2022 Everything/Mix Exam 100% Correctly Answered and Verified +600Q

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2022 Everything/Mix Exam 100% Correctly Answered and Verified +600Q A nurse is caring for a client who has a recent diagnosis of a terminal illness. The nurse should identify which of the following a... s an indication of hopelessness?.The client has a decreased energy level A nurse is preparing to collect data on a preschooler. Which of the following behaviors by the child indicates that he is ready to cooperate? (Select all that.Allows the nurse to touch him on the arm. Answers questions asked by the nurse. Makes eye contact with the nurse A nurse on a mental health unit is planning care for a group of clients. Which of the following clients should the nurse see first?.A client who has schizophrenia and is having command hallucinations A nurse is caring for a client who recently gave birth to her first child. The newborn is crying and the client states, " I can't seem to do anything right. What should I do?" Which of the following responses should the nurse make?."Let me show you how to swaddle and cuddle him, then you try A nurse is using a glucometer to measure a client's capillary blood glucose level, Which of the following actions should the nurse take?.Keep the finger in a dependent position A nurse is reviewing the home medications of a client who recently had transient ischemic attacks and is to begin taking clopidogrel. The nurse should instruct the client that which of the following over-the-counter medications interacts adversely with clopidogrel?.Naproxen A nurse is collecting data from a client who has a long leg cast that was applied 2 days ago. The client's foot is pale with a weak pedal pulse, and the client reports foot numbness. Which of the following actions should the nurse plan to take first.Check for pain with passive movement of the affected extremity A nurse in a provider's office is reinforcing teaching about cigarette smoking with a client. Which of the following adverse effects should the nurse include in the teaching?.Somnolence A nurse is contributing to the development of an in-service program for mental health nursing staff. The nurse should include that the staff can medicate a client against his will, without a court hearing, in which of the following situations?.A client who is attempting to hurt himself or others A nurse is reinforcing teaching with a client who has a new prescription for digoxin. Which of the following instructions should the nurse include in the teaching."Monitor for muscle weakness while taking the medication." A charge nurse is discussing confidentiality requirements with a newly licensed nurse when sharing a client's medical information. Which of the following individuals should the charge nurse identify as appropriate with whom to share client information..A social worker who is assigned to an involuntary committed school-age client A nurse is collecting data from a client who is 4 hr postoperative following a hemicolectomy. Which of the following findings is the nurse's priority, requiring immediate intervention?.Oxygen saturation 89% A nurse in a provider's office is collecting data from a client who has a history of hypertension during his annual physical examination. Which of the following findings should the nurse report to the provider immediately?.Blurred vision A nurse is caring for a client who suddenly develops chest pain and dyspnea. Which of the following actions should the nurse take first?.Elevate the head of the client's bed A nurse is reinforcing teaching on a client who has diabetes mellitus. Which of the following laboratory tests is the most accurate of blood glucose effective management?.Glycosylated hemoglobin A charge nurse on a mental health unit is supervising a newly licensed nurse. For which of the following actions by the newly licensed nurse should the supervising nurse intervene?.Tells a client he will lose his phone privileges if he does not take his medication A nurse is supervising an assistive personnel (AP) obtain supplies for a client who is on seizure precautions. Which of the following materials should the AP place in the client's room?.Oral suction equipment A nurse is reinforcing discharge teaching with the faculty of a client who has dependent personality disorder. Which of the following instructions should the nurse indicate in the teaching?.Encourage the client to be assertive A nurse is reinforcing discharge teaching with a client who had a right total hip arthroplasty. Which of the following instructions should the nurse indicate?."You should avoid crossing your legs for 3 months." A nurse is reinforcing dietary teaching with a client who has hyperemesis gravidarum. Which of the following instructions should the nurse include in the teaching.Eat a small meal every 2 to 3 hr A nurse is reinforcing teaching with a client who has GERD and a prescription for ranitidine. Which of the following statements by the client indicates an understanding of the teaching?."i have to take this medication at morning and night" A nurse is assisting with the admission of a client who has pulmonary tuberculosis. Which of the following types of isolation precautions should the nurse include?.Airborne A nurse is reinforcing discharge teaching with a client who has COPD and reports problems with maintaining adequate nutrition. Which of the following instructions should the nurse include?."Perform pulmonary hygiene 1 hour before meals. A nurse is administering pancreatic enzymes to a client who has cystic fibrosis. Which of the following outcomes should the nurse expect as a therapeutic effect of the treatment?.Reduced fat in the stools A nurse is caring for a client who has paranoid schizophrenia and believes that she is being followed by FBI agents who are pretending to be psychiatric staff. Which of the following responses should the nurse make?.The psychiatric staff is not FBI. They are here to help you. A nurse is assisting in the care of a client who has a fractured femur and is in Buck's traction, which of the following actions should the nurse take?.Ensure that the weights are hanging freely A nurse is reviewing the medication record of a client who requires continuous oxygen saturation monitoring. Which of the following should the nurse identify as a factor that can affect the validity of the readings?.Peripheral vascular disease A nurse is collecting data from a group of clients. Which of the following clients should the nurse identify as having xanthelasma?.Lady with eyes closed with nodules on eye lid A nurse is assisting with the admission of a client who has Vancomycin resistant enterococcus of the urine. Which of the following types of precautions should the nurse implement for this client?.Contact precautions A community health nurse is assisting in the development of a brochure about hypertension. Which of the following actions should the nurse take?.Explain medical terminology using basic, one-syllable words A nurse is collecting data from an adolescent during an annual physical examination. Which of the following statements by the client is the nurse's priority?."I would rather be alone than with my friends. A nurse is placing a dressing over a stage 1 pressure ulcer on a client's heel, which of the following types of wound dressing should the nurse use?.Transparent film A nurse is caring for an older adult client who reports pain and has a prescription for ketorolac 15 mg IM every 5 hr PRN. The client's current blood pressure is 114/55 mm Hg. Which of the following actions should the nurse take?.Administer the medication to the client A charge nurse in a long-term care facility is developing a performance improvement plan for an assistive personnel (AP). Which of the following actions should the nurse take when developing the plans? (Select all that apply).A, Set a specific time frame for meeting performance goals b. Ask the nurse supervisor to review the plan C, Include the performance standard that the AP should meet nurse is reinforcing teaching with a client who is undergoing radiation therapy to the neck. Which of the following instructions should the nurse include in the teaching?.Avoid exposing the neck to the cold A nurse is assisting with the admission of an older adult client who has impaired mobility and is at risk for falls. Which of the following fall precautions should the nurse plan to implement?.Determine the client's ability to use the call light A nurse is reinforcing teaching with a client about intermittent catheterization to measure residual urine. Which of the following information should the nurse include in the teaching?.You will need to urinate before the procedure. A nurse is caring for a client who has terminal cancer and has declined treatment. The nurse attempts to convince the client to reconsider his decision and discusses this attempt with the charge nurse. Which of the following actions should the charge nurse take?.Talk with the nurse about the need to support the client's decision A nurse is reinforcing teaching about breastfeeding with a client who gave birth 2 days ago. Which of the following information should the nurse include?.Feed the newborn 8 to 12 times every 24 hr A nurse is assisting with the admission of a school-aged child. Which of the following actions should the nurse plan to take?.Initiate contact precautions for the child A nurse is contributing to the plan of care for a client who has ascites due to cirrhosis. Which of the following interventions should the nurse recommend to include in the plan?.Measure the client's abdominal girth daily A nurse is reinforcing teaching with a client who has a prescription for antibiotic therapy. The client tells the nurse that he always experiences diarrhea when he takes antibiotics. Which of the following food choices should the nurse recommend to lessen the occurance of diarrhea?.Yogurt A nurse is assisting with the care of a client who has increased intracranial pressure following a closed head injury. Which of the following actions should the nurse take?.Elevate the head of the bed to 30 degrees A nurse is assisting with the plan of care for a client who is in the third trimester of pregnancy and has ankle edema. Which of the following interventions should the nurse include in the client's plan of care?.Apply support stockings A nurse is contributing to the plan of care for a client who is experiencing delirium. Which of the following interventions should the nurse recommend?.Remind the client of the day and time often A community health nurse is assisting with the development of a pamphlet regarding choking hazards for toddlers. Which of the following foods should the nurse include.grapes A nurse is reinforcing discharge teaching with a client who has a new diagnosis of tuberculosis. Which of the following instructions should the nurse include in the teaching?."You should have a sputum examination every 4 weeks. A nurse is assisting with the care of a client who is at 37 weeks of gestation and is undergoing a nonstress test. Which of the following actions should the nurse take?.Remind the client to press the button when she feels fetal movement A nurse is contributing to the plan of care for a client who has dysphagia. Which of the following interventions should the nurse include?.Tilt the client's head forward during meals A nurse is reinforcing teaching with a client who is at 18 weeks of gestation and has a medical history of mild hypertension. For which of the following findings should the nurse instruct the client to monitor and report to the provider?.Persistent headache A nurse is talking with the partner of a client who recently died, which of the following statements should the nurse make?."Tell me what I can do for you at this time. A nurse is assisting with the admission of a client who states, "The last time I was in the hospital, the nurses took forever to answer my call light." Which of the following is an appropriate response by the nurse?.That must have been a difficult experience for you." A nurse in a provider's office is caring for a group of clients who have communicable diseases. Which of the following infections should the nurse report to the state health department?.Neisseria gonorrhoeae A nurse is assisting with the admission of an adolescent client who is suspected to have bacterial meningitis. Which of the following findings should the nurse expect?.Nuchal rigidity A nurse is reviewing laboratory findings for four clients. Which of the following laboratory values is an expected finding for a client who has end stage kidney disease?.Creatinine 15 mg/dl A nurse is caring for a client who is taking warfarin and has an INR of 5.5. The nurse should expect which of the following instructions from the provider?.Obtain an aPTT level A nurse is assisting with the care of a client who is receiving a continuous IV infusion. Which of the following indicates fluid volume excess?.Distended neck veins A nurse is reinforcing teaching with the parents of an infant who has a Pavlik harness. Which of the following statements should the nurse include in the teaching?."The harness can promote hip joint development A nurse is caring for a client who is 2 days postoperative. The client has a prescription for acetaminophen 300 mg with codeine 30 mg, 1 tablet every 3 to 4 hr PRN for pain. The nurse inadvertently administers 2 tablets to the client. In which of the following locations should the nurse document this error?.Incident report A nurse is preparing a sterile field to perform a dressing change for a client's leg wound, which of the following actions should the nurse take?.Place sterile objects at least 2.5 cm (1 in) from the edge of the sterile field A nurse begins to bath a newly admitted client who reports that she has not had anything to eat that day. The nurse interrupts the bath and obtains a healthy meal for the client. This action by the nurse is an example of which of the following?.Countertransference A nurse is contributing to the plan of care for a client who has herpes simplex. The nurse should plan to initiate which of the following isolation precautions when caring for this client?.Contact precautions A nurse is documenting client care in the nurses notes and notices that a space was left blank. Which of the following actions should the nurse take?.Draw a horizontal line through the space and sign at the end of the line A nurse is caring for a client who has AIDS. Which of the following solutions should the nurse disinfect the client's overhead table following a blood spill?.bleach A home health nurse is caring for an older adult client who has rheumatoid arthritis. Which of the following findings should the nurse identify as a safety risk?.The client's electrical wires are run under carpeting A nurse is reinforcing teaching with a client who is about to undergo surgery. Which of the following statements about informed consent should the nurse include in the teaching?."You can sign the informed consent form after the provider explains the pros and cons of the procedure. A nurse is reinforcing teaching with a client who has a trichomoniasis vaginalis infection and a new prescription for metronidazole. Which of the following instructions should the nurse include in the teaching?.You should expect your urine to turn brown A nurse is obtaining informed consent from a client who is scheduled for an invasive procedure. The client states, "I don't understand why this procedure is necessary." Which of the following actions should the nurse take?.Notify the charge nurse about the situation A nurse is reviewing information about advance directives with a newly admitted client. Which of the following statements by the client indicates an understanding of the information?."Advance directives include a living will" A nurse is collecting data from the caregiver of a client who has Alzheimer's disease. The caregiver reports the client has difficulty sleeping at night and wanders throughout the house. Which of the following interventions should the nurse