precautions should the nurse plan to initiate for this client?
ANS: Airborne
RAT: The nurse should initiate airborne precautions for a client who has rubeola. This includes a private room with negative-pressure airflow and an air filtration system. Facility personnel are required to wear an N95 respirator while in th
A nurse is reinforcing teaching about strategies to promote eating with a client who has COPD. Which of the following instructions should the nurse include in the teaching?
ANS: Drink high-protein and high-calorie nutritional supplements
RAT: The nurse should instruct the client to drink high-protein and high-calorie nutritional supplements to maintain respiratory muscle function. COPD causes respiratory stress that can lead
A nurse is working in a long-term care facility. Which of the following actions should the nurse take when using computer based client records?
ANS: Shred printouts of client care information when they are no longer needed
RAT: Nurses should destroy documents that contain information regarding client care when they are no longer needed to avoid compromising client confidentiality
A nurse is assisting a client who is postoperative to sit on the side of the bed. Which of the following actions should the nurse take?
ANS: Elevate the head of the client's bed
RAT: The nurse should elevate the head of the client's bed to decrease the distance the client has to move to sit on the side of the bed
A nurse is caring for a client who is 12 hr postoperative following a total hip arthroplasty. Which of the following actions should the nurse take?
ANS: Place an abduction wedge between the client's legs when in bed
RAT: The nurse should place an abduction wedge between the client's legs while in bed to prevent adduction of the legs and hip dislocation following a total hip arthroplasty
A nurse is assisting with teaching a group of local residents at a community health fair about the Dietary Approaches to Stop Hypertension (DASH) diet. Which of the following statements by a resident indicates an understanding of the teaching?
ANS: "I will keep my intake of sodium less than 2,300 milligrams per day."
RAT: DASH principles include limiting daily sodium intake to less than 2,300 mg/day. Individuals who have an increased risk for hypertension such as clients who have kidney disease
A nurse is reviewing the critical pathway of a client who is 4 days postoperative following a total knee arthroplasty. The client's vital signs are oral temperature 102.4, heart rate 116/min, respiratory rate 24/min, and blood pressure 152/92 mm Hg. Which
ANS: Document the findings as a variance
RAT: Whenever a client does not meet the goals or outcomes in the critical pathway due to unexpected findings or a need for additional interventions, the nurse should document the details as a variance in the criti
A nurse in a long-term care facility notices a client who has Alzheimer's disease standing at the exit doors at the end of the hallway. The client appears to be anxious and agitated. Which of the following actions should the nurse take?
ANS: Escort the client to a quiet area on the nursing unit
RAT: A client who has Alzheimer's disease experiences chronic confusion. Guiding the client to a quiet, familiar area will help decrease agitation
A nurse is reviewing laboratory results for a client who is receiving mechanical ventilation. Which of the following findings should the nurse recognize as a potential complication of mechanical ventilation?
ANS: pH 7.5
RAT: The nurse should identify that a pH level of 7.5 indicates alkalosis and is above the expected reference range. Excessive ventilation can cause this finding
A nurse is administering morning medications to a client. The client questions the nurse regarding a medication that they do not recognize. Which of the following actions should the nurse take first?
ANS: Verify the prescription in the client's medical record
RAT: The first action the nurse should take when using the nursing process is to collect more data. By verifying the prescription in the client's medical record, the nurse can ensure that the med
A nurse is caring for a client who has a head injury. Using the Glasgow Coma Scale to collect data, the nurse should obtain which of the following information?
ANS: Motor response
RAT: The nurse should collect data about the client's motor response and assign the response a score of 1 to 6, according to the Glasgow Coma Scale
A nurse is reinforcing teaching about self-administration of enoxaparin. Which of the following instructions should the nurse include?
ANS: Administer by subcutaneous injection
RAT: The nurse should include that enoxaparin should be injected into the subcutaneous tissue
A nurse is monitoring a school-age child who has anemia and is receiving a transfusion of packed RBCs. Which of the following statements by the child indicates a possible hemolytic transfusion reaction that the nurse should report to the charge nurse and
ANS: "I am really cold. May I have another warm blanket?"
