Test Answers on RN comprehensive online practice 2016 B – Flashcards
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A nurse is reviewing the laboratory results of a toddler who has hemophilia A. Which of the following aPTT values should the nurse expect?
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Seeks input from the other nurses
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A nurse manager is planning to use a democratic leadership style with the nurses on the unit. Which of the following actions by the nurse manager demonstrates a democratic leadership style?
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Inspect the client's mucosa for petechiae every 8 hr.
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A nurse on the oncology unit is administering doxorubicin to a client who has breast cancer. Which of the following actions should the nurse take?
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"My child has only a small amount of mucus after percussion therapy."
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A home health nurse is evaluating a school-age child who has cystic fibrosis. The nurse should initiate a request for a high-frequency chest compression vest in response to which of the following parent statements?
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Instruct the client to elevate the affected extremity when sitting.
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A nurse is caring for a client who has deep-vein thrombosis. Which of the following actions should the nurse take?
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"You should keep both eyes open during the testing."
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A nurse is conducting visual acuity testing using the Snellen letter chart for a school-age child who has eyeglasses. Which of the following instructions should the nurse give to the child?
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Borderline
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A nurse in a mental health clinic is assessing a client who has a history of seeking counseling for relationship problems. The client shows the nurse multiple superficial self-inflicted lacerations on her forearms. The nurse should identify these behaviors as characteristics of which of the following personality disorders?
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Difficulty performing ADLs
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A nurse on a medical-surgical unit is assessing a client who has had a stroke. For which of the following findings should the nurse initiate a referral for occupational therapy?
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Verify the client and blood product information with another licensed nurse.
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A nurse is preparing to administer a blood transfusion to a client. Which of the following procedures should the nurse follow to ensure proper client identification?
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Administer high dose antibiotic therapy.
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A nurse is creating a plan of care for a newly admitted child. Which of the following actions should the nurse include in the plan? (Click on the "Exhibit" button for additional information about the client. There are three tabs that contain separate categories of data.)
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Tremors
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A nurse is caring for a client who has hyperthyroidism. Which of the following findings should the nurse expect?
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Recommend rescreening in 1 year.
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A nurse in a provider's office is caring for an 18-month old toddler who has a blood lead level of 3 mcg/dL. Which of the following actions should the nurse take?
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"Have grab bars installed around your bathtub and toilet."
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A community health nurse is providing teaching about home safety with a group of older adult clients. Which of the following statements should the nurse make?
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Ensure that the client understands the medication regimen.
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A nurse is providing discharge teaching about disease management for a client who has a new diagnosis of type 1 diabetes mellitus. Which of the following activities is the nurse's priority?
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125
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A nurse is preparing to administer dextrose 5% in water (D5W) 1,000 mL IV to infuse over 8 hr to a client. The nurse should set the IV pump to deliver how many mL/hr? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)
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Serum sodium 136 mEq/L
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A nurse is caring for a child who has hypotonic dehydration and is receiving an oral rehydration solution. Which of the following laboratory results indicates that the treatment regimen is effective?
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Hyponatremia
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A nurse is caring for a client who is in the resuscitation phase of burn injury. Which of the following findings should the nurse expect?
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"Notify your provider if you experience increased thirst."
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A nurse is providing teaching about lithium to a client who has bipolar disorder. Which of the following statements should the nurse include in the teaching?
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The client is pacing around the chair in which his partner is sitting.
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A nurse on an inpatient mental health unit is monitoring a visit between a client who has a history of aggressive behavior and the client's partner. Which of the following observations should the nurse identify as an indication for potential violence?
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Fiber
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A nurse is preparing to teach about dietary management to a client who has Crohn's disease and an enteroenteric fistula. Which of the following nutrients should the nurse instruct the client to decrease in his diet?
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Applies lubricating lotion to her feet
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A nurse is providing teaching to a client who has peripheral arterial disease. Which of the following client actions indicates an understanding of the teaching?
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Decreased hallucinations
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A nurse is caring for a client who has a prescription for chlorpromazine. Which of the following findings should the nurse identify as an indication that the medication is effective?