recommend?.Encourage the client to take frequent walks during the day A nurse is assisting in the care of a client who is 8hr postpartum and has uterine atony with increased bleeding. Which of the following actions should the nurse take? (Select all that apply.Assist the client to empty her bladder A nurse is reinforcing teaching with the support person of a client who is in the first stage of labor. Which of the following instructions should the nurse include regarding effleurage?.Gently stroke her abdomen during contractions. A nurse is caring for an older adult client who is postoperative following a total hip arthroplasty. The client is incontinent of stool and urine. Which of the following actions should the nurse take to prevent skin breakdown?.Use a moisture barrier on the client's skin A nurse is caring for a client who has terminal cancer. Which of the following actions should the nurse take to promote the client's autonomy?.Allow the client to choose treatment times A nurse in a clinic is caring for a client who is at 40 weeks of gestation and experiences a sudden gush of vaginal fluids. Which of the following findings is evidence of an obstetric complication?.Appears greenish-brown in color A nurse is assisting with the care of an adolescent client immediately following a lumbar puncture. Which of the following actions should the nurse take?.inform the adolescent that he might experience a headache A nurse is reinforcing teaching about advance directives with a client who has end stage heart failure. Which of the following statements by the client indicates an understanding of the teaching?."I should discuss this document with my family after I sign it." A nurse is caring for a client who has continuous bladder irrigation following a transurethral resection of the prostate. The nurse notices clots and dark red blood in the catheter collection bag. Which of the following actions should the nurse take?.Irrigate the bladder with 20 to 30 mL of 0.9% sodium chloride irrigation A nurse is planning to obtain a 12-lead ECG for a client who has a history of cardiac dysrhythmias. Which of the following actions should the nurse plan to take?.Instruct the client to remain as still as possible during the recording A nurse is reinforcing teaching with a client who has genital herpes. Which of the following information should the nurse include in the teaching?."You should increase fluid intake to relieve dysuria A nurse is preparing to empty a postoperative client's closed-wound drainage system. Which of the following actions should the nurse plan to take?.Compress the container before replacing the drainage plug A nurse is reinforcing teaching with the parents of a toddler who has a new diagnosis of asthma and a prescription for montelukast. Which of the following instructions should the nurse include in the teaching?.Administer the medication to the toddler each evening A nurse in an acute mental health facility is caring for a newly admitted client. Which of the following should occur during the orientation phase of the nurse-client relationship.Defining responsibilities A nurse is caring for a client who reports having a decrease in fetal movement following an external cephalic version 6 hr ago. The nurse identifies the fetus is in the right occiput anterior position. The nurse should place the fetal heart monitor on which of the following sites to auscultate the fetal heart rate?.lower left A charge nurse is observing a newly licensed nurse perform suctioning for a client who has a tracheostomy. For which of the following actions by the newly licensed nurse should the charge nurse intervene?.Suctions for 30 seconds A nurse is reviewing the medication administration record of a client who takes atenolol PO and supplies a nitroglycerin transdermal patch daily. Which of the following interactions should the nurse monitor with this client?.Hypotension A nurse in an acute care setting is preparing to administer medications to a client. Which of the following actions should the nurse verify the client's identity?.Verify the client's identity using a photograph A nurse in a provider's office is collecting data from a client who has psoriasis. Which of the following statements made by the client should she report to the provider?."I try not to look at the scales on my body." A nurse is completing chart reviews in a long-term care facility in response to an increase in falls. Which of the following responses in the chart should the nurse use to determine the potential causes of falls?.Medication record A nurse is making client care assignments for an assistive personnel (AP). Which of the following tasks should the nurse assign to the AP?.Complete post mortem care for a client who has died A nurse is reinforcing teaching with a client who is taking allopurinol about the risk for developing Stevens-Johnsons syndrome. For which of the following manifestations should the nurse instruct the client to monitor and report?.Skin rash with fever A charge nurse in a long-term care facility is reinforcing teaching with a group of nurses about fall precautions. Which of the following statements made by the nurse indicates an understanding of the teaching?."I will instruct the client to sit when putting on a pair of pants." A nurse is recommending clients for discharge to allow for admission of clients following a tornado disaster. Which of the following clients should the nurse recommend for discharge?.A client who has a sodium level of 140 mEq/L after one episode of diarrhea A nurse is assisting with the plan of care for a newly admitted client who has anorexia nervosa. Which of the following interventions should the nurse include in the plan?.Administer liquid supplements A charge nurse is reinforcing teaching with a newly licensed nurse about floating to a different unit. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?."I will document in the medical record the support nurse who assists with planning care for my clients." A nurse is caring for a client who has dehydration due to diarrhea. Which of the following findings should the nurse report to the provider?.Urine output 12 mL/hr A nurse is participating in a performance improvement program. Which of the following actions should the nurse take to evaluate the effectiveness of the program?.Identify data collection methods A nurse in an assisted-living facility is reinforcing teaching with staff members about preparing for an external chemical disaster. Which of the following instructions should the nurse include?."Move clients to a room above ground with few windows. A nurse is assisting in the care of a client who has an arteriovenous (AV) shunt in his right arm. Which of the following actions should the nurse take?.Check a bruit over the shunt on a regular basis A nurse is caring for a client who has been admitted to the mental health unit. While reinforcing teaching about the client's prescribed exacerbations, the nurse communicates truthfully about the adverse effects of the medications. Which of the following ethical concepts is the nurse exhibiting?.Veracity A nurse is caring for a client who is postoperative following a subtotal thyroidectomy. The nurse should place the client in which of the following positions?.Semi-fowler's A nurse is reinforcing teaching with the parents of a child who has a new diagnosis of Wilms tumor. Which of the following interventions should the nurse include in the teaching?."You should not palpate your child's abdomen prior to surgery. A nurse enters the room of a school-age child and finds him on the floor experiencing a tonic-clonic seizure. Which of the following actions should the nurse take?.Place a pillow under the child's head A nurse is contributing to the plan of care for a client who is to begin receiving intermittent enteral feedings. Which of the following actions should the nurse recommend?.Place the client in high-fowler's position during feedings A nurse is collecting data from a client in an outpatient clinic and observes extensive bruising on the client's arms. This nurse suspects the client is experiencing intimate partner abuse. Which of the following is the nurse's priority action?.Offer support and create a safe, trusting environment A nurse in an urgent care clinic is caring for a client who reports recently using methylenedioxy-methamphetamine. Which of the following findings should the nurse expect?.Hallucinations A nurse is collecting data from a client who received oxytocin 10 units IM 30 min ago for excessive vaginal bleeding. Which of the following findings should the nurse expect?.Boggy fundus 3 fingerbreadths above the umbilicus A nurse is attending an educational workshop about client confidentiality. Which of the following actions by the nurse indicates an understanding of the teaching?.Changes her personal login password at random intervals A nurse is assisting with discharge planning for a group of clients. Which of the following clients should the nurse recommend a home health referral?.An older adult client who has heart failure and lives alone A nurse is reinforcing teaching with a female client who is taking phenytoin. Which of the following instructions should the nurse include in the teaching?.You might experience swollen gums while taking this medication A nurse is preparing to administer paroxetine 15 mg PO oral suspension to a client who has a depressive disorder. The amount available is 10 mg/ 5 mL. How many mL should the nurse administer?(Round answer to the nearest tenth.).7.5ml A nurse is reinforcing teaching with a client who is at 38 weeks of gestation and is to undergo a contraction stress test. Which of the following statements by the client indicates an understanding of the teaching?.I am having this test because my baby was not reactive during a nonstress test A nurse is discussing health practices with the mother of a toddler who is from a different cultural background than the nurse. Which of the following statements by the mother indicates that she practices cupping?.I sometimes place a bottle containing steam against my child's skin A nurse is reinforcing teaching with a client who has primary open-angle glaucoma and has a prescription for timolol eye drops. Which of the following statements by the client indicates an understanding of the teaching?.I should check my heart rate while taking this medication A nurse is collecting data from a preschooler who has severe dehydration. Which of the following findings should the nurse expect?.Weight loss of 10% A nurse is contributing to the plan of care for an older adult client. Which of the following physiological changes should the nurse consider when administering medication?.Decreased kidney function A nurse is caring for a client who is taking multiple medications and asks about possible interactions. To which of the following members of the interdisciplinary team should the nurse make a referral?.Advanced practice nurse A nurse is collecting data from a client who just received his first dose of sulfasalazine to treat ulcerative colitis. Which of the following findings should the nurse identify as an indication of an allergic reaction to this medication?.Dyspnea A nurse is collecting nutritional data from a group of adult clients. For which of the following clients should the nurse recommend an interprofessional care conference with a dietician?.A client who has a body mass index of 32 A charge nurse is reinforcing teaching with a newly licensed nurse about infection control measures. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?.Soiled dressings should be placed in a biohazard trash receptacle A nurse is preparing a vitamin K injection to give to a newborn. The newborn's mother questions the purpose of this medication. Which of the following responses should the nurse make?.This medication will decrease the risk of hemorrhage in your newborn A nurse is collecting data from a client who has diabetic ketoacidosis. Which of the following findings should the nurse report to the provider?.Fruity breath odo A nurse is caring for a client who has a vacuum-assisted closure system to treat a pressure ulcer. Which of the following actions should the nurse take.Use an adhesive remover to remove tape before reapplying a dressing A nurse is verifying informed consent for a client who is preoperative for a vaginal hysterectomy. Which of the following statements should the nurse identify as an indication that the client has given informed consent?.I am thankful I am done having children A nurse is caring for a client who is experiencing a tonic-clonic seizure. Which of the following actions should the nurse take?.Measure the duration of the seizure A nurse is collecting data from a client who is at 12 weeks of gestation. The client states, "We've been trying to get pregnant for several months, but now I'm not so sure I'm ready." Which of the following responses should the nurse make.Many women experience feelings of ambivalence during pregnancy A nurse is caring for four clients. Which of the following situations require a signed consent form?.Administering an iron injection Z-track method A nurse is receiving a report on four clients. The nurse should plan to collect data from which of the following clients first?.A preschooler who has epiglottis and is drooling A nurse is caring for a client who reports frequent headaches after taking chewable isosorbide dinitrate. Which of the following statements should the nurse include?.The headaches should decrease as you get used to the medication A nurse is implementing a bladder training program for a client who had a stroke. Which of the following interventions should the nurse take?.Check for residual urine after voiding A nurse is contributing to the plan of care for a client who is pregnant and reports having trouble sleeping. Which of the following instructions should the nurse include in the plan of care?.Lie on your left side with your top leg forward A nurse is reinforcing teaching with a client who has a new prescription for amitriptyline. Which of the following findings should the nurse include in the teaching as an adverse effect of this medication?.Orthostatic hypotension A nurse is contributing to the plan of care for a client who has major depressive disorder. Which of the following recommendations should the nurse include in the plan of care?.Encourage the client to use positive self talk A nurse is preparing to administer ibuprofen solution 60 mg orally to a 7 month old infant who is febrile. Available is ibuprofen 50 mg/ 1.25 mL. How many mL should the nurse administer?.1.5ml A nurse is caring for a child who has terminated cancer. Which of the following responses by the child's school-age brother should the nurse expect ?.Believes his bad behavior is causing his brother's death A nurse is caring for a client who is experiencing alcohol withdrawal. Which of the following medications should anticipate administering to prevent complications of withdrawal.Lorazepam A nurse is reinforcing dietary teaching with a client whose pre pregnancy BMI was 30.5. The nurse should recognize that the client understands the teaching when she states that she should expect to gain how many pounds during her pregnancy?.16lb A nurse is assisting with the care of a client following electroconvulsive therapy for the treatment of a depressive disorder. Which of the following findings should the nurse expect 15 min following this procedure?.Disorientation A nurse is caring for an adolescent client who has bulimia nervosa. Which of the following actions should the nurse take first?.Observe the client during and after meals A nurse is monitoring a client who is postoperative. Which of the following actions should the nurse take when collecting data about the client's respirations?.Observe the movements of the client's chest wall A nurse is preparing to give change-of-shift report on a client who is 2 days postoperative following a total knee arthroplasty. Which of the following information about the client should the nurse include in the report?.Time of last pain medication