RAT: The nurse should recognize that a report from the child of feeling cold or having chills is a possible indication of a hemolytic transfusion reaction. This reaction occurs when the RBCs being
A nurse is reinforcing teaching with a client who has hypertension and is beginning medication therapy with captopril. Which of the following over-the-counter medications should the nurse instruct the client to avoid?
ANS: Ibuprofen
RAT: Ibuprofen, or any other nonsteroidal anti-inflammatory medications, can reduce the antihypertensive effects of this medication. Therefore, the nurse should instruct the client who is taking captopril to avoid taking ibuprofen
A nurse is collecting data from a client who has chronic pancreatitis and is receiving pancrelipase. Which of the following client findings indicates a therapeutic effect of this medication?
ANS: Reports a decrease in the number of stools
RAT: Pancrelipase is administered as replacement therapy for a deficiency in pancreatic enzymes, which result in steatorrhea, or fatty stools. The nurse should monitor for improved nutrition and a decrease i
A nurse is caring for a client who has borderline personality disorder and states, "I am going to kill my partner when I get out of here." Which of the following actions should the nurse take?
ANS: Notify the client's care team about the threats against their partner
RAT: The nurse should notify the client's care team about the threats the client makes toward others. Failure of the nurse to report threats made toward others is considered neglig
A nurse is reinforcing teaching about advance directives with a client. Which of the following statements by the client indicates an understanding of the teaching?
ANS: "I can change my health care decisions even if I have advance directives."
RAT: The nurse should instruct the client that they are free to make changes to advance directives at any time. Treatment decisions might change as a client's health status ch
A nurse is checking the reflexes of a newborn. Which of the following techniques should the nurse use to elicit the Babinski reflex?
ANS: Stroke the sole of the newborn's foot upward and toward the great toe
RAT: The nurse should stroke upward along the lateral aspect of the sole of the foot, beginning at the heel, to elicit the Babinski reflex
A nurse is monitoring a client who is 12 hr postoperative following a cholecystectomy and received morphine 30 min ago for pain. The nurse should identify which of the following findings as an adverse effect of the medication?
ANS: Respiratory rate 10/min
RAT: A respiratory rate of 10/min indicates respiratory depression, which is an adverse effect of morphine
A nurse is caring for a client who is scheduled for peritoneal dialysis. Which of the following actions should the nurse take first?
ANS: Ensure the dialysate solution is at room temperature
RAT: Evidence-based practice indicates the nurse should administer the dialysate solution at a temperature of 98.6; therefore, the first action the nurse should take is to warm the prescribed solut
A nurse is reviewing the laboratory report of a client who is 2 days postoperative following thoracic surgery. Which of the following laboratory results should the nurse report to the provider?
ANS: WBC 25,000/mm
RAT: The nurse should identify a WBC of 25,000/mm is above the expected reference range and is an indication that the client might have a postoperative infection; therefore, the nurse should report this finding to the provider
A nurse in a long-term care facility is reviewing standard precaution guidelines with an assistive personnel (AP). The nurse should instruct the AP to use which of the following to clean up a blood spill?
ANS: Chlorine bleach solution
RAT: The nurse should instruct the AP to use a bleach solution to clean up a blood spill. A 1:10 bleach-to-water solution will destroy all bloodborne pathogens
A nurse is reinforcing teaching with a client who has a new prescription for phenytoin. Which of the following instructions should the nurse include as a measure to assist with the possible adverse effects of this medication?
ANS: Perform daily gum massage
RAT: Gingival hyperplasia is a common adverse effect of this medication. Massaging the gums will help minimize this effect
A nurse is monitoring a client who is receiving IV fluids. For which of the following findings should the nurse stop the infusion?
ANS: Edema above the catheter insertion site
RAT: Edema above the catheter site indicates infiltration. The nurse should stop the IV infusion
A nurse is contributing to the plan of care for a client who has viral meningitis. Which of the following interventions should the nurse include?
