PN Comprehensive Online Practice 2020/2021 update, Graded A+

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PN Comprehensive Online Practice 2020/2021 update, Graded A+ A nurse is assisting with the care of a client who has a terminal illness. The client practices Orthodox Judaism. Which of the followi... ng 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 need for intervention 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 indicated 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 around the neck. However, petechiae all over the newborn's body can indicate infection or a decreased platelet count and should be reported to the provider 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 greater indicates that the client is at risk for bleeding. Therefore, the nurse should notify the provider about this laboratory value 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 risk of injury from electronic equipment. 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 toothbrush. These actions will minimize trauma to the gums and prevent bleeding of the oral cavity 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 disease, breast cancer, and hypertension 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 of sanguineous drainage from the child's chest tube is excessive and the nurse should report this finding to the provider immediately 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, remote memory remains in place for a longer period of time and can elicit feelings of happiness 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 nurse will need to suction the oral cavity to maintain a patent airway 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 need for a teaching plan regarding the new colostomy and request that this client be reassigned to an RN. The scope of practice of an LPN does allow the nurse to reinforce teaching once the plan has been established 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 hair care items in hot water for 10 min kills lice and nits. Exposing bedding and clothing to prolonged heat by washing in hot dryer for at least 20 min is an appropriate strategy 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 intervals to drain urine from the client's pouch. 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 stressful situation 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 understanding of the procedure, including its risks and benefits 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 treatment to be successful, the nurse should involve the client in the care decision-making process. This ensures the treatment program meets the client's individual needs and demonstrates caring by the nurse 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 [Show More]

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