A nurse is reinforcing discharge teaching with a client who has a bipolar disorder and a new prescription for carbamazepine. Which of the following statements by the client indicates an understanding of the teaching?.I will plan to avoid grapefruit juice while taking this medication An assistive personnel tells the charge nurse that her assignment is too demanding. She angrily tells the nurse to reassign one of her tasks to another AP. Which of the following actions should the nurse take to resolve the conflict?.Ask the AP to discuss the issue in a private area A nurse is reinforcing teaching with a client who has arthritis. Which of the following instructions should the nurse include in the teaching?.Engage in low-impact aerobic exercises A nurse is caring for a female client who has an indwelling catheter with a urinary drainage system. Which of the following actions should the nurse take?.Secure the tubing with adhesive tape to the lower abdomen A nurse is assisting with a support group for clients who have experienced intimate partner violence. The nurse should identify which of the following client statements as indicating the greatest risk for violence?.I have decided to tell my husband I am leaving him A nurse is collecting data from a client who is receiving magnesium sulfate via continuous IV infusion for preterm labor. Which of the following findings should the nurse expect?.Hypotension A charge nurse working in a long-term care facility overhears two AP's in the nurses stations discussing a client who was just admitted. Which of the following actions should the charge nurse take?.Tell the APs to stop the conversation A nurse is reinforcing teaching with a client who is scheduled for an intravenous pyelogram. Which of the following statements made by the client indicates an understanding of the teaching?.I will feel a warming sensation after the injection of the dye A nurse is assisting with the plan of care for a client who has end-stage amyotrophic lateral sclerosis and has developed pneumonia. Which of the following actions should the nurse take?.Verify the status of the client's advance directive A nurse is reinforcing teaching with a new mother on facility security measures. Which of the following statements by the mother indicates an understanding of the teaching?.I will have an identification band that matches the one my baby wears A nurse is caring for a client who is 2 days postoperative following a total bilateral mastectomy. The client is tearful and looks away when her surgical dressings are removed. The nurse should place the priority action on which of the following actions?.Identifying the client's perception of the changes in her physical appearance A nurse is reinforcing teaching with a client who is at risk for hypertension. Which of the following risk reduction strategies should the nurse include in the teaching.Walk for 30 min 5 days per week A nurse is caring for a client who has dependent personality disorder. Which of the following manifestations should the nurse expect?.Submissive A nurse is assisting with the admission of a client who has varicella zoster. Which of the following interventions should the nurse plan to implement?.Initiate contact precautions for the client A nurse is planning to administer four different medications to a client via gastrostomy tube. Which of the following actions should the nurse take?.Allow separate medications to flow through the tube by gravity A nurse is preparing to administer medications to a client who has pneumonia and is on droplet precautions. Which of the following supplies should the nurse use while caring for this client?.Surgical mask A nurse is reinforcing dietary teaching with a client who is at risk for cardiovascular disease. Which of the following statements by the client indicates an understanding of the teaching?.I have unsalted pretzels for a snack A nurse in an inpatient psychiatric unit is caring for a client who was raised in an Asian culture. Which of the following communication techniques by the nurse demonstrates cultural sensitivity?.Holding eye contact for brief instances A nurse is reinforcing teaching about safe food handling with a client who is recovering from food poisoning. Which of the following statements by the client indicates an understanding of the teaching?.I will be sure to cook chicken to 180 degrees fahrenheit A nurse is assisting with the discharge plan for a client who has burns on his arms and hands. Which of the following referrals should the nurse recommend to improve the client's ADL's?.Occupational therapist A nurse is assisting with a prenatal examination of a client who is at 8 weeks of gestation. The nurse notes that the clients vagina and vulva are a purplish color. The nurse should document this finding as which of the following?.Chadwick's sign A nurse should recognize that a client's right to confidentiality has been breached when which of the following occur?.A nurse tells the chaplain that her assigned client has a new diagnosis of cancer A nurse on a medical-surgery unit is preparing to assist with the admission of clients who were injured in a tornado. Which of the following clients should the nurse recommend for discharge to make room for the new admissions?.A client who had a radical mastectomy 36 hr ago and has a surgical drain A nurse is reviewing laboratory values for a client who has respiratory acidosis. Which of the following arterial blood gas values should the nurse expect?.pH 7.30, PaCO2 50 mm Hg A nurse is caring for a client who is receiving oxygen when a fire starts in an adjacent room. Identify the sequence of actions the nurse should take. (Move steps in order).Move the client to a safe location 2. Pull the nearest fire alarm Shut all doors and window s 4. Attempt to extingui sh the fire A nurse is caring for a client who is receiving morphine for pain. Which of the following findings indicate that the client is experiencing an adverse effect of the medication?.Urinary retention A nurse is reinforcing dietary teaching with a client who has cholecystitis. Which of the following food choices should indicate that the client understands the teaching?.Skim milk A nurse is caring for a client who has a new mastectomy. Which of the following statements by the client should indicate to the nurse that the client is beginning to cope with the changes in her body image?.I am afraid to discuss my concerns with my husband A nurse is caring for an adult client who reports having trouble getting to sleep at night. Which of the following recommendations should the nurse make?.Establish a daily exercise routine A nurse is caring for an adolescent that states, "I joined the track and field team, so I won't argue with my brothers anymore." The nurse should identify that the client is using which of the following defense mechanisms?.Sublimation A nurse is reinforcing teaching with a client who has a new prescription for transdermal nitroglycerin patches. Which of the following statements by the client indicates an understanding of this medication?.I will place the patch on a hairless area of skin a home health nurse is conducting a home inspection for a client who is at risk for falls. Which of the following instructions should the nurse provide for the client?.move the clients bed to the main floor of the house a nurse is collecting data from a client who received oxytocin 10 units IM 30 mins ago for excessive vaginal bleeding. Which of the following findings should the nurse expect?.client report of uterine cramping a nurse in a providers office is reinforcing teaching about skin care with a client who has new diagnosis of systemic lupus erythematousus. Which of the following statements by the client indicates an understanding of the teaching?.i will dry my skin by patting it with a towel a nurse is collecting data from a 4 month old infant at a well child visit. For which of the following findings should the nurse notify the provider?.presence of grasp reflex a nurse is collecting data from a client who is 8 hours postoperative following an appendectomy. Which of the following manifestations is the best indications that the client needs a PRN analgesic?.the client reports pain as 7 on a scale of 0-10 a nurse is about to administer an intermittent enteral feeding to a client who has an NG tube in place. Besides obtaining an xray, which of the following methods should the nurse use to verify placement?.test the ph of the gastric asparate a nurse working in a clinic is reinforcing with a client who has hep a. which of the following client statements indicates an understanding of the teaching?.i will use different hand towels than others in my home a nurse is reinforcing teaching with a client who has a prescription for ferrous sulfate elixir. Which of the following statements by the client indicates an understanding of the teaching?.i will mix the medication with a full glass of water a nurse is reinforcing teaching with a newly licensed nurse about caring for a client who has a history of dysphagia. Which of the following instructions should the nurse include in the teaching?.place oral suction equipment next to the client's bedside a nurse is assisting with the care of a client who is 6 hour postoperative following a right total knee arthoplasty. which of the following actions should the nurse take?.maintain the head of the bed in high fowlers position a nurse is providing a client with IV fluids and finds that the iv pump screen is malfunctioning. Which of the following actions should the nurse take?.discontinue use and tag the iv pump a nurse in an acute mental health facility is caring for an adolescent who is exhibiting destructive behavior. Which of the following actions should the nurse take after applying physical restraints to the client?.monitor the client's range of motion every 60 min a nurse is collecting data from a client who is 1 day post op following a TURP. which of the following findings should the nurse report to the provider?.dark red urine a nurse is contributing to the plan of care for a client who is scheduled to receive ECT for the treatment of depression. Which of the following actions should the nurse recommend to include in the plan?.provide frequent reorientation after ECT a nurse is participating in an interprofessional client care conference for a client who has experienced a stroke. The nurse should identify that which of the following client care requires reporting to the interprofessional team?.the client is unable to grasp eating utensils a nurse is reinforcing teaching about preventing dental caries with the parent of a 12 month old toddler. Which of the following instructions should the nurse provide?.clean the teeth with a small soft bristled toothbrush a nurse is caring for a client who has a prescription for NPH insulin 10 units and regular insulin 15 units subcutaneously. After injecting 10 units of air into the NPH insulin vial, which of the following actions should the nurse take next?.inject 15 units of air into the regular insulin vial a nurse in a mental health facility is caring for a client who reports palpitations and a sense of impending doom. Which of the following actions should the nurse take first?.explain to the client that anxiety causes physical manifestations a nurse is assisting with the plan of care for a client who has burns to his lower extremities. Which of the following actions should the nurse include in the plan?.apply dressings with sterile gloves a nurse is completing postmortem documentation for a client. Which of the following information should the nurse include in the documentation?.location of the identification tag on the client's body a nurse is caring for a client who has major depressive disorder and is taking an antidepressant. The nurse should identify which of the following findings as the priority to report to the provider?.the client has a sudden increase in energy a nurse is reinforcing teaching about common discomforts during the first trimester with a client who is at 10 weeks of gestation. Which of the following examples should the nurse include?.leukorrhea a nurse enters a client's room and finds her sitting on the floor next to the shower. The client states that she slipped on some water outside of the shower. Which of the following actions should the nurse take first?.measure the client's vital signs a nurse is collecting data from a client who is in the manic phase of bipolar disorder. Which of the following findings should the nurse expect?.grandiose thinking a nurse is reinforcing teaching with a client about monitoring her blood pressure at home with a digital device. Which of the following statements by the client indicate an understanding of the teaching?.i will know my b/p is too high if i get a reading of 140 over 90 or higher a nurse is collecting data from a client who is in renal failure. The nurse should identify that which of the following findings is a manifestation of hyperkalemia?.irregular heart rate a nurse is caring for a client who has been given methylegonivine intramuscularly for a postpartum hemorrhage. The nurse should monitor for which of the following adverse effects?.hematuria a nurse is supervising an AP who is providing client care. The nurse should identify that which of the following actions by the AP demonstrate effective use of supplies?.wears clean gloves when performing oral care. a nurse is contributing to the plan of care for a client who is experiencing panic level anxiety and reports visual hallucinations. Which of the following actions should the nurse recommend including in the plan of care?.use a low pitched voice when speaking to the client a nurse determines that clients who receive zolpidem post op have an increased fall rate compared to other postoperative clients. To which of the following members of the health care team should the nurse report these findings?.the risk manager a nurse is reinforcing teaching with the parents of a child who has ADHD and is taking methylphenidate. Which of the following statements by the parents indicates that the medication is effective?.our child is able to complete his homework on time a nurse is assisting with a community health program for caregivers of clients who have alzheimers disease. Which of the following information should the nurse include?.limit the number of choices for the client a nurse is caring for a client who is on isolation precautions. Which of the following pieces of personal protective equipment should the nurse remove first?.gloves a nurse is collecting data from a client who has left sided heart failure. For which of the following findings should the nurse notify the provider?.productive cough with pink, frothy sputum a nurse is assisting with the care of a client who is in the latent stage of labor and has pelvic pain with contractions. Which of the following actions should the nurse take?.instruct the client to change positions frequently a nurse is caring for a client who is postoperative following abdominal surgery and has a wound evisceration. Which of the following actions should the nurse take?.cover the wound with sterile saline soaked gauze a nurse is reviewing medical record of a client who is taking acetaminophe to relieve headache pain. Which of the following conditions in the clients history should the nurse identify as a contraindication?.hep c a nurse is reinforcing teaching about passive range of motion exercises with the family of a client who has had a stroke. Which of the following instructions should the nurse include in the teaching?.support the extremity a nurse is reinforcing teaching with a client who is undergoing radiation therapy to the neck. Which of the following instructions should the nurse include in the teaching?.avoid exposing the neck to the cold a nurse is caring for a client who is unable to perform ADL's and wears dentures. Which of the following actions should the nurse take when providing denture care?.place a towel in the sink when cleaning the dentures a nurse is caring for a client who has peptic ulcer disease