ANS: Place the client in a private room
RAT: The nurse should place a client who has viral meningitis in a private room to prevent the transmission of the virus. Direct contact with a contaminated surface or the saliva, mucus, or feces of the person who h
A nurse is reviewing the medical history of a client who is scheduled for a colonoscopy to establish a diagnosis of diverticulitis. Which of the following findings should the nurse identify as increasing the client's risk for developing diverticular disea
ANS: Chronic constipation
RAT: Diverticular disease is a disorder in which pouches or sac-like projections occur in the bowel mucosa through weakened areas of the muscular layer of the intestines. The nurse should identify chronic constipation as a risk f
A nurse is making assignments for the upcoming shifts. Which of the following tasks should the nurse plan to delegate to an assistive peronnel (AP)?
ANS: Perform postmortem care for a client who died 1 hr ago
RAT: Performing postmortem care is within the range of function for an AP. Therefore, the nurse should delegate this task to an AP
A nurse is caring for a client who is in the final stages of cancer. Which of the following client situations should the nurse identify as an ethical dilemma?
ANS: The client asks the nurse to help them die peacefully in their sleep
RAT: This situation presents an ethical issue for the nurse because the client is asking for a variation of active euthanasia, also known as assisted suicide, which is in violation
A nurse in a long-term care facility is collecting data from a client who has been receiving betaxolol to treat glaucoma. Which of the following findings is an adverse effect of this medication?
ANS: Bradycardia
RAT: Betaxolol is a beta blocker that can produce systemic effects, such as bradycardia
A nurse in a long-term care facility is documenting the care of an older adult client. Which of the following information should the nurse include in the weekly nursing care summary?
ANS: Hydration status
RAT: Older adults are at risk for dehydration. Therefore, the nurse should be vigilant about monitoring the client's hydration status and include this information in the weekly nursing care summary
A nurse in an inpatient mental health facility is contributing to the plan of care for a newly admitted client who has anorexia nervosa. Which of the following actions should the nurse include in the plan of care?
ANS: Record the amount of food the client consumes
RAT: The nurse should record the amount of food the client consumes to ensure the client is consuming adequate nutrition
A nurse in an urgent care clinic is completing a client examination. after listening to the clients lungs, which of the following adventitious sounds should the nurse document?
Wheeze
A nurse in a urgent care clinic is caring for a child who has a minor burn on his palm after touching the burner on a hot stove. Which of the following actions should the nurse take?
1. Clean the burn with mild soap and tepid water
2. Remove any embedded debris
3. Apply an antimicrobial ointment
4. Wrap the hand in a gauze dressing
5. Inform the parent of dressing change schedule
A nurse in a providers office is collecting growth and development data from a 7 month old infant during a well child visit. Which of the following images should the nurse identify indicates expected gross motor skills for the infant
sitting and leaning forward using both hands for support is an expected finding for a 7 month old infant
a nurse in a providers office is caring for a client who is at 34 weeks of geststion. which of the following instructions should the nurse anticipate providing to the client?
monitor your blood pressure using your right arm daily
a nurse is collecting data from a school age child who has hypoglycemia. which of the following clinical manifestations should the nurse expect?
sweating
a nurse is assisting with the care of a client who has a terminal cancer. which of the following statements by the clients family should indicate to the nurse that they are coping with their situation?
Dad, i remember the time we all went fishing at the lake.
A nurse in a providers office is caring for four clients. which of the following clients should the nurse see first?
A client who is 36 weeks of gestation and reports a painless vaginal bleeding
A nurse is collecting a urine specimen from a female client who has iabetes insipidus. the nurse should expect which of the following findings?
urine specific gravity of 1.002
A nurse is reinforcing teaching for a client who has Meniere's disease and a new prescription for meclizine. The nurse should inform the client that which of the following is an adverse effect of this medication?
Sedation
A nurse is reinforcing teaching with a client who is scheduled for an exercise ECG stress test. which of the following actions should the nurse take?
