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A nurse is planning care for a 2 newborn who has hyperbilirubinemia and is to receive phototherapy. Which of the following interventions should the nurse include? 3 an assistive personnel tells the... nurse that several client measurements were obtained with morning vital signs. Which of the following clients should the nurse plan to assess? Head injury HR 60 5 A community health nurse recognizes that the teen pregnancy rate in the community has increased. Which of the following program-planning strategies should the nurse implement first? 6 After making morning rounds, the charge nurse on a surgical unit delegates the following task to the assistive personnel, which of the following task does the nurse direct the AP to complete first? 7 A nurse is caring for a client who is receiving a localized epidural analgesia infusion. Which of the following nursing actions is appropriate? 8 A nurse is performing disaster triage following a natural disaster. Which of the following should the nurse identify as the highest priority to receive care? 9 A nurse is planning to provide community education about viral hepatitis. Which of the following should the nurse plan to include in the teaching? 10 A nurse in the emergency department caring for a client who has abdominal pain. Which of the following actions by nurse demarcates veracity? 11 A nurse is about to administer an injection to a client who states, “I don’t want that injection. The last time I got that I was sore for a week.” The nurse goes ahead and administers the injection against the client’s wishes. The nurse committed which of the following? Battery 12 A home health nurse is assessing a client who is receiving from an acute myocardial infarction (MI). Which of the following assessment findings should the nurse report to the provider as a possible indication of left-sided heart failure? Bilateral lung crackles 13//// 14 A nurse is caring for a group of clients. The nurse should request a referral for a speech language pathologist for which of the following clients? 15 A nurse is preparing to provide education about electroconvulsive therapy (ECT) for a client who has major depressive disorder. Which of the following should the nurse include in the teaching? 16 A nurse is caring for a mother who prescribed methadone during pregnancy. The nurse should assess the newborn for which of the following manifestations of neonatal abstinence syndrome 17 A nurse is caring for a client following an open colectomy. Which of the following findings places the client at risk for delayed wound healing? 18 A nurse who typically works on the postpartum unit is assigned to float to the maternal newborn unit. The nurse is very anxious about floating and uncomfortable with the assignment the charge nurse has selected. Which of the following actions is appropriate for nurse to take? 19 A client hospitalized for a bone marrow transplant is in protective isolation while undergoing total body radiation and intense chemotherapy. The client’s sibling comes visit but has obvious manifestations of an upper respiratory infection. Which of the following nursing actions is appropriate at this time? 20 A nurse is caring for a client following insertion of a subclavian nontunneled percutaneous central venous catheter (CVC). The provider writes a prescription to initiate an IV infusion ringer’s lactate at 150 mL per hr. prior to starting the infusion, which of the following actions should the nurse take? 21 A nurse is providing teaching to an adolescent client who has cystic fibrosis and has a prescription for pancrealipase. Which of the following should the nurse include in the teaching? 22 A nurse is assessing laboratory values on a client who has taken an overdose of acetaminophen. The nurse should expect which of the following laboratory values indicative of organ damage from the overdose? 23 A nurse on an orthopedic floor is completing morning assessments on several clients. Which of the following clients has the greatest risk for fat embolism syndrome (FES)? 24 A nurse is caring for a client who has end stage liver disease. The daughter of the client asks about her father’s do-not-resuscitate request. Which of the following is a therapeutic response by the nurse? 25 A nurse is providing teaching to the parent of preschooler who was newly diagnosed with a latex allergy. The nurse should discuss that a cross reaction may occur with which of the following foods? 26 A nurse is planning to admit a client who has hyperthyroidism. Which of the following rooms is appropriate for the nurse to assignment client to? 27 A nurse has just returned to the nursing unit following cardiac catheterization. In the immediate postprocedure period, which of the following is the priority nursing action? 28 A nurse is caring for an infant who is being treated for dehydration. Which of the following findings indicate the treatment is effective? 29 A nurse is reviewing medical for four clients. Which of the following represents appropriate documentation? 30 A nurse in the clinic is providing information to a client who has mastitis of the left breast. The client asks the nurse, “does this mean that I must stop nursing my baby?” which of the following is an appropriate statement by the nurse? 31 A nurse in a mental health clinic is observing clients in the day room. The nurse sits down to talk with an adolescent client who was admitted with clinical depression. After a few minutes of conversation, the adolescent asks the nurse, “why did you choose to talk to me out of this room full of kids?” which of the following responses by the nurse is therapeutic? 32 A nurse working in an inpatient mental health facility observes a client who is agitated and threatening staff members in the day room. Which of the following actions should the nurse take first? 33 A client who is precepting a nursing student is brings the following client observation to the nurse’s attention. Which of the following client should the nurse assess first? 