and is scheduled to undergo an esophagogastroduodenoscopy. Which of the following actions should the nurse take prior to the procedure?.ensure that the client gave informed consent a nurse is monitoring a client who has received external radiation for throat cancer. Which of the following findings should the nurse expect?.loss of taste a nurse is reviewing lab values for a client who is at 34 weeks of gestation. Which of the following findings should the nurse report to the provider?.urine protein 3+ a nurse is reinforcing teaching with a client who has GERD and a prescription for pantoprazole. Which of the following statements indicate an understanding of the teaching?.i have to take this medication on an empty stomach a nurse is caring for an older adult client who has acute delirium. Which of the following actions should the nurse take first?.determine the client's level of consciousness a nurse is reinforcing teaching with a client who is scheduled to have a colonoscopy in 1 week. Which of the following client statements indicates an understanding of the teaching?.ill have my friend drive me home after the procedure. a nurse is reinforcing teaching with a parent of a 4 month old infant during a home visit. Which of the following statements by the parent indicates an understanding of the teaching?.i will use a cool mist vaporizer in my babys room a nurse at a long term care facility is reviewing the plan of care for a client who has a prescription for mitten restraints. Which of the following tasks should the nurse assign to an assistive personnel?.assist the client with range of motion exercises of the hands a nurse is caring for a client who has anorexia nervosa and a behavioral management plan in place. Which of the following findings should the nurse identify as an indication that the behavioral plan is effective?.potassium 3.5 a nurse is collecting data from a client who has pyelonephritis and is receiving gentamicin via iv infusion. Which of the following manifestations should the identify as an adverse effect of the treatment?.new onset of hearing loss a nurse is caring for a preschooler who recently experienced the death of a parent. Which of the following findings should the nurse identify as consistent with this age group?.believes the death is punishment for bad behavior a nurse is caring for a client who has toxoplasmosis and asks the cause of the infection. Which of the following responses should the nurse make?.handling cat feces a nurse is administering hydromorphone to a client who is experiencing postoperative pain. Which of the following findings is an adverse effect of this med?.urinary retention a nurse is providing pre op care to a client who reports he has no one at home to help him after his outpatient surgery. Which of the following actions should the nurse take?.assist with a referral to a home health care agency a nurse is assisting with monitoring a client who is receiving a unit of packed rbcs. which of the following findings indicates the client is experiencing a transfusion reaction?.temp 38.8C (101.8F) a nurse is reinforcing teaching with a client who is postop following a partial gastrectomy. Which of the following instructions should the nurse include to prevent dumping syndrome?.include one serving of protein with each meal a nurse is reinforcing teaching with a client who has a new prescription for a cervical cap as a form of contraception. Which of the following statements by the client indicates an understanding of the teaching?.i need to keep the cap in place for at least 6 hours after intercourse a nurse is preparing to apply a thigh length sequential compression device for a client who is post op. Which of the following actions should the nurse take?.measure the circumference of the client's upper leg a nurse is collecting data from a client during a routine prenatal visit. The client is in their second trimester of pregnancy and reports feeling dizzy, has a racing heart, and becomes pale while lying on their back. Which of the following actions should the nurse take?.position the client on their left side a nurse in an acute setting is assisting in collecting client information to include in a referral for a physical therapist. Which of the following information should the nurse plan to include?.physical assessment findings a nurse is collecting data from a client who has acute cholecystitis. which of the following findings should the nurse expect?.pain in the right upper abdomen a nurse is reinforcing teaching about newborn care with a new guardian. Which of the following statements by the guardian indicates an understanding of the teaching?.i will wash my babys face with a warm wet washcloth without soap a nurse is reinforcing teaching with new parents about car seat safety. Which of the following instructions should the nurse include?.place the shoulder harness at the level of the infants shoulders a nurse is reinforcing teaching with a client who has a new prescription for albuterol PRN. The nurse should reinforce with the client that the medication can help treat which of the following manifestations?.shortness of breath a nurse is contributing to an in service for newly licensed nurses about situations requiring an incident report. WHich of the following expamples should the nurse include?.a nurse discovers that an electronic Iv pump delivered twice the prescribed amount of fluid to a child a nurse is assisting with the care of a client who is receiving chemotherapy and radiation for advanced breast cancer. The client states I am thinking about stopping the treatment. which of the following responses should the nurse make?.tell me more about what you are thinking a charge nurse is monitoring a group of assistive personnel regarding the use of gloves in contact isolation. For which of the following actions by an AP should the charge nurse intervene?.removes gloves last after other personal protective equipment. a nurse is reinforcing teaching with a parent of a newborn about home safety precautions. Which of the following statements by the parent indicates an understanding of the teaching?.i will make sure than i can fit one finger between the matress and the side of my newborns crib a nurse is reinforcing teaching with a client who is at 12 weeks of gestation and has hyperemesis gravidarum. which of the following client statements indicate an understanding of the nurses instructions?.i will eat or drink something every 2 to 3 hours throughout the day a nurse on a hospice unit is caring for a client who has a cancer and is in the active phase of dying. Which of the following findings requires intervention by the nurse?.an ap is encouraging intake of oral fluids a nurse is assisting with the care of a client who has schizophrenia and auditory hallucinations. Which of the following responses should the nurse make?.lets talk about what the voices are saying to you a nurse is caring for a client who has a femur fracture with the leg in bucks traction. which of the following actions should the nurse take?.compare bilateral pedal pulses a nurse is caring for a client who is 2 days post op following an above the knee amputation. which of the following actions should the nurse take to promote progression toward indepenedence and mobility for the client?.encourage the client to use the overbed trapeze a nurse is reinforcing teaching about palliative care to a client who has cancer. Which of the following statements should the nurse make?.it enhances quality of life by promoting comfort a nurse is reinforcing teaching with a client who has cystocele. Which of the following statements by the client indicates an understanding of the teaching?.i will practice perineal exercises to decrease urinary leakage a nurse is caring for a client who has dementia. which of the following findings should the nurse expect?.acute onset of confusion a nurse is caring for a client who was admitted for observation following a head injury. which of the following findings by the nurse indicates the client is experiencing increased ICP?.irritability a nurse is caring for a client who has recently died. which of the following actions should the nurse take?.place a pillow under the client's head a nurse on a med surgical unit is assisting with the admission of a client who has advanced lung cancer. which of the following statements regarding advance directives should the nurse take?.document the clients decisions about end of life care in the med record a nurse is collecting data from a client who is 12 hours post op following intestinual surgry. which of the following findings should the nurse report to the charge nurse prior to the clients ambulation?.oxygen sat 90% a nurse is caring for a client who speaks a different language than the nurse. the client's partner tells the nurse that the client would like to go home against medical advice. which of the following actions should the nurse take?.request the services of an interpreter to determine the client's wishes a nurse in a providers office is caring for a group of clients who have communicable diseases. Which of the following infections should the nurse report to the state health department?.neisseria gonorrhoeae a nurse is preparing to delegate the client care to an ap which of the following information should the nurse verify prior to delegations?.the ap's job description A nurse is caring requesting assistance with smoking cessation. The nurse should anticipate prescription for which of the following? .Bupropion. A nurse is collecting data from a client who has sickle cell anemia and is experiencing a Vaso-occlusive crisis. Which of the following actions should the nurse take? .Recommend a transfusion of packed RBC's. A nurse is contributing to the development of an in-service training about the differences in mental health beliefs across various cultural groups. Which of the following culture-bound syndromes should the nurse include when discussing Navajo Indian cultural beliefs? .Ghost sickness A nurse is assisting with the care of a client who has schizophrenia and auditory hallucinations. Which of the following responses should the nurse make? ."Let's talk about what the voices are saying to you." A nurse is discussing informed consent with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding of the information? ."A client can withdraw consent at any time after signing the informed consent form." A nurse is reinforcing teaching with a client who has hypertension about decreasing sodium intake. Which of the following foods should the nurse recommend? .1 baked potato. A nurse is caring for a client who is postoperative following a transurethral resection of the prostate. The nurse notes bright red urinary drainage after notifying the surgeon which of the following actions should the nurse take? .Request a prescription to obtain the clients bun level. A nurse is reinforcing teaching with another nurse about how to change an ostomy appliance for a client who has a sigmoid colostomy which of the following instruction should the nurse include in the teaching? .Empty clients pouch before removing skin barrier. A charge nurse is observing a newly licensed nurse performing dressing change on a peripheral IV site. For which of the following actions by the new nurse should the charge nurse intervene? .Use a sterile glove to remove the old dressing. A nurse is caring for a client who has a peanut allergy. The client states "I feel like my throat is closing", which of the following actions should the nurse take? .Give epinephrine intramuscularly. A nurse is transcribing a clients prescription for erythromycin 500 mg four times per day which of the following information shared the news clarify with the provider? .Time A nurse in a long-term care facility is caring for a client who has Methicillin Resistant Staphylococcus Aureus (MRSA). Which of the following actions should the nurse take? .Wear a gown when assisting the client with personal hygiene A nurse is reinforcing teaching about hand hygiene with a newly licensed nurse. Which of the following information should the nurse include in the teaching? .Interlace the fingers while rubbing hands together. A nurse is reinforcing teaching with a client who has diabetes mellitus and is taking insulin lispro and insulin glargine which of the following instruction should the nurse include in the teaching? .Draw up the insulin lispro and insulin glargine in separate syringes. A nurse is contributing to the plan of care for a client who has ascites due to cirrhosis. Which of the following interventions should the nurse recommend to include in the plan? .Measure the clients abdominal girth daily. A nurse is caring for a newborn who has hyperbilirubinemia and is receiving photo therapy. Which of the following findings should the nurse report to the provider? .Loose stools. A nurse is caring for a client who is postoperative. The client has a prescription for acetaminophen 300 mg with codeine 30 mg one tablet every 3 to 4 hours PRN for pain. The nurse in advertently administers two tablets to the client in which of the following location should the nurse document the error? .Controlled substance inventory record A nurse is caring for an adolescent client who has bulimia nervosa. Which of the following actions should the nurse take first? .Observe the client during and after meals. A nurse has assigned an assistive personnel to perform a Gastrostomy Feeding for a client who has been receiving feedings at home. Which of the following actions should the nurse take to monitor the APs performance of the task? .Request the AP to provide a return demonstration of the task. A community health nurse is developing a brochure about hypertension. Which of the following actions should the nurse take? .Explain the medical terminology using basic one syllable words. A charge nurse assigned a nurse to care for a group of clients. Which of the following client should the nurse ask the charge nurse to reassign to an RN? .A client who has a new diagnosis of diabetes mellitus and needs to learn self-administration of insulin. A nurse is caring for a client who has depressive disorder. The client states everyone will be better off if I were not around. Which of the following responses should the nurse make? .Are you thinking of hurting yourself? A nurse is Reinforcing teaching with the Client family about home oxygen use via nasal cannula. Which of the following statements by a family member indicates an understanding of the teaching? .We will frequently check the top of his ears for sores. A nurse is caring for a client who has been giving methylergonovine intramuscularly for postpartum hemorrhage which of the following should the nurse monitor for adverse reactions? We will frequently check the top of his ears for sores? .Elevated blood pressure. A nurse is collecting data from a child who is one hour postoperative following a tonsillectomy which of the following findings is the nurses' priority? .Frequent swallowing. A nurse is caring for a client who is in stage kidney disease. The client has decided to stop dialysis treatment which of the following actions should the nurse take? .Support the clients decision and stop the treatment. A nurse is receiving change of shift report on a group of clients, which of the following client should the nurse see first? .A client who is postoperative following hip arthroplasty and reports calf pain. A charge nurse working in a long-term care facility overhears to assistive personnel in the nurses station discussing a client who was just admitted which of the following actions should the charge nurse take? .Tell the APs to stop the conversation. A nurse is caring for a client who has a prescription for Warfarin. Which of the following laboratory test should the nurse monitor? .INR. A nurse is preparing to perform a wet to dry dressing change for a client who has an infected abdominal wound. Which of the following techniques should the nurse use when performing the dressing change? .Clean the wound from center to outer edges. A nurse is reinforcing