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Turn off the CPM machine during mealtime.
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A nurse is caring for a client who has a prescription for a continuous passive motion (CPM) machine following a total knee arthroplasty. Which of the following actions should the nurse take?
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Ideas of self-harm
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A nurse on a mental health unit is conducting a mental status examination (MSE) on a newly admitted client. Which of the following components of the MSE is the priority for the nurse to assess?
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Instruct the client to avoid deep breathing during the procedure.
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A nurse is preparing to assist with a thoracentesis for a client who has pleurisy. The nurse should plan to perform which of the following actions?
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Arrange the lunch tray for a client who has a hip fracture.
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A nurse is caring for four clients. Which of the following tasks should the nurse delegate to an assistive personnel (AP)?
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The child exhibits discomfort while sitting.
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A nurse in the emergency department is assessing a preschooler who has a facial laceration. The nurse should identify which of the following findings as a potential indication of sexual abuse?
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Maintain sterile objects within the line of vision.
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A nurse is preparing a sterile field to perform a sterile dressing change. Which of the following interventions should the nurse use to maintain surgical aseptic technique?
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A 10-year-old child who is awaiting surgery for an appendectomy and experienced sudden relief from pain
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A nurse on a pediatric unit has received change-of-shift report for four children. Which of the following children should the nurse assess first?
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Withhold the heparin infusion.
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A nurse is caring for a client who has a pulmonary embolism. The client is receiving heparin via a continuous IV infusion at 1,200 units/hr and warfarin 5 mg PO daily. The morning laboratory values for the client are aPTT 98 seconds and INR 1.8. Which of the following actions should the nurse take?
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Autonomy
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A nurse manager is reviewing clients' rights with the nurses on the unit. The nurse manager should tell the nurses that informed consent promotes which of the following ethical principles?
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Serum liver enzyme levels
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A nurse is caring for a school-age child who is taking valproic acid. The nurse should expect the provider to order which of the following diagnostic tests?
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A client who is receiving an MAOI and is requesting a cheeseburger for dinner
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A nurse has received change-of-shift report on four assigned clients. For which of the following clients should the nurse intervene to prevent a potential food and medication interaction?
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Noting the progress of the group toward assigned goals
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A nurse is assigning task roles for a group of clients in a community mental health clinic. Which of the following tasks should the nurse assign to the member of the group functioning as the orienter?
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Place the skin barrier over the stoma and hold it for 30 seconds.
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A nurse is providing care for a client who has a colostomy. Which of the following actions should the nurse take?
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Infuse IV fluids.
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A nurse is caring for a child who has sickle cell anemia and is having a vaso-occlusive crisis. Which of the following interventions should the nurse implement first?
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aPTT
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A nurse is caring for a client who is receiving a continuous heparin infusion. Which of the following laboratory tests should the nurse review prior to adjusting the client's heparin?
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Aspirate contents from the tube and verify the pH level.
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A nurse is assessing for correct placement of a client's NG feeding tube prior to administering a bolus feeding. Which of the following actions should the nurse take?
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Increasing oxygen via nasal cannula to 6 L/min
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A nurse is caring for a client who has COPD and becomes extremely short of breath. Which of the following interventions by the nurse requires completion of an incident report?
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Droplet
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A nurse is admitting a client who has pneumonia. The nurse should initiate which of the following isolation precautions for the client?
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Wear clothing made with cotton fabrics while oxygen is in use.
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A nurse is providing discharge teaching to a client who is to receive home oxygen therapy. Which of the following instructions should the nurse include in the teaching?
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Delegate non-nursing tasks to ancillary staff.
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A nurse manager is preparing an educational session for nursing staff about how to provide cost-effective care. Which of the following methods should the nurse include in the teaching?
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Pink, frothy sputum
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A nurse is assessing a client who has pulmonary edema. Which of the following findings should the nurse expect?
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Support the client's left arm on a pillow while sitting.
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A nurse is creating a plan of care for a client who has left-sided weakness following a stroke. Which of the following interventions should the nurse include in the plan?
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Oxytocin
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A nurse is assessing a client following a vaginal delivery and notes heavy lochia and a boggy fundus. Which of the following medications should the nurse expect to administer?