34 A nurse is planning teaching for a client who is at 10 weeks gestation and has a history of urinary tract infections (UTIs). Which of the following information should the nurse plan to include in the teaching about UTI prevention? 35 A nurse in the emergency department is providing discharge teaching to a client who has a sprained ankle. For the first 24 hr following injury, the nurse should instruct the client to do which of the following? 36 After evaluating the morning laboratory results on several clients, the provider writes prescriptions for four clients assigned to the nurse’s care. Which of the following prescriptions is the nurse’s highest priority? 37 a nurse is caring for a client who has ruptured ribs, has developed thrombophlebitis, and is being treated with a heparin drip. The client develops hematuria and has an activated partial thromboplastin time (aPTT) of 100 seconds. Which of the following should the nurse take first? 38 A nurse is caring for a client who has a hearing impairment. When speaking to the client, the nurse should incorporate which of the following communication methods? 39 A nurse is reviewing morning values of several clients. Which of the following findings is the highest priority for the nurse to report to the provider? 40 A nurse is caring for a client who has a new prescription for chlorpromazine by IM injection. Which of the following is an appropriate action? 41 A nurse is caring for a postoperative client. Which of the following interventions will reduce the risk of deep-vein thrombosis? 42 A nurse is caring for a client who is manic. Which of the following activities is appropriate for the nurse to suggest? 43 A nurse is planning to perform wound irrigation for a client who has an open secondary wound. When creating a sterile field, which of the following actions should the nurse take? 44 A nurse is reviewing the history and physical on a client who has right ventricular heart failure. Which of the following is an associated finding? 45 A nurse is assessing a client who has schizophrenia. Which of the following findings indicates a risk for self-harm? 46 A nurse is providing postoperative teaching to a client who has a newly inserted pacemaker. Which of the following statements by the client indicates that the teaching has been effective? 47 A nurse is discussing care with a newly licensed nurse for a client who practices Orthodox Judaism. Which of the following meal suggestions by the newly licensed nurse indicates a need for further teaching? 48 A nurse is preparing to auscultate a client’s apical pulse at the point of maximal impulse (PMI). The nurse should place the diaphragm of the stethoscope at which of the following locations? 49 A charge nurse in the emergency department is reviewing the data of four young children who are receiving treatment. Which of the following should alert the charge nurse to the possibly of child abuse? 50 A nurse is planning care for a client who is prescribed a cane for ambulation. Which of the following nursing actions should the nurse include in the plan of care? 51 A nurse is providing discharge teaching to a client who is postpartum and plans to breastfeed. Which of the following should the nurse recommend the client increase in her diet during lactation? 52 A nurse in the postanesthesia care unit is caring for four postoperative clients. The nurse realizes that coughing poses a risk to which of the following clients. 53 A home health nurse is admitting a client who is prescribed peritoneal dialysis. Which of the following actions should the nurse initiate first? 54 A visiting nurse is writing a plan of care for a client who is homebound and has stage 2 Alzheimer’s disease. Which of the following should the nurse include in the plan of care? 55 A nurse suspects another nurse is chemically impaired during the shift. Which of the following is an appropriate action for the nurse to take? 56 A nurse is preparing to administer potassium chloride intravenously to a client who has hypokalemia. The client is receiving a current infusion of 0.9% sodium chloride at 125 mL/hr. Which of the following actions should the nurse plan to take? 57 A nurse is caring for a client who had a partial laryngectomy and is receiving continuous enteral feedings at 65 mL/hr through a gastrostomy tube. Which of the following findings requires immediate intervention by the nurse? 58 A nurse is admitting an unidentified female infant who was brought to the emergency department. Based on the assessment findings, the nurse should estimate the infant’s age to be which of the following? 59 A nurse is preparing to administer eye drops to a client. Which of the following nursing actions is appropriate? 60 A nurse is caring for a client who reports the use of chondroitin and glucosamine. The health benefit of this supplement combination is to do which of the following? 61 A nurse is performing a nutritional assessment on a client who has a calcium deficiency. The nurse should identify that the client is at risk for which of the following? 62 A nurse is assessing a client who has systemic lupus erythematous (SLE). Which of the following is an expected finding? 63 A nurse is assessing a client who is 8 hr postoperative following a right-modified radical mastectomy. Which of the following should the nurse recognized as the priority finding? 64 A nurse in a provider’s office is caring or a client who has Parkinson’s disease and has been taking levodopa for the past 5 weeks. The client reports a new onset of muscle twitching. Which of the following statements by the nurse is appropriate? 65 A nurse in the labor and delivery unit is receiving medications for a group of clients. Which of the following medications places the fetus at risk for teratogenic effects? 66 A nurse is providing discharge teaching about disease prevention to a client who has active tuberculosis. Which of the following should the nurse include? 