teaching with a parent of a preschooler who has night terrors. Which of the following instructions should the nurse include? .Use a night light near the child's bed. A nurse is assisting with the community health education course for a family members who have an Alzheimer's disease. Which of the following information should the nurse include? .Limit number of choices for the client. Following a kosher diet, which of the following on the menu is ok? .Roasted salmon. Which of the following breaks Patient confidentiality? .A nurse tells the chaplain that her assigned client has a new diagnosis of cancer. A nurse is collecting data on a client who has alcohol use disorder and is experiencing withdrawal. Which of the following manifestations should the nurse expect ? .Hypertension. A nurse is reviewing the medical record of a client who has COPD. Which of the following laboratory findings indicates a need to request a dietary referral for the client ? .Pre-albumin 13 mg /dl. A nurse is collecting data from a client who has anorexia nervosa which of the following findings should the nurse identify as a positive outcome to treatment ? .The client resumes menstruation. A nurse is caring for a client who has an abdominal surgical incision and notices an evisceration which of the following actions should the nurse take ? .Cover the one with a transparent dressing. A nurse is reinforcing teaching about breastfeeding with the mother of a full-term newborn who is 5 days old. Which of the following statements by the mother indicates an understanding of the teaching? .My baby should breast-feed 5 to 10 minutes on each breast. A nurse is reinforcing teaching with a client who has a new prescription for a cervical cap as a form of contraception which of the following statements by the client indicates an understanding of the teaching? .I need to keep the cap in place for at least six hours after intercourse. A nurse is assisting a client who requests to take a tub bath which of the following actions should the nurse take ? .Add bath oil after the client gets into the tub. A nurse is reviewing guidelines for documenting client care. Which of the following should the nurse plan to take? .document info telephoned by a nurse who left the unit for the day. A nurse is reviewing the guidelines for documenting client care. Which of the following actions should the nurse plan to take? .Avoid quoting client comments when documenting. A nurse is reinforcing teaching with a client who has a new prescription for transdermal nitroglycerin patches which of the following statements by the client indicates an understanding? .I will place the pitch on a hairless area of skin. A nurse is reinforcing discharge teaching with a client who has tuberculosis. Which of the following statements by the client indicates an understanding of the teaching? ."I should throw away my used tissues in a closed plastic bag". A nurse is receiving change-of-shift report for a group of clients. Which of the following clients should the nurse check first? .A client admitted to the facility who has ascending Guillain-Barré syndrome. A nurse is collecting data from a client who is at 20 weeks of gestation. Which of the following findings should the nurse monitor as a common adverse effect of iron and has been taking ferrous sulfate. For which the following findings should the nurse report to the provider? .Constipation. A nurse is reinforcing teaching with a client who is to have a plaster cast applied to his right arm. Which of the following information should the nurse include in the teaching? .The client's extremity Should be elevated after the cast is applied. A nurse is caring for a client whose newborn is receiving Phytonadione injection. Which of the following statements should the nurse make? .This medication prevents your baby from developing bleeding problems. A nurse is caring for a client who has antisocial personality disorder who request to smoke outside of a scheduled smoke break which of the following is an appropriate response by the nurse ? .The smoking times on the unit or after each meal. A nurse in a mental health facility is reinforcing teaching with a client about panic attacks. Which of the following statements by the client indicates an understanding of the instructions? .I will use abdominal breathing at the first sign of a panic attack. A nurse is caring for a female client who has an indwelling catheter with a urinary drainage system. Which of the following actions should the nurse take? .Instruct the client to hold the drainage bag a waist height when ambulating. A nurse is collecting data from a newborn who was born 18 hours ago. Which of the following findings should the nurse report to the provider? .Yellow sclerae. A nurse is reinforcing teaching with a parent of a preschooler who has varicella about expected clinical manifestations. Which of the following manifestations should the nurse include (select all that apply)? .Vessels that form crust pruritis. A nurse is reinforcing teaching with a female client who has Tuberculosis and a new prescription for rifampin. Which of the following statements by the client indicates an understanding of the teaching? .I should use supplemental birth control while I am taking this medication. A nurse is caring for an adolescent client who has been hospitalized for several weeks. Which of the following actions should the nurse take relative to the clients developmental stage? .Arrange for uninterrupted visits with the clients friends. A charge nurse is observing a newly licensed nurse who is having difficulty finishing all client care activities by the end of his shift which of the following statements should the nurse make to help the newly licensed nurse improve his time management skills? .Complete the task for one client before moving onto the next client. A nurse is reinforcing teaching with a client who has diabetes mellites about a 24-hour creatinine clearance test .Which of the following statements should the nurse include in the teaching? .You can begin collection of urine after discarding your first morning void. A nurse is caring for a client who has Graves' disease which of the following findings should indicate to the nurse that the client is developing a thyroid storm? .Tachycardia. A nurse is caring for a client who has paranoid schizophrenia and believes that she is being followed by FBI agents who are pretending to be psychiatric staff which of the following responses should the nurse make? .This must be frightening to you, let's talk more about it. A nurse is assisting a client who has cancer to select high protein foods. Which of the following foods should the nurse recommend as the highest source of protein? .8 ounce chopped hard boil egg. A nurse is reviewing the plan of care for a client who is receiving treatment for anorexia nervosa. Which of the following laboratory findings indicates that the clients nutrition plan is effective? .Cholesterol 190 mg/dL. A nurse is collecting data from a client who has taken MEDROXYPROGESTERONE acetate for the past six months. Which of the following statements by the client should the nurse report to the provider immediately? .I have breast tenderness. A nurse is planning care for a client who is six hours postoperative following a right knee arthroplasty which of the following interventions should the nurse include in the clients plan of care? .Use the continuous passive motion machine intermittently. A nurse is preparing to administer eyedrops to a child which of the following actions should the nurse take ? .Apply pressure to the lacrimal punctum after administering drops. A nurse is reinforcing teaching with a 36-year-old client who is 16 weeks of gestation and is scheduled for amniocentesis. The nurse should include in the teaching the amniocentesis is performed to identify which of the following findings? .Chromosomal abnormalities. A nurse in an acute care setting is preparing to administer medications to a client. Which of the following information should the nurse obtain to identify the client? .Client's telephone number. A nurse is collecting data from an adult client who has a history of angina and reports having chest pressure, they radiates to the left side of his neck. Which of the following is the priority medication the nurse should anticipate the provider prescribes? .Nitroglycerin. A nurse on a hospice unit is caring for a client who has cancer and is in the active phase of dying. Which of the following findings requires intervention by the nurse? .An assistive personnel is encouraging intake of oral fluids. A nurse is discussing home care concerns with the son of a client who has Alzheimer's disease. The son states "I am so tired all the time, but mom needs me". Which of the following responses should the nurse make? .Let me give you some information about respite care for your mother. A nurse is assisting with the care of a client who is receiving mechanical ventilation for respiratory failure, which of the following actions should the nurse take? .Performed passive range of motion every two hours. A nurse is discussing risk factors for child abuse with members of the parenting group, the nurse should identify which of the following findings as a characteristic of perpetrators of child abuse? .Rigid expectations of behavior. A nurse is assisting with the admission of a client who has varicella zoster which of the following intervention should the nurse plan to implement? .Initiate contact precautions for the client. A nurse is caring for a client who has major depressive disorder and is taking an antidepressant. The nurse should identify which of the following findings is the priority to report to the provider? .The client has a sudden increase in energy. A client who is postoperative following joint replacement and he has a new prescription for enoxaparin, for which of the following reactions should the nurse monitor? .Epistaxis. A nurse in a providers office is caring for a client who states, "my doctor is always in a big hurry, it makes me nervous, and I forget what I wanted to ask her". Which of the following responses should the nurse make? .Let's make a list of what you'd like to ask the doctor before she comes in to see you. A nurse is preparing to administer enoxaparin 1.5 mg per kilogram subcutaneously to a client who has a pulmonary embolism. The client weighs 132 pounds. The amount available is 100 mg/mL how many milliliters should the nurse administer? .0.9 ml. A nurse is assisting with the green needle examination of a client who is in eight weeks of gestation, the nurse notes the clients vagina and vulva are a purplish color. The nurse should document to find them as which of the following? .Chadwick sign . A nurse is contributing to the plan of care for a client who has urinary incontinence. Which of the following intervention should the nurse suggest to help prevent skin breakdown? .Dry the skin thoroughly after cleansing the perennial area. The nurse is reinforcing teaching with a client who is receiving chemotherapy and develop stomatitis, which of the following instruction should the nurse include in the teaching? .Use a soft bristle toothbrush. A nurse is collecting data from a client who is receiving magnesium sulfate via continuous IV infusion to treat preeclampsia. Which of the following findings indicate that the medication is here in a therapeutic affect? .Deep tendon reflexes 2+. A nurse is reinforcing teaching with a client about advance directives and a healthcare proxy. Which of the following client statements indicates an understanding of the teaching? .I do not need to name a relative as my designee in my health care proxy. A nurse is caring for a client who is today's postoperative, which of the following findings should the nurse identify as an indication of postoperative infection? .Serous drainage in the close section collection device. A nurse is caring for a client who was admitted for observation following head injury. Which of the following findings by the nurse indicates the client is experiencing increased intracranial pressure? .Decreased BP. A nurse is reviewing the medical record of a client who has hepatic cirrhosis, which of the following lab values should the nurse report to the provider? .Potassium 3.1 mEq per liter. A nurse is observing an assistive personnel take a client's tympanic temperature, which of the following actions should the nurse identify as an indication that the AP understands how to perform the procedure? .The AP pulls the pinna up and back. A nurse is collecting data from a female client who reports she wants to begin taking oral contraceptives. Which of the following findings is a contra indication for this client? .Hypertension . A nurse is re-enforcing discharge teaching with a client who has stable angina pectoris. Which of the following statements by the client indicates an understanding of what to do when chest pain occurs? .Stop what I am doing and lie down. A nurse is receiving a telephone prescription from a clients provider which of the following actions should the nurse take (select all that apply)? .Ask the provider to spell out the name of the medication, request that the provider confirm the read back of the prescription, record the date and time of the telephone prescription. A nurse is reinforcing teaching about passive range of motion exercises with the family of a client who has had a stroke. Which of the following instructions should the nurse include in the teaching? .Support the extremity above and below each joint during the exercises. A nurse is caring for a client who receives cyclosporine instead of Cycloserine. The nurse should monitor the client for which of the following adverse effects? .Respiratory depression. A nurse is reviewing the medical record for a child who is scheduled to receive a varicella immunization. Which of the following findings in the clients record should the nurse recognize as a contraindication? .Chemotherapy treatments. A nurse in a long-term care facility is delegating care for a group of clients for the upcoming shift. Which of the following tasks should the nurse delegate to an assistive personnel (select all that apply)? .Measure vital signs for a client who requires contact precaution, record urine output for a client who has a super pubic catheter, trees for a client who is receiving radiation therapy to radiology. A nurse in an inpatient medical health facility is reinforcing teaching with a client who signed an informed consent form for electroconvulsive therapy. Which of the following statements about a client indicates an understanding of the procedure? .I might have short term memory loss after the procedure. A nurse is assisting with discharge planning for a group of clients during a mass casualty incident. Which of the following client should the nurse recommend for discharge? .A client who had diabetic ketoacidosis and has a blood glucose level of 120 mg/Dl. A nurse is caring for a client who is postoperative following a sub total thyroidectomy. The nurse should place the client in which of the following positions? .Semi Fowler's. A nurse is discussing the plan of care with an assistive personnel for a client who is four hours postoperative and has a urostomy. Which of the following statements should the nurse include in the discussion? .We need to check the clients urine output every hour. A nurse is collecting data from a client who has heart failure. The nurse notes the client has crackles in the bases of the lungs, shortness of breath and a respiratory rate of 24 bpm. Which of the following actions should the nurse take? .Maintain the client and high Fowlers position. A nurse is preparing to administer 0.9% sodium chloride 250 mL IV to infuse over 30 minutes to a client. The nurse just set the IV pump to deliver how many milliliters per hour? .500. A nurse is collecting data from a client who has a urinary tract infection and is taking Ciprofloxacin. The client reports pain in her calf muscle. Which of the following statements should the nurse make? .Discontinue