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A client who is at 33 weeks of gestation and has severe gestational hypertension
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An antepartum nurse is caring for four clients. For which of the following clients should the nurse initiate seizure precautions?
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"I can designate my partner as my health care surrogate."
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A nurse is providing teaching about advance directives to a middle adult client. Which of the following client responses indicates an understanding of the teaching?
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Administer granulocyte colony-stimulating factor to the child.
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A nurse is creating a plan of care for a child who has acute lymphoid leukemia and an absolute neutrophil count of 400/mm3. Which of the following interventions should the nurse include in the plan?
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inspect auscultation percussion palpation
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A nurse is performing an abdominal assessment on a client. Identify the sequence of actions the nurse should take. (Move the steps into the box on the right, placing them in the selected order of performance. Use all the steps.)
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Shake the medication bottle well before each dose is given Store the medication in the refrigerator Report diarrhea to the provider immediately
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A nurse is providing discharge teaching for the parents of a preschool-age child who has a new prescription for amoxicillin/clavulanate suspension. Which of the following instructions should the nurse include in the teaching? (Select all that apply.)
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The client reports a decrease in episodes of nausea.
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A nurse is assessing a client who is at 11 weeks of gestation and reports drinking ginger tea. Which of the following findings indicate the client's use of ginger tea is effective?
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Jaundice
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A nurse is caring for a client who is taking valproic acid for seizure control. For which of the following adverse effects should the nurse monitor and report?
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broccoli yogurt cream cheese
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A nurse is providing dietary teaching to a client who has a new prescription for phenelzine. Which of the following food recommendations should the nurse make? (Select all that apply.)
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A middle adult client who has unstable vital signs
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A nurse working in an emergency department is triaging four clients. Which of the following clients should the nurse recommend for treatment first?
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Agency for Healthcare Research and Quality
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A rural community health nurse is developing a plan to improve health care delivery for migrant farmworkers. To identify health services data for this minority group, the nurse should gather information from which of the following sources?
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A client who channels her energy into a new hobby following the loss of her job
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A nurse in an outpatient mental health clinic is caring for four clients. The nurse should recognize that which of the following clients is effectively using sublimation as a defense mechanism?
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holding baby's hands
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A nurse in a pediatric clinic is assessing the reflexes of an infant who is 1 week old. Which of the following images demonstrates the correct procedure to elicit the palmer grasp reflex?
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"I told my doctor that I would like to start a support group for other women who are sick in my community."
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A nurse is talking with a client who has stage IV breast cancer. The nurse should recognize which of the following statements by the client as a constructive use of a defense mechanism?
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"You can provide a list of family members who can receive information about your diagnosis."
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A nurse is providing teaching for a client about his right to confidentiality. Which of the following statements should the nurse make?
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Check the client's oxygen saturation level.
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A nurse is caring for a client who is postoperative after receiving moderate (conscious) sedation. The client suddenly becomes restless and reports feeling lightheaded. Which of the following actions should the nurse take?
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Use a three-point gait.
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A nurse is providing teaching for a client who has a fracture of the right fibula with a short-leg cast in place. The client is non-weight bearing for 6 weeks. Which of the following instructions should the nurse include in the teaching?
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Irrigate the catheter with 0.9% sodium chloride irrigation.
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A nurse is caring for a client who is receiving continuous bladder irrigation following a transurethral resection of the prostate. The client reports bladder spasms and the nurse observes a decreased urinary output. Which of the following actions should the nurse take?
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Albumin 2.8 g/dL
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A nurse is caring for an older adult client who is experiencing chronic anorexia and is receiving enteral tube feedings. Which of the following laboratory values indicates that the client needs additional nutrients added to the feeding?
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Determine the client's reading skills.
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A nurse is updating the plan of care for a client who is 48 hr postoperative following a laryngectomy and is unable to speak. Which of the following actions should the nurse plan to take first?
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Use a protective cover on the scale when weighing the infant.
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A nurse is caring for a newborn immediately after delivery. Which of the following interventions should the nurse implement to prevent heat loss by conduction?