Recommend the client wear comfortable shoes during the test
a nurse is collecting data from an older adult client who has a gastric ulcer. which of the findings should the nurse identify as a complication to report to the provider?
hematemesis
A nurse is reinforcing teaching with a client who has asthma and has a prescription for theophylline which of the following statements should the nurse make?term-126
Discontinue drinking caffeinated beverages
A nurse is caring for a client who is refusing a prescribed medication. Which of the following actions should the nurse take first?
Identify the client's concerns about receiving the medication
A nurse is reviewing the electronic health records of four clients. Which of the following client conditions should the nurse recognize as reportable to a regulatory agency?
A client who is newly diagnosed with tuberculosis
A nurse is caring for a client who is actively dying from cancer. Which of the following actions should the nurse take?
Moisten the client's conjunctiva with sterile normal saline
A nurse is caring for a client who is receiving continous feedings via a gastrostomy tube. Which of the following actions should the nurse plan to take?
Flush the tube with 60 mL of water if it becomes clogged
A nurse is preparing to administer an IM immunization to a preschooler. Which of the following statements should the nurse plan to make prior to performing the injection?
Let's give the medicine to your doll first.
A nurse is collecting data from a client who has schizophrenia which of the following statements by the client should the nurse identify as delusional?
My doctors glasses have lasers that will burn holes in my brain if i look at him.
A nurse is collecting data from an older adult client who has a hip fracture. which of the following findings should the nurse expect?
External rotation
A nurse is performing postmortem care for a client. Which of the following actions should the nurse take?
Elevate the head of the client's bed.
A nurse is preparing to perform tracheostomy care for a client. which of the following actions should the nurse take first?
Open sterile packages
A nurse is caring for a client who reports an excruciating headache, nuchal rigidity, nausea and vomiting along with fever and chills. which of the following diagnostic test should the nurse expect the provider to prescribe?
Cerebrospinal fluid analysis
A nurse is reinforcing teaching with a client who is to self administer epoetin alfa. which of the following instructions should the nurse include?
Administer the medication subcutaneously
A nurse enters a clients room and sees smoke coming from a wastebasket next to the bed. which of the following actions should the nurse take first?
Assist the client to a nearby waiting area
a nurse is caring for a client who is 12hr postop following gastrointestinal surgery and has an NG tube for gastric decompression. which of the following actions should the nurse take?
Keep the plugged tube above the level of the stomach when the client is ambulating
A nurse is caring for a client who is expressing sadness about amputation of her leg 72 hr ago due to trauma. the nurse must leave the room but promises to return as soon as possible. which of the following ethical principles is the nurse demonstrating wh
Fidelity
A nurse is reinforcing teaching with an older adult client who has osteoarthritis. which of the following instructions should the nurse include?
Apply capsaicin cream 4 times daily
A nurse in a providers office is reinforcing teaching with a client who is to follow a 2000mg sodium restricted diet. which of the following client food selections indicates an understanding of the teaching?
Canned peaches
A nurse is reinforcing teaching with a female client who has tuberculosis and a new prescription for rifampin. Which of the following statements by the client indicates understanding of the teaching?
I will use condoms in addition to birth control pills to decrease my risk of becoming pregnant.
A nurse is reinforcing teaching about managing manifestations of anxiety with a client who has generalized anxiety disorder. which of the following information should the nurse include?
Say the word "stop" when upsetting thoughts occur.
A nurse is collecting data from a client following a lumbar puncture. For which of the following adverse effects should the nurse monitor?
Headache
A nurse is preparing to insert an indwelling catheter for a female adult client. Which of the following actions should the nurse take? (Select all that apply.)
Cleanse the clients labia and meatus using a front to back motion
Use the nondominant hand to expose the clients urinary meatus
Advance the cathter 5-7 in into the clients urinary meatus
Ask the client to bear down while inserting the catheter
A nurse is preparing to perform venipuncture to obtain a blood sample from a client. Which of the following actions should the nurse take?
Select a site in the antecubital fossa