67 A nurse is planning care for a client who has neutropenia. Which of the following nursing interventions is appropriate to include in the care plan? 68 A nurse is planning to change the dressing on a school age child who has sustained multiple burns. Which of the following actions should the nurse plan to take? 69 An older adult client tells the nurse,” I thought immunizations were for kids.” The nurse informs the client that older adults should receive which of the following immunizations? 70 a nurse is caring for a client who was involuntarily admitted to the psychiatric unit following a failed suicide attempt. The provider prescribes a medication that is part of an experimental treatment. Which of the following actions should the nurse take? 71 A nurse analyzing the laboratory data on a client who has dehydration. Which finding should the nurse anticipate in a client who has fluid volume deficit? 72 a community health nurse is evaluating eligibility for home assistance for a client who is quadriplegic. Which of the following actions should the nurse perform first? 73 a nurse is caring for a client who has heart failure and has started taking a loop diuretic. Which of the following findings indicates the client is experiencing an adverse effect of the medication? 74 A nurse is assessing a client who is preparing for surgery. The client tells the nurse, “If something happens to me from which I cannot recover don’t want to go on a ventilator.” Which of the following is an appropriate response by the nurse? 75 A nurse is interviewing a client who presents with multiple injuries that are consistent with intimate partner abuse. After establishing trust and rapport, which of the following should the nurse say? 76 A nurse is caring for a client who reports pain. Which of the following laboratory findings indicates myocardial damage? 77 a nurse is caring for a client who is prescribed furosemide. The nurse understands this medication is used to treat which of the following client conditions? 78 A nurse manager at a public health clinic is concerned about the rising number of sexually transmitted infections in the community of which of the following is to generate new ideas to address the public health concern? 79 a nurse on a medical-surgical unit is caring for a group of clients. Which of the following clients would benefit from a three-way indwelling catheter? 80 A nurse manager is presenting information to the nursing staff regarding the appropriate use of the client restraints. Which of the following should the nurse include? 81 A nurse supervisor receives notification of a disaster in the community and the possibility for multiple admissions to eh facility. Which of the following clients should the nurse recommend for discharge? A 82 A nurse is admitting a client who has chronic gout. The nurse anticipates which of the following provider prescriptions? 83. A nurse is caring for a client who is 2 days postoperative following a lumber laminectomy and is reporting nausea. Which of the following actions should the nurse take first? 84. A nurse in the recovery room is a client who has a new tube. The nurse finds that the water seal is no longer tidaling. The nurse should identify these finding as resulting from which of the following? 85. A nurse is planning for a group of clients. Which of the following tasks is appropriate for the nurse to delegate to the assistive personnel AP? 86. An assistive personnel (AP) at a long-term care facility reports to the nurse that another AP has spent the entire morning on the phone and has not completed the morning assignment. Which of the following is an appropriate action by the nurse? 87. A community health nurse is completing a newborn home visit and observes family members smoking cigarettes in the house. Which of the following is a priority intervention? 88. A nurse is teaching a prenatal class about evidence of effective breastfeeding to a group of parents. Which of the following information should be included? 89. A nurse is caring for a client who will be having a transfusion of platelets. The nurse recognizes that the outcome of will be which of the following? 90. A nurse in a prenatal clinic is caring for an adolescent client is now in her third trimester of pregnancy. The nurse identifies that the client is at an increased risk for the which of the following? 91. A nurse is planning dietary intervention for a client who is immobile due to pelvic and femur fractures. Which of the following should the nurse include in the plan? 92. A home health nurse is providing teaching about self-administration of insulin to a client who is newly diagnosed with DM. Which of the following statements by the client a need for further teaching? 93. A school nurse is assessing a child who has scabies. Which of the following is an expected finding? 94. A nurse is caring for a client who is postoperative and at risk for development of DVT. Which of the following should the nurse identify as increasing the risk of developing venous stasis? 95. A nurse is caring for a client who is receiving enteral nutrition. Which of the following findings indicates a need to decrease the rate of the enteral feeding? 96. A nurse is assessing a client 1 week after a successful bone marrow transplant. The client reports peeling of skin on her hands and feet. The nurse should recognize this desquamation as an indication of which of the following complications? 97. A nurse is providing education to the mother of a toddler who has pertussis. which of the following statements by the parent indicates the teaching has been effective? 98. A nurse at the family planning clinic triages several clients over the phone. Which of the following clients should the nurse instruct to come to the clinic? 99. A nurse in a pediatric unit is caring for a group of clients. For which of the following diseases should the nurse implement droplet precautions? 100. A nurse is planning the discharge of an infant who has tetralogy of Fallot. The nurse anticipates the need for which of the following equipment? 101. A nurse is admitting a client to the medical-surgical unit. Which of the following actions should the nurse take first? 