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An older adult client who is anxious and attempting to pull out his IV line
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A nurse is caring for a group of clients. Which of the following clients should the nurse attend to first?
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The newborn has six to eight wet diapers per day.
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A home health nurse is assessing a 2-week-old newborn who had a birth weight of 3.64 kg (8 lb) and is being breastfed. Which of the following findings indicates effective breastfeeding?
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Floating dark spots
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A nurse at an urgent care clinic is assessing a client who reports impaired vision in one eye. Which of the following reports by the client should indicate to the nurse that the client has a detached retina?
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Instruct the client to void.
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A nurse is preparing a client for a paracentesis. Which of the following actions should the nurse take?
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Nasal flaring
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A nurse is assessing a newborn following a vaginal delivery. Which of the following findings should the nurse report to the provider?
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"You're afraid that your other kidney will fail at some point after the organ donation."
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A nurse is caring for a client who recently signed an informed consent form to donate a kidney to her sibling who has end-stage kidney disease. The donor states to the nurse, "I don't want my brother to die, but what if I need this kidney one day?" Which of the following responses should the nurse make?
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Respiratory acidosis
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A nurse is reviewing the ABG values of a client. The client has a pH of 7.20, PaCO2 of 60 mm Hg, and HCO3- of 25 mEq/L. The nurse should identify that the client has which of the following acid-base imbalances?
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Avoid caffeine.
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A nurse is providing teaching to a client who at 26 weeks of gestation and is to have an oral glucose tolerance test. Which of the following actions should the nurse instruct the client to take before the test?
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Irritability when being held
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A nurse is assessing an infant who has hydrocephalus and is 6 hr postoperative following placement of a ventriculoperitoneal (VP) shunt. Which of the following findings should the nurse report to the provider?
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Measure the client's daily weight.
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A nurse is caring for a client who has fluid volume overload. Which of the following tasks should the nurse delegate to an assistive personnel (AP)?
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Irritability
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A nurse is providing teaching to a client who has a new diagnosis of type 1 diabetes mellitus. The nurse should instruct the client to monitor for which of the following findings as a manifestation of hypoglycemia?
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"A client who requires airborne precautions should be placed in a negative-pressure airflow room."
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A charge nurse is providing an educational session about infection control for a group of staff nurses. Which of the following statements by one of the staff nurses indicates an understanding of isolation precautions?
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"I will be checking you once with your eyes open and once with them closed."
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A nurse is providing information to a client immediately before his scheduled Romberg test. Which of the following statements should the nurse make?
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Have the client wear a surgical mask while being transported outside the room.
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A nurse is caring for a client who has active tuberculosis (TB). Which of the following actions should the nurse plan to take to prevent the transmission of the disease?
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Inject air into both vials prior to withdrawing the medications.
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A nurse is preparing to mix haloperidol lactate 5 mg/mL and diphenhydramine 25 mg/1.5 mL to administer IM for a client who is agitated. Which of the following actions should the nurse plan to take?
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Starts a task by determining what supplies are needed
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A nurse preceptor is evaluating the performance of a newly licensed nurse. Which of the following actions by the newly licensed nurse requires intervention by the preceptor?
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Form a committee of staff members to investigate current staffing issues.
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A nurse manager in a long-term care facility is having difficulty with staffing for weekend shifts and is planning to implement some changes to the scheduling procedure. Which of the following actions should the nurse manager take first?
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Take the medication 15 min before playing sports.
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A nurse is providing teaching to a school-age child who has asthma about using an albuterol metered-dose inhaler. Which of the following instructions should the nurse include?
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Initiate continuous cardiac monitoring.
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A nurse is caring for a client who has a magnesium level of 2.5 mEq/L. Which of the following interventions should the nurse plan to take?
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contacvt
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A nurse is caring for a newborn who has herpes simplex virus (HSV). Which of the following isolation precautions should the nurse initiate?
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Use the ventrogluteal site.
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A nurse is preparing to administer an IM injection to a client who is obese. Which of the following actions should the nurse plan to take?