the medication I will ask your provider for another antibiotic. A home health nurse is conducting a home inspection for a client who is it at risk for falls. Which of the following instruction should the nurse provide for the client? .Move the clients bed to the main floor on the house. A nurse in an acute mental health facility is caring for an adolescent who is exhibiting destructive behavior. Which of the following actions should the nurse take after applying physical restraints to the client? .Plan to remove the restraints as soon as the client is calm. A charge nurse in a long-term care facility notices the smell of alcohol on a nurses breath. Which of the following actions should the nurse take first? .Call the supervisor to ask for another nurse. A nurse is caring for a client who is receiving intermittent internal feeding and he has diarrhea. Which of the following actions should the nurse take? .Deliver a smaller amount of formula more frequently. A nurse is feeding a client who had a stroke resulting in left sided weakness. Which of the following actions should the nurse take? .Encourage the client to drink a small amount of liquids to clear his mouth of food. A nurse is caring for a client who is taking furosemide. Which of the following adverse effects should the nurse monitor? .Hypokalemia. A nurse is reinforcing teaching with a client who has a UTI. Which of the following instruction should the nurse include in the teaching? .Wear cotton underwear. A nurse is reinforcing dietary teaching with a client whose pre-pregnancy BMI was 30.5. The nurse should recognize that the client understands the teaching when she states she should expect to gain how many pounds during her pregnancy? .16 pounds. A nurse is caring for a client who is taken acetaminophen overdose. Which of the following findings should the nurse expect? .Diarrhea. A nurse is reinforcing teaching with a newly licensed nurse about performing a 12 lead ECG. Which of the following statements about a newly licensed nurse indicates an understanding of the teaching? .The test will show conduction patterns and different paths of cardiac electrical activity. A nurse is reinforcing teaching with a parent of a newborn about home safety precaution. Which of the following statements by the parent indicates an understanding of the teaching? .I will make sure that I can fit one finger between the mattress and the side of my newborns crib. A nurse is collecting data from a client who is receiving IV therapy. The nurse suspects fluid infiltration, which of the following findings should the nurse expect at the insertion site? .Edema. A nurse is reinforcing teaching about foot care with a client who has diabetes mellitus. Which of the following instruction should the nurse include in the teaching? .Cut your toenails straight across. A nurse is caring for four clients, which of the following situations require a signed consent form? .Giving a Haemophiles influenza B vaccine to an infant. A nurse is administering a client's morning oral medications, which of the following actions should the nurse take? .Verify the medication three times with the medication administration record . A nurse is collecting data from a middle adult client who reports experiencing sexual dysfunction. The nurse should identify that which of the following medications the client states can cause sexual dysfunction? .FLUOXETINE. A community health nurse is assisting with the development of a pamphlet regarding choking hazards for toddlers which of the following foods should the nurse include? .Grapes. A nurse manager in a long-term care facility is discussing evidence-based practice with a group of staff nurse. Which of the following activities should the nurse manager identify as an example of evidence-based practice? .Staffing the unit based on client acuity and needs. A nurse is caring for a client who states I feel we have a good relationship, and you will keep my information confidential. I want you to know I am planning to commit suicide today. Which of the following responses should the nurse make? .I can't keep a conversation like this to myself. A nurse is assisting with the plan of care for an order of the client who has dementia and is experiencing nocturnal confusion. Which of the following actions should the nurse take to decrease the clients risk for injury? .Activate bed alarm. A nurse is reinforcing teaching with a client who has a new diagnosis of COPD. Which of the following statements by the client indicates an understanding of the teaching? .I should practice pursed lip breathing exercises . A nurse is reinforcing teaching with a group of adolescent male clients about testicular examination which of the following statements by a client indicates an understanding of the teaching? .I should expect one testicle to be larger than the other. A nurse is reinforcing teaching with a client who is in 16 weeks of gestation and has a prescription for ferrous sulfate to treat Iron deficiency anemia. Which of the following recommendations should the nurse make to improve the absorption of the medication? .Avoid drinking milk with the iron supplement A nurse is collecting data from a client who is at risk for a pulmonary embolism following surgery. Which of the following findings should the nurse monitor? .Dyspnea. A nurse on a mental health unit observes a client yelling at another client which of the following actions should the nurse take first? .State expectations for the clients behavior. A nurse delegates a task to an AP and the AP refuses to take the assigned task. Which of the following actions should the nurse take? .Report the A.P to the risk manager. A nurse is reinforcing teaching with the partner of a client who is receiving hospice care about music therapy for management. Which of the following statements by the partner indicates an understanding of the teaching? .Music will distract my husband's awareness of the pain. A nurse is assisting with the plan of care for a group of clients. Which of the following client should the most recommend for an interprofessional conference? .A client who has a spinal cord injury. A nurse is reinforcing teaching with a parent of a 4-month-old infant during a home visit. Which of the following statements by the parent indicates an understanding of the teaching? .I will use a cool mist vaporizer in my baby's room. A nurse is receiving change of shift report on 4 clients. Which of the following clients should the nurse plan to see first? .A client who has a femur fracture and reports numbness of the toes. A nurse is caring for a client who has a recent diagnosis of a terminal illness. The nurse should identify which of the following as an indication of hopelessness? .The client has a decreased energy level. A nurse is preparing to collect data on a preschooler. Which of the following behaviors by the child indicates that he is ready to cooperate? (Select all that Apply)? .Allows the nurse to touch, him on the arm, Answers questions asked by the nurse, Makes eye contact with the nurse. A nurse on a mental health unit is planning care for a group of clients. Which of the following clients should the nurse see first? .A client who has schizophrenia and is having command hallucinations. A nurse is caring for a client who recently gave birth to her first child. The newborn is crying and the client states, " I can't seem to do anything right. What should I do?" Which of the following responses should the nurse make? ."Let me show you how to swaddle and cuddle him, then you try. A nurse is using a glucometer to measure a client's capillary blood glucose level, which of the following actions should the nurse take? .Keep the finger in a dependent position. A nurse is reviewing the home medications of a client who recently had transient ischemic attacks and is to begin taking clopidogrel. The nurse should instruct the client that which of the following over-the-counter medications interacts adversely with clopidogrel? .Naproxen. A nurse is collecting data from a client who has a long leg cast that was applied 2 days ago. The client's foot is pale with a weak pedal pulse, and the client reports foot numbness. Which of the following actions should the nurse plan to take first? .Check for pain with passive movement of the affected extremity. A nurse in a provider's office is reinforcing teaching about cigarette smoking with a client. Which of the following adverse effects should the nurse include in the teaching? .Somnolence A nurse is contributing to the development of an in-service program for mental health nursing staff. The nurse should include that the staff can medicate a client against his will, without a court hearing, in which of the following situations? .A client who is attempting to hurt himself or others. A nurse is reinforcing teaching with a client who has a new prescription for digoxin. Which of the following instructions should the nurse include in the teaching? ."Monitor for muscle weakness while taking the medication." A nurse is reviewing laboratory values for a client who is at 34 weeks of gestation. Which of the following findings should the nurse report to the provider? .Urine protein 3+. A nurse is collecting data from a client who is 4 hr postoperative following a hemicolectomy. Which of the following findings is the nurse's priority, requiring immediate intervention? .Oxygen saturation 89%. A nurse in a provider's office is collecting data from a client who has a history of hypertension during his annual physical examination. Which of the following findings should the nurse report to the provider immediately? .Blurred vision. A nurse is reinforcing teaching on a client who has diabetes mellitus. Which of the following laboratory tests is the most accurate of blood glucose effective management? .Glycosylated hemoglobin. A charge nurse on a mental health unit is supervising a newly licensed nurse. For which of the following actions by the newly licensed nurse should the supervising nurse intervene? .Tells a client he will lose his phone privileges if he does not take his medication. A nurse is supervising assistive personnel (AP) obtain supplies for a client who is on seizure precautions. Which of the following materials should the AP place in the client's room? .Oral suction equipment. A nurse is reinforcing discharge teaching with the faculty of a client who has dependent personality disorder. Which of the following instructions should the nurse indicate in the teaching? .Encourage the client to be assertive. A nurse is reinforcing discharge teaching with a client who had a right total hip arthroplasty. Which of the following instructions should the nurse indicate? ."You should avoid crossing your legs for 3 months." A nurse is reinforcing dietary teaching with a client who has hyperemesis gravidarum. Which of the following instructions should the nurse include in the teaching? .Eat a small meal every 2 to 3 hr. A nurse is assisting with the admission of a client who has pulmonary tuberculosis. Which of the following types of isolation precautions should the nurse include? .Airborne. A nurse is reinforcing discharge teaching with a client who has COPD and reports problems with maintaining adequate nutrition. Which of the following instructions should the nurse include? ."Perform pulmonary hygiene 1 hour before meals. A nurse is caring for a client who has paranoid schizophrenia and believes that she is being followed by FBI agents who are pretending to be psychiatric staff. Which of the following responses should the nurse make? .The psychiatric staff is not FBI. They are here to help you. A nurse is assisting in the care of a client who has a fractured femur and is in Buck's traction, which of the following actions should the nurse take? .Ensure that the weights are hanging freely. A nurse is reviewing the medication record of a client who requires continuous oxygen saturation monitoring. Which of the following should the nurse identify as a factor that can affect the validity of the readings? .Peripheral vascular disease. A nurse is collecting data from a group of clients. Which of the following clients should the nurse identify as having xanthelasma? .Lady with eyes closed with nodules on eye lid. A nurse is assisting with the admission of a client who has Vancomycin resistant enterococcus of the urine. Which of the following types of precautions should the nurse implement for this client? .Contact precautions. A community health nurse is assisting in the development of a brochure about hypertension. Which of the following actions should the nurse take? .Explain medical terminology using basic, one-syllable words. A nurse is collecting data from an adolescent during an annual physical examination. Which of the following statements by the client is the nurse's priority? ."I would rather be alone than with my friends." A nurse is placing a dressing over a stage 1 pressure ulcer on a client's heel, which of the following types of wound dressing should the nurse use? .Transparent Film. A nurse is caring for an older adult client who reports pain and has a prescription for ketorolac 15 mg IM every 5 hr PRN. The client's current blood pressure is 114/55 mm Hg. Which of the following actions should the nurse take? .Administer the medication to the client. A charge nurse in a long-term care facility is developing a performance improvement plan for an assistive personnel (AP). Which of the following actions should the nurse take when developing the plans? (Select all that apply) .a, set a specific time frame for meeting performance goals b. Ask the nurse supervisor to review the plan C, Include the performance standard that the AP should meet. A nurse is reinforcing teaching with a client who is undergoing radiation therapy to the neck. Which of the following instructions should the nurse include in the teaching? .Avoid exposing the neck to the cold. A nurse is assisting with the admission of an older adult client who has impaired mobility and is at risk for falls. Which of the following fall precautions should the nurse plan to implement? .Determine the client's ability to use the call light. A nurse is reinforcing teaching with a client about intermittent catheterization to measure residual urine. Which of the following information should the nurse include in the teaching? .You will need to urinate before the procedure. A nurse is caring for a client who has terminal cancer and has declined treatment. The nurse attempts to convince the client to reconsider his decision and discusses this attempt with the charge nurse. Which of the following actions should the charge nurse take? .Talk with the nurse about the need to support the client's decision. A nurse is reinforcing teaching about breastfeeding with a client who gave birth 2 days ago. Which of the following information should the nurse include? .Feed the newborn 8 to 12 times every 24 hr. A nurse is assisting with the admission of a school-aged child. Which of the following actions should the nurse plan to take? .Initiate contact precautions for the child. A nurse is reinforcing teaching with a client who has a prescription for antibiotic therapy. The client tells the nurse that he always experiences diarrhea when he takes antibiotics. Which of the following food choices should the nurse recommend to lessen the occurrence of diarrhea? .Yogurt. A nurse is assisting with the care of a client who has increased intracranial pressure following a closed head injury. Which of the following actions should the nurse take? .Elevate the head of the bed to 30 degrees. A nurse is assisting with the plan of care for a client who is in the third trimester of pregnancy and has ankle edema. Which of the following interventions should the nurse include in the client's plan of care? .Apply support stockings. A nurse is contributing to the plan of care for a client who is experiencing delirium. Which of the following interventions should the nurse recommend? .Remind the client of the day and time often. A nurse is reinforcing discharge teaching