102. A charge nurse on a pediatric unit is making assignments for a float nurse from the medical unit. Which of the following clients is appropriate to assign to the float nurse? 103. A nurse in a residential mental health facility is planning care for a new client who has OCD. Which of the following is appropriate for the nurse to include in the plan of care? 104. A nurse delegates tasks to an LPN and AP. When admitting a client who is experiencing acute liver failure and who has ascites and an NG tube, which of the following tasks is most appropriate for the nurse to delegate to the LPN? 105. A nurse is preparing to provide discharge teaching to a client who has an ileal conduit due to treatment for bladder cancer. Which of the following instructions should the nurse include in the teaching? 106. A nurse is caring for a client who has cirrhosis of the liver. Which of the following actions by the nurse is appropriate? 107. A nurse is providing teaching to the parent of a child who has pediculosis capitis. Which of the following information should be included in the teaching? 108. A nurse is teaching a client who has left-leg weakness how to use a standard walker. Which of the following actions by the client indicates a need for further teaching? 109. A nurse is caring for a client who has just returned to the unit following a bronchoscopy. Which of the following actions by the assistive personnel AP requires the nurse to intervene? 110. A nurse is caring for a client who is 2 hr postoperative following an ileal conduit procedure for bladder cancer. For which of the following finding should the nurse notify the provider? 111. A nurse is providing teaching for the parents of a school-age boy who has hemophilia. The parents tell the nurse that the child loves soccer. The child is adamant about playing with his peers on the school team next year, and the parents state that, “We are unable to say anything to convince him that is impossible.” Which of the following is an appropriate suggestion? 112. A nurse is taking care of a client who has a diagnosis of HIV. Which of the following client statement should the nurse address first? 113. A nurse is caring for a client who has I left femur fracture is a skeletal traction. The client reports pain due to muscle spasms in the affected leg. Which of the following action is appropriate by the nurse? 114. A nurse educator is discussing about modes of transmission with nursing students. Which of the following should the nurse educator include as an example of vector-borne transmission? 115. A nurse is creating an activity plan for a home-bound older adult client. In the planning the nurse considers the physiologic changes that may affect pulmonary function related to the normal aging process. Which of the following age-related physiologic changes should the nurse consider in the plan? 116. An emergency department nurse triages a group of school children injured in a school bus crash. Which of the following children should the nurse have the provider evaluate first? 117. A nurse plans to ambulate a client on the third day after cardiac surgery. Which of the following interventions should the nurse take so that the client will best tolerate ambulation? 118. A nurse is electronically documenting assessment findings for a client. Which of the following is an example of subjective data? 119. A nurse notice smoke coming from a client’s room and discovers a fire in the wastebasket. After moving the client to safety, which of the following is the priority action? 120. A nurse is caring for a client who has a diagnosis of antisocial personality disorder. The nurse should expect the client to demonstrate which of the following? 121. A client who has a diagnosis of complete placenta previa is admitted to the labor and delivery suite at 36 weeks gestation with contractions 5 min in frequency and 1 in in duration. Which of the following actions should the nurse take? 122. A nurse is planning care for a child who is unresponsive and increased ICP. Which of the following actions should the nurse take? 123. A nurse is planning care for a client who takes haloperidol the treatment of schizophrenia. Which of the following should the nurse include in the plan of care? 124. A nurse is caring for a client who was involved in a motor-vehicle crash. The client reports shortness of breath and chest pain and asks the nurse, “Am I dying?” Which of the following actions should the nurse take first? 125. A nurse is caring for a client who is receiving gentamicin. Which of the following findings indicates the client is developing toxicity? 126. A nurse is caring for a client who has just given birth to a stillborn newborn. Which of the following is the priority task for the nurses to facilitate the client’s grief process? 127. A nurse is teaching a client who has a new diagnosis of gastroesophageal reflux disease. Which of the following instructions should the nurse include in the teaching? 128. A nurse is caring for a client who has atypical depression and is taking phenelzine. Which of the following is appropriate for the nurse to offer as an evening snack? 129. A nurse is admitting an infant who has bacterial meningitis. Which of the following actions should the nurse take first? 130. A client asks the nurse if it is safe for him to take a glucosamine supplement. The nurse should assess for which of the following potential contraindications? 131. A nurse is analyzing the cardiac rhythms of four telemetry clients in the coronary care unit. Identify the rhythm strip that the nurse should recognize as indicative of a client who should be receiving warfarin. 132. A nurse in a postpartum unit is caring for several clients. After receiving a change of shifassess first? 133. A nurse is teaching a family about hospice care. Which of the following appropriate for the nurse to include in the teaching? 134. An infection control nurse is reviewing care procedures for four clients. Which of the following requires the nurse to intervene? [Show More]

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