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Time the medication was given
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A nurse administers an incorrect dose of medication to a client. The nurse recognizes the error immediately and completes an incident report. Which of the following facts related to the incident should the nurse document in the client's medical record?
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February 15
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A nurse is performing an admission assessment on a client who had a recent positive pregnancy test. The first day of her last menstrual period (LMP) was May 8. According to Nägele's rule, which of the following dates should the nurse document as the client's estimated date of birth (EDB)?
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I will cover my baby's body when I wash her hair I will use the bulb syringe first in her mouth and then in her nose
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A nurse is providing discharge instructions about newborn care to a client who is 2 days postpartum. Which of the following statements indicates to the nurse that the client understands the teaching? (Select all that apply.)
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Proceed with provision of medical care.
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A nurse in an emergency department is caring for a client who is unconscious and requires emergency medical procedures. The nurse is unable to locate members of the client's family to obtain consent. Which of the following actions should the nurse take?
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Ask the client to lie on the left side.
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A nurse is caring for a client who has gastrointestinal bleeding and an NG tube in place. While performing gastric lavage, which of the following actions should the nurse take?
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Acute confusion
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A nurse is assessing an older adult client who has pneumonia. Which of the following findings should the nurse expect?
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Auscultate the affected extremity for a bruit.
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A nurse is caring for a client who is receiving hemodialysis with an arteriovenous (AV) fistula in the right arm. Which of the following interventions should the nurse include in the client's plan of care?
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Ask another nurse to witness the disposal of the new patch.
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A nurse is preparing to replace a client's transdermal fentanyl patch after 72 hr of use. After the nurse opens the packet containing the new pouch, the client declines to accept it. Which of the following actions should the nurse take?
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Edema
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A nurse is assessing a client for compartment syndrome. Which of the following findings should the nurse expect?
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Pinches the skin prior to injecting the insulin
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A nurse is teaching self-administration of insulin to a client who has a new prescription for a short-acting and intermediate-acting insulin. Which of the following actions by the client indicates an understanding of the teaching?
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"You seem to be having a difficult time right now."
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A nurse is assessing a client whose partner recently died. The client states, "I don't know what to do without my partner. Life is just not worth living." Which of the following responses should the nurse make?
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"We can expect the hospice nurse to provide support for us after our mother's death."
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A hospice nurse is consulting with a client and her family about receiving home services. Which of the following statements should the nurse identify as an indication that the family understands home hospice care?
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"I would like to talk to you about the unit policies regarding break time."
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A charge nurse notices that one of the nurses on her shift frequently violates unit policies by taking an extended amount of time for break. Which of the following statements should the charge nurse make to address this conflict?
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Sodium 148 mEq/L
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A nurse is reviewing the laboratory report of a client who has end-stage kidney disease and received hemodialysis 24 hr ago. Which of the following laboratory values should the nurse report to the provider?
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Survey the scene for potential hazards to staff and children.
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A school nurse is notified of an emergency in which several children were injured following the collapse of playground equipment. Upon arrival at the playground, which of the following actions should the nurse take first?
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c-by ear
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A nurse is assessing a client who has hypocalcemia. Which of the following sites should the nurse tap to elicit a positive Chvostek's sign? (You will find hot spots to select in the artwork below. Select only the hot spot that corresponds to your answer.)
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Advocacy is a leadership role that helps others to self-actualize.
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A nurse manager is preparing an educational session about advocacy to a group of nurses. The nurse manager should include which of the following information in the teaching?
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pH 7.31
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A nurse is assessing a client who has COPD. Which of the following findings should the nurse expect?
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Blowing the nose
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A nurse is developing a discharge plan for a school-age child who has thrombocytopenia. The nurse should instruct the child to avoid which of the following?
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Report of chest pain
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A nurse is assessing a client after administering epinephrine for an anaphylactic reaction. Which of the following findings should the nurse identify as an adverse effect of this medication?
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Short-term memory loss
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A nurse is providing teaching to a client who is to undergo electroconvulsive therapy (ECT). The nurse should inform the client that which of the following findings is an adverse effect of ECT?
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"Tell me more about your understanding of the options."