with a client who has a new diagnosis of tuberculosis. Which of the following instructions should the nurse include in the teaching? ."You should have a sputum examination every 4 weeks. A nurse is assisting with the care of a client who is at 37 weeks of gestation and is undergoing a nonstress test. Which of the following actions should the nurse take? .Remind the client to press the button when she feels fetal movement. A nurse is contributing to the plan of care for a client who has dysphagia. Which of the following interventions should the nurse include? .Tilt the client's head forward during meals. A nurse is reinforcing teaching with a client who is at 18 weeks of gestation and has a medical history of mild hypertension. For which of the following findings should the nurse instruct the client to monitor and report to the provider? .Persistent headache. A nurse is talking with the partner of a client who recently died, which of the following statements should the nurse make? ."Tell me what I can do for you at this time". A nurse is assisting with the admission of a client who states, "The last time I was in the hospital, the nurses took forever to answer my call light." Which of the following is an appropriate response by the nurse? .That must have been a difficult experience for you." A nurse in a provider's office is caring for a group of clients who have communicable diseases. Which of the following infections should the nurse report to the state health department? .Neisseria gonorrhoeae. A nurse is assisting with the admission of an adolescent client who is suspected to have bacterial meningitis. Which of the following findings should the nurse expect? .Nuchal rigidity. A nurse is reviewing laboratory findings for four clients. Which of the following laboratory values is an expected finding for a client who has end stage kidney disease? .Creatinine 15 mg/dl. A nurse is caring for a client who is taking warfarin and has an INR of 5.5. The nurse should expect which of the following instructions from the provider? .Obtain an aPTT level. A nurse is reinforcing teaching with the parents of an infant who has a Pavlik harness. Which of the following statements should the nurse include in the teaching? ."The harness can promote hip joint development". A nurse is caring for a client who is 2 days postoperative. The client has a prescription for acetaminophen 300 mg with codeine 30 mg, 1 tablet every 3 to 4 hr PRN for pain. The nurse inadvertently administers 2 tablets to the client. In which of the following locations should the nurse document this error? .Incident report. A nurse is preparing a sterile field to perform a dressing change for a client's leg wound, which of the following actions should the nurse take? .Place sterile objects at least 2.5 cm (1 in) from the edge of the sterile field. A nurse begins to bath a newly admitted client who reports that she has not had anything to eat that day. The nurse interrupts the bath and obtains a healthy meal for the client. This action by the nurse is an example of which of the following? .Countertransference. A nurse is contributing to the plan of care for a client who has herpes simplex. The nurse should plan to initiate which of the following isolation precautions when caring for this client? .Contact precautions. A nurse is documenting client care in the nurses notes and notices that a space was left blank. Which of the following actions should the nurse take? .Draw a horizontal line through the space and sign at the end of the line. A nurse is caring for a client who has AIDS. Which of the following solutions should the nurse disinfect the client's overhead table following a blood spill? .Bleach. A home health nurse is caring for an older adult client who has rheumatoid arthritis. Which of the following findings should the nurse identify as a safety risk? .The client's electrical wires are run under carpeting. A nurse is reinforcing teaching with a client who is about to undergo surgery. Which of the following statements about informed consent should the nurse include in the teaching? ."You can sign the informed consent form after the provider explains the pros and cons of the procedure. A nurse is reinforcing teaching with a client who has a trichomoniasis vaginalis infection and a new prescription for metronidazole. Which of the following instructions should the nurse include in the teaching? .you should expect your urine to turn brown. A nurse is obtaining informed consent from a client who is scheduled for an invasive procedure. The client states, "I don't understand why this procedure is necessary." Which of the following actions should the nurse take? .Notify the charge nurse about the situation. A nurse is reviewing information about advance directives with a newly admitted client. Which of the following statements by the client indicates an understanding of the information? ."Advance directives include a living will". A nurse is collecting data from the caregiver of a client who has Alzheimer's disease. The caregiver reports the client has difficulty sleeping at night and wanders throughout the house. Which of the following interventions should the nurse recommend? .Encourage the client to take frequent walks during the day. A nurse is assisting in the care of a client who is 8hr postpartum and has uterine atony with increased bleeding. Which of the following actions should the nurse take? (Select all that apply). .Assist the client to empty her bladder. A nurse is caring for an older adult client who is postoperative following a total hip arthroplasty. The client is incontinent of stool and urine. Which of the following actions should the nurse take to prevent skin breakdown? .Use a moisture barrier on the client's skin. A nurse is caring for a client who has terminal cancer. Which of the following actions should the nurse take to promote the client's autonomy? .Allow the client to choose treatment times. A nurse in a clinic is caring for a client who is at 40 weeks of gestation and experiences a sudden gush of vaginal fluids. Which of the following findings is evidence of an obstetric complication? .Appears greenish brown in color. A nurse is assisting with the care of an adolescent client immediately following a lumbar puncture. Which of the following actions should the nurse take? .inform the adolescent that he might experience a headache. A nurse is reinforcing teaching about advance directives with a client who has end stage heart failure. Which of the following statements by the client indicates an understanding of the teaching? ."I should discuss this document with my family after I sign it." A nurse is caring for a client who has continuous bladder irrigation following a transurethral resection of the prostate. The nurse notices clots and dark red blood in the catheter collection bag. Which of the following actions should the nurse take? .Irrigate the bladder with 20 to 30 mL of 0.9% sodium chloride irrigation. A nurse is planning to obtain a 12-lead ECG for a client who has a history of cardiac dysrhythmias. Which of the following actions should the nurse plan to take? .Instruct the client to remain as still as possible during the recording. A nurse is reinforcing teaching with a client who has genital herpes. Which of the following information should the nurse include in the teaching? ."You should increase fluid intake to relieve dysuria. A nurse is preparing to empty a postoperative client's closed-wound drainage system. Which of the following actions should the nurse plan to take? .Compress the container before replacing the drainage plug. A nurse is reinforcing teaching with the parents of a toddler who has a new diagnosis of asthma and a prescription for montelukast. Which of the following instructions should the nurse include in the teaching? .Administer the medication to the toddler each evening. A nurse in an acute mental health facility is caring for a newly admitted client. Which of the following should occur during the orientation phase of the nurse-client relationship? .Defining responsibilities. A nurse is caring for a client who reports having a decrease in fetal movement following an external cephalic version 6 hr ago. The nurse identifies the fetus is in the right occiput anterior position. The nurse should place the fetal heart monitor on which of the following sites to auscultate the fetal heart rate? .lower left. A charge nurse is observing a newly licensed nurse perform suctioning for a client who has a tracheostomy. For which of the following actions by the newly licensed nurse should the charge nurse intervene? .Suctions for 30 seconds. A nurse is reviewing the medication administration record of a client who takes atenolol PO and supplies a nitroglycerin transdermal patch daily. Which of the following interactions should the nurse monitor with this client? .Hypotension. A nurse in an acute care setting is preparing to administer medications to a client. Which of the following actions should the nurse verify the client's identity? .Verify the client's identity using a photograph. A nurse in a provider's office is collecting data from a client who has psoriasis. Which of the following statements made by the client should she report to the provider? ."I try not to look at the scales on my body." A nurse is completing chart reviews in a long-term care facility in response to an increase in falls. Which of the following responses in the chart should the nurse use to determine the potential causes of falls? .Medication record. A nurse is making client care assignments for an assistive personnel (AP). Which of the following tasks should the nurse assign to the AP? .Complete postmortem care for a client who has died. A nurse is reinforcing teaching with a client who is taking allopurinol about the risk for developing Stevens-Johnsons syndrome. For which of the following manifestations should the nurse instruct the client to monitor and report? .Skin rash with fever. A charge nurse in a long-term care facility is reinforcing teaching with a group of nurses about fall precautions. Which of the following statements made by the nurse indicates an understanding of the teaching? ."I will instruct the client to sit when putting on a pair of pants." A nurse is recommending clients for discharge to allow for admission of clients following a tornado disaster. Which of the following clients should the nurse recommend for discharge? .A client who has a sodium level of 140 mEq/L after one episode of diarrhea A nurse is assisting with the plan of care for a newly admitted client who has anorexia nervosa. Which of the following interventions should the nurse include in the plan? .Administer liquid supplements. A charge nurse is reinforcing teaching with a newly licensed nurse about floating to a different unit. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching? ."I will document in the medical record the support nurse who assists with planning care for my clients." A nurse is caring for a client who has dehydration due to diarrhea. Which of the following findings should the nurse report to the provider? .Urine output 12 mL/hr. A nurse is participating in a performance improvement program. Which of the following actions should the nurse take to evaluate the effectiveness of the program? .Identify data collection methods. A nurse in an assisted-living facility is reinforcing teaching with staff members about preparing for an external chemical disaster. Which of the following instructions should the nurse include? ."Move clients to a room above ground with few windows. A nurse is assisting in the care of a client who has an arteriovenous (AV) shunt in his right arm. Which of the following actions should the nurse take? .Check a bruit over the shunt on a regular basis. A nurse is caring for a client who has been admitted to the mental health unit. While reinforcing teaching about the client's prescribed exacerbations, the nurse communicates truthfully about the adverse effects of the medications. Which of the following ethical concepts is the nurse exhibiting? .Veracity A nurse is reinforcing teaching with the parents of a child who has a new diagnosis of Wilms tumor. Which of the following interventions should the nurse include in the teaching? ."You should not palpate your child's abdomen prior to surgery. A nurse enters the room of a school-age child and finds him on the floor experiencing a tonic-clonic seizure. Which of the following actions should the nurse take? .Place a pillow under the child's head. A nurse is contributing to the plan of care for a client who is to begin receiving intermittent enteral feedings. Which of the following actions should the nurse recommend? .Place the client in high-fowler's position during feedings. A nurse is collecting data from a client in an outpatient clinic and observes extensive bruising on the client's arms. This nurse suspects the client is experiencing intimate partner abuse. Which of the following is the nurse's priority action? .Offer support and create a safe, trusting environment. A nurse in an urgent care clinic is caring for a client who reports recently using methylenedioxymethamphetamine. Which of the following findings should the nurse expect? .Hallucinations. A nurse is collecting data from a client who received oxytocin 10 units IM 30 min ago for excessive vaginal bleeding. Which of the following findings should the nurse expect? .Boggy fundus 3 fingerbreadths above the umbilicus. A nurse is attending an educational workshop about client confidentiality. Which of the following actions by the nurse indicates an understanding of the teaching? .Changes her personal login password at random intervals. A nurse is assisting with discharge planning for a group of clients. Which of the following clients should the nurse recommend a home health referral? .An older adult client who has heart failure and lives alone. A nurse is reinforcing teaching with a female client who is taking phenytoin. Which of the following instructions should the nurse include in the teaching? .You might experience swollen gums while taking this medication. A nurse is preparing to administer paroxetine 15 mg PO oral suspension to a client who has a depressive disorder. The amount available is 10 mg/ 5 mL. How many mL should the nurse administer? (Round answer to the nearest tenth.) .7.5ml A nurse is reinforcing teaching with a client who is at 38 weeks of gestation and is to undergo a contraction stress test. Which of the following statements by the client indicates an understanding of the teaching? .I am having this test because my baby was not reactive during a nonstress test. A nurse is discussing health practices with the mother of a toddler who is from a different cultural background than the nurse. Which of the following statements by the mother indicates that she practices cupping? .I sometimes place a bottle containing steam against my child's skin. A nurse is reinforcing teaching with a client who has primary open-angle glaucoma and has a prescription for timolol eye drops. Which of the following statements by the client indicates an understanding of the teaching? .I should check my heart rate while taking this medication. A nurse is collecting data from a preschooler who has severe dehydration. Which of the following findings should the nurse expect? .Weight loss of 10%. A nurse is contributing to the plan of care for an older adult client. Which of the following physiological changes should the nurse consider when administering medication? .Decreased kidney function. A nurse is caring for a client who is taking multiple medications and asks about possible interactions. To which of the following members of the interdisciplinary team should the nurse make a referral? .Advanced practice nurse. A nurse is collecting data from a client who just received his first dose of sulfasalazine to treat ulcerative colitis. Which of the following findings should the nurse identify as an indication of an allergic reaction to this medication? .Dyspnea. A nurse is collecting nutritional