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A nurse is caring for a client who has cancer and is deciding between two treatment plans. The client asks the nurse for assistance in making a decision. Which of the following responses should the nurse make?
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"Have you had any stomach pain or bloody stools?"
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A nurse in a provider's office is assessing an adolescent who has been taking ibuprofen for 6 months to treat juvenile idiopathic arthritis. Which of the following questions should the nurse ask to assess for an adverse effect of this medication?
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Timolol
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A nurse is caring for a client who asks about taking ginseng to improve her appetite. The nurse should identify that ginseng can decrease the effectiveness of which of the following client medications?
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Insert a lubricated gloved finger and advance along the rectal wall.
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A nurse is caring for a client who has a fecal impaction. Which of the following actions should the nurse take when digitally evacuating the stool?
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Dry mouth
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A nurse is caring for a client who has a new prescription for clonidine. The nurse should inform the client that which of the following findings is an adverse effect of this medication?
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Auscultate the apical pulse and count beats for at least 1 min.
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A nurse is assessing a newborn's heart rate. Which of the following actions should the nurse take?
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Dyspnea
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A client is receiving IV fluids at 150 mL/hr. Which of the following findings indicates that the client is experiencing fluid overload?
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Blurred vision
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A nurse is assessing a client who has depressive disorder and is taking amitriptyline. Which of the following findings should the nurse identify as an adverse effect of the medication?
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Coughing at night
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A nurse is assessing a client who is taking propranolol. Which of the following findings should indicate to the nurse that this client is experiencing an adverse reaction to propranolol?
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"You will need to fast the night before the test."
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A nurse is providing teaching to a client who is at 24 weeks of gestation and is scheduled for a 3-hr oral glucose tolerance test. Which of the following instructions should the nurse include in the teaching?
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The client tells visitors how much the newborn looks like her sister.
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A nurse is caring for a client who is 2 days postpartum. Which of the following behaviors should indicate to the nurse that the client is bonding with her newborn?
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Explore the client's reasons for refusing the treatment.
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A nurse is caring for a client who has acute blood loss following a trauma. The client refuses a blood transfusion that might potentially save his life. Which of the following actions should the nurse take first?
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Implement fall precautions for the client.
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A nurse on an inpatient unit is caring for a client who has schizophrenia and recently started taking risperidone. Which of the following actions should the nurse take?
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Increased opacity of the lens
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A nurse is assessing a client who has decreased visual acuity due to cataracts. The nurse should identify that which of the following physiological changes is the cause for the client's visual loss?
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Contact child protective services.
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A nurse in an emergency department is assessing a school-age child who was brought in by her parents and has scald burns to both hands and wrists. The nurse suspects physical abuse. Which of the following actions should the nurse take?
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"I will make sure my child receives a yearly influenza vaccination."
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A nurse is providing education to the parent of a school-age child who has asthma. Which of the following statements by the parent indicates an understanding of the teaching?
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A client who was abused as a child describes the abuse as if it happened to someone else.
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A nurse at a mental health clinic is caring for four clients. The nurse should recognize that which of the following clients is using dissociation as a defense mechanism?
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Cervical laceration
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A nurse is caring for a multiparous client following a vacuum-assisted birth. The nurse should assess the client for which of the following possible complications related to the birth method?
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Flight of ideas
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A nurse is assessing a client who has bipolar disorder. Which of the following alterations in speech is the client using? (Click on the audio button to listen to the clip.)
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Remove the client from the room.
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A nurse enters a client's room and sees smoke coming from a small fire in the trash can. Which of the following actions should the nurse take first?
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The time of the client's last dose of pain medication
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A nurse is preparing to transfer a client from the ICU to the medical floor. The client was recently weaned from mechanical ventilation following a pneumonectomy. Which of the following information should the nurse include in the change-of-shift report?
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Facilitate an interdisciplinary conference at the new facility for the family.
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A nurse is preparing to transfer a client who has had a stroke to a rehabilitation facility. The client's family tells the nurse they are concerned about the level of care the client will receive. Which of the following actions should the nurse take?
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A nurse administered a medication via the wrong route.
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A nurse educator is teaching a group of newly licensed nurses about the need to complete an incident report. Which of the following examples should the nurse include as a reportable incident and an indication for completing a report?
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Use pictures to illustrate the procedure to the client.
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A nurse is providing teaching to a client who speaks a different language than the nurse about an upcoming diagnostic procedure. Which of the following actions should the nurse take?
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Making a list of activities to complete
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A nurse manager is preparing to teach a group of newly licensed nurses about effective time management. Which of the following steps of the time management process should the nurse manager include as the priority?
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Sedentary lifestyle
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A nurse is developing a client education program about osteoporosis for older adult clients. The nurse should include which of the following variables as a risk factor for osteoporosis?
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"I will wear a supportive bra overnight."
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A nurse is teaching a client who is at 20 weeks of gestation about common prenatal discomfort. Which of the following statements by the client indicates an understanding of the teaching?
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Hemoglobin 14.9 g/dL
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A nurse is assessing a client who received 2 units of packed RBCs 48 hr ago. Which of the following findings should indicate to the nurse that the therapy is effective?
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Protein
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A nurse is reviewing the urinalysis report of a client who has acute glomerulonephritis. Which of the following findings should the nurse expect in the client's urine?
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"Your body temperature might decrease slightly just prior to ovulation."
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A nurse is providing client teaching about the basal body temperature method of birth control. Which of the following information should the nurse include in the teaching?
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Initiate transmission-based precautions.
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A nurse in an emergency department is caring for a child who has a fever and fluid-filled vesicles on the trunk and extremities. Which of the following interventions should the nurse identify as the priority?
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18
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A nurse is preparing to administer mannitol 0.2 g/kg IV bolus over 5 min as a test dose to a client who has severe oliguria. The client weighs 198 lb. What is the amount in grams the nurse should administer? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)
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Tension pneumothorax
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A nurse is caring for a client who is receiving positive end expiratory pressure (PEEP) via mechanical ventilation. The nurse should monitor the client for which of the following adverse effects of PEEP?
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Use a reward system to modify the child's behavior.
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A nurse is providing teaching to the parents of a child who has autism spectrum disorder. Which of the following instructions should the nurse include?
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The LPN and the AP grasp the client under his arms to lift him up in bed.
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An RN is observing a licensed practical nurse (LPN) and an assistive personnel (AP) move a client up in bed. For which of the following situations should the nurse intervene?
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A client who is postoperative with abdominal distention and no bowel sounds
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A nurse has just received change-of-shift report on four clients. Which of the following clients should the nurse assess first?
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Amount of vaginal bleeding
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A nurse is caring for a client who is in the fourth stage of labor who is receiving oxytocin via continuous IV infusion. Which of the following assessments is the nurse's priority?
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Make a referral for social services.
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A nurse on a medical-surgical unit is caring for a client who has a new diagnosis of terminal cancer. The client tells the nurse that he would like to go home to be with family and loved ones. Which of the following actions should the nurse take?
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Move the client to a room near the nurses' station.
answer
During a change-of-shift report, a night shift nurse informs the day shift nurse that a newly admitted client was disoriented and combative during the night. Which of the following actions should the day shift nurse take?
question
"You have the right to refuse to have the ECT, even after you have agreed to it."
answer
A nurse is caring for a client who has major depressive disorder and has signed an informed consent to receive electroconvulsive therapy (ECT).The client states to the nurse, "I'm not sure about this now. I'm afraid it's too risky." Which of the following responses should the nurse make?
question
Perform gastrostomy feedings through a client's established gastrostomy tube.
answer
A nurse is planning to delegate client care tasks to an assistive personnel (AP). Which of the following tasks should the nurse plan to delegate to the AP?
question
A client who has cellulitis and is receiving oral antibiotics every 8 hr
answer
A nurse must recommend clients for discharge in order to make room for several critically injured clients from a local disaster. Which of the following clients should the nurse recommend for discharge?
question
Urine specific gravity 1.052
answer
A nurse in an emergency department is caring for a client who reports nausea and vomiting for the past 2 days. Which of the following findings should the nurse expect?