data from a group of adult clients. For which of the following clients should the nurse recommend an interprofessional care conference with a dietician? .A client who has a body mass index of 32. A nurse is preparing a vitamin K injection to give to a newborn. The newborn's mother questions the purpose of this medication. Which of the following responses should the nurse make? .This medication will decrease the risk of hemorrhage in your newborn. A nurse is collecting data from a client who has diabetic ketoacidosis. Which of the following findings should the nurse report to the provider? .Fruity breath odor. A nurse is caring for a client who has a vacuum-assisted closure system to treat a pressure ulcer. Which of the following actions should the nurse take? .Use an adhesive remover to remove tape before reapplying a dressing. A nurse is verifying informed consent for a client who is preoperative for a vaginal hysterectomy. Which of the following statements should the nurse identify as an indication that the client has given informed consent? .I am thankful I am done having children. A nurse is caring for a client who is experiencing a tonic-clonic seizure. Which of the following actions should the nurse take? .Measure the duration of the seizure. A nurse is collecting data from a client who is at 12 weeks of gestation. The client states, "We've been trying to get pregnant for several months, but now I'm not so sure I'm ready." Which of the following responses should the nurse make? .Many women experience feelings of ambivalence during pregnancy. A nurse is caring for four clients. Which of the following situations require a signed consent form? .Administering an iron injection Z-track method. A nurse is receiving a report on four clients. The nurse should plan to collect data from which of the following clients first? .A preschooler who has epiglottis and is drooling. A nurse is caring for a client who reports frequent headaches after taking chewable isosorbide dinitrate. Which of the following statements should the nurse include? .The headaches should decrease as you get used to the medication. A nurse is implementing a bladder training program for a client who had a stroke. Which of the following interventions should the nurse take? .Check for residual urine after voiding. A nurse is contributing to the plan of care for a client who is pregnant and reports having trouble sleeping. Which of the following instructions should the nurse include in the plan of care? .Lie on your left side with your top leg forward. A nurse is reinforcing teaching with a client who has a new prescription for amitriptyline. Which of the following findings should the nurse include in the teaching as an adverse effect of this medication? .Orthostatic hypotension. A nurse is contributing to the plan of care for a client who has major depressive disorder. Which of the following recommendations should the nurse include in the plan of care? .Encourage the client to use positive self-talk. A nurse is preparing to administer ibuprofen solution 60 mg orally to a 7-month-old infant who is febrile. Available is ibuprofen 50 mg/ 1.25 mL. How many mL should the nurse administer? .1.5ml. A nurse is caring for a client who is experiencing alcohol withdrawal. Which of the following medications should anticipate administering to prevent complications of withdrawal? .Lorazepam. A nurse is assisting with the care of a client following electroconvulsive therapy for the treatment of a depressive disorder. Which of the following findings should the nurse expect 15 min following this procedure? .Disorientation. A nurse is monitoring a client who is postoperative. Which of the following actions should the nurse take when collecting data about the client's respirations? .Observe the movements of the client's chest wall. A nurse is preparing to give change-of-shift report on a client who is 2 days postoperative following a total knee arthroplasty. Which of the following information about the client should the nurse include in the report? .Time of last pain medication. A nurse is reinforcing discharge teaching with a client who has a bipolar disorder and a new prescription for carbamazepine. Which of the following statements by the client indicates an understanding of the teaching? .I will plan to avoid grapefruit juice while taking this medication. An assistive personnel tells the charge nurse that her assignment is too demanding. She angrily tells the nurse to reassign one of her tasks to another AP. Which of the following actions should the nurse take to resolve the conflict? .Ask the AP to discuss the issue in a private area. A nurse is reinforcing teaching with a client who has arthritis. Which of the following instructions should the nurse include in the teaching? .Engage in low-impact aerobic exercises. A nurse is caring for a female client who has an indwelling catheter with a urinary drainage system. Which of the following actions should the nurse take? .Secure the tubing with adhesive tape to the lower abdomen. A nurse is assisting with a support group for clients who have experienced intimate partner violence. The nurse should identify which of the following client statements as indicating the greatest risk for violence? .I have decided to tell my husband I am leaving him. A nurse is collecting data from a client who is receiving magnesium sulfate via continuous IV infusion for preterm labor. Which of the following findings should the nurse expect? .Hypotension A nurse is collecting data from a client who received oxytocin 10 units IM 30 mins ago for excessive vaginal bleeding. Which of the following findings should the nurse expect? .Client report of uterine cramping. A nurse in a providers office is reinforcing teaching about skin care with a client who has new diagnosis of systemic lupus erythematosus. Which of the following statements by the client indicates an understanding of the teaching? .I will dry my skin by patting it with a towel A nurse is collecting data from a 4-month-old infant at a well child visit. For which of the following findings should the nurse notify the provider? .Presence of grasp reflex A nurse is collecting data from a client who is 8 hours postoperative following an appendectomy. Which of the following manifestations is the best indications that the client needs a PRN analgesic? .The client reports pain as 7 on a scale of 0-10 A nurse is reinforcing teaching with the support person of a client who is in the first stage of labor. Which of the following instructions should the nurse include regarding effleurage? .Gently stroke her abdomen during contractions. A nurse is assisting with the admission of an adolescent client who is suspected to have bacterial meningitis. Which of the following findings should the nurse expect? .gently stroke her abdomen during contractions? Nuchal rigidity A nurse is about to administer an intermittent enteral feeding to a client who has an NG tube in place. Besides obtaining an x-ray, which of the following methods should the nurse use to verify placement? .Test the ph of the gastric aspirate A nurse working in a clinic is reinforcing with a client who has hep a. which of the following client statements indicates an understanding of the teaching? .I will use different hand towels than others in my home. A nurse is reinforcing teaching with a client who has a prescription for ferrous sulfate elixir. Which of the following statements by the client indicates an understanding of the teaching? .I will mix the medication with a full glass of water. A nurse is reinforcing teaching with a newly licensed nurse about caring for a client who has a history of dysphagia. Which of the following instructions should the nurse include in the teaching? .Place oral suction equipment next to the client's bedside. A nurse is assisting with the care of a client who is 6 hours postoperative following a right total knee arthroplasty. which of the following actions should the nurse take? .Maintain the head of the bed in high fowlers position. A nurse is providing a client with IV fluids and finds that the iv-pump screen is malfunctioning. Which of the following actions should the nurse take? .Discontinue use and tag the IV Pump. A nurse in an acute mental health facility is caring for an adolescent who is exhibiting destructive behavior. Which of the following actions should the nurse take after applying physical restraints to the client? .Monitor the client's range of motion every 60 min. A nurse is collecting data from a client who is 1 day post op following a TURP. which of the following findings should the nurse report to the provider? .Dark red urine. A nurse is contributing to the plan of care for a client who is scheduled to receive ECT for the treatment of depression. Which of the following actions should the nurse recommend to include in the plan? .Provide frequent reorientation after ECT. A charge nurse is discussing confidentiality requirements with a newly licensed nurse when sharing a client's medical information. Which of the following individuals should the charge nurse identify as appropriate with whom to share client information? .a. Social worker who is assigned to an involuntary committed school age client. A nurse is reviewing the medical record of five clients. For which of the following events should the nurse write an incident report? (SELECT ALL THAT APPLY). .a. A client fell when ambulating to the bathroom alone, d. a client who has an infection refused the evening meal. A nurse is participating in an interprofessional client care conference for a client who has experienced a stroke. The nurse should identify that which of the following client care requires reporting to the interprofessional team? .a. The client is unable to grasp eating utensils. nurse is reinforcing teaching about preventing dental caries with the parent of a 12-monthold toddler. Which of the following instructions should the nurse provide? .b. Clean the teeth with a small soft bristled toothbrush. A nurse is caring for a client who has a prescription for NPH insulin 10 units and regular insulin 15 units subcutaneously. After injecting 10 units of air into the NPH insulin vial, which of the following actions should the nurse take next? .a. Inject 15 units of air into the regular insulin vial. A nurse is caring for a client who recently gave birth to her first child. The newborn is crying and the client states, "I can't seem to do anything right. What should I do?" Which of the following responses should the nurse make? .c. Let me show you how to swaddle and cuddle him, then you try. A nurse is reinforcing teaching with a client who has an electrolyte imbalance. Which of the following foods should the nurse include as the lowest in potassium? .d. Wheat bread. A nurse in a mental health facility is caring for a client who reports palpitations and a sense of impending doom. Which of the following actions should the nurse take first? .b. Explain to the client that anxiety causes physical manifestations. A nurse is assisting with the plan of care for a client who has burns to his lower extremities. Which of the following actions should the nurse include in the plan? .d. Apply dressings with sterile gloves. A nurse is completing postmortem documentation for a client. Which of the following information should the nurse include in the documentation? .Location of the identification tag on the client's body. A nurse is collecting data from a client who has alcohol use disorder and is experiencing withdrawal. which of the following manifestations should the nurse expect? .c. Hypertension. A nurse is caring for a child who has terminal cancer. Which of the following responses by the child's school age brother should the nurse expect? .Believes his bad behavior is causing his brother's death. A charge nurse is reinforcing teaching with a newly licensed nurse about infection control measures. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching? .Soiled dressings should be placed in a biohazard trash receptacle. A nurse is reinforcing teaching about common discomforts during the first trimester with a client who is at 10 weeks of gestation. Which of the following examples should the nurse include? .b. Leukorrhea. A nurse enters a client's room and finds her sitting on the floor next to the shower. The client states that she slipped on some water outside of the shower. Which of the following actions should the nurse take first? .b. Measure the client's vital signs. A nurse is receiving change of shift report on four clients. Which of the following clients should the nurse plan to see first? .c. a Client who has a femur fracture and reports numbness of the toes. A nurse is collecting data from a client who is in the manic phase of bipolar disorder. Which of the following findings should the nurse expect? .b. Grandiose thinking. A nurse is reinforcing teaching with a client about monitoring her blood pressure at home with a digital device. Which of the following statements by the client indicate an understanding of the teaching? .a. I will know my blood pressure is too high if I get a reading of 140 over 90 or higher. A nurse on a medical surgical unit is preparing to assist with the admission of clients who were injured in a tornado. Which of the following clients should the nurse recommend for discharge to make room for the new admission ? .a. A client who had a radical mastectomy 36 hours ago and has a surgical drain. A nurse is collecting data from a client who is in renal failure. The nurse should identify that which of the following findings is a manifestation of hyperkalemia? .c. Irregular heart rate. A nurse is caring for a client who has been given methylergonovine intramuscularly for a postpartum hemorrhage. The nurse should monitor for which of the following adverse effects? .Hematuria. A nurse is supervising an AP who is providing client care. The nurse should identify that which of the following actions by the AP demonstrate effective use of supplies? .b. Wears clean gloves when performing oral care. A nurse is contributing to the plan of care for a client who is experiencing panic level anxiety and reports visual hallucinations. Which of the following actions should the nurse recommend including in the plan of care? .a. Use a low-pitched voice when speaking to the client. A nurse determines that clients who receive zolpidem post op have an increased fall rate compared to other postoperative clients. To which of the following members of the health care team should the nurse report these findings? .c. The risk manager. A nurse is reinforcing teaching with the parents of a child who has ADHD and is taking methylphenidate. Which of the following statements by the parents indicates that the medication is effective? .d. Our child is able to complete his homework on time. A nurse is assisting with a community health program for caregivers of clients who have Alzheimer's disease. Which of the following information should the nurse include? .d. Limit the number of choices for the client. A nurse is caring for a client who is on isolation precautions. Which of the following pieces of personal protective equipment should the nurse remove first? .a. Gloves. A nurse is administrating pancrelipase to a child who has cystic fibrosis. Which of the following outcomes should the nurse expect as a therapeutic effect of the treatment? .a. Reduced fat in the stools. A nurse is collecting data from a client who has left sided heart failure. For which of the following findings should the nurse notify the provider? .a. Productive cough with pink, frothy sputum. A nurse is assisting with the care of a client who is in the latent stage of labor and has pelvic pain with contractions. Which of the following actions should the nurse take? .d. Instruct the client to change positions frequently. A nurse is caring for a client who is postoperative following abdominal surgery and has a wound evisceration. Which of the following actions should the nurse take? .a. Cover the wound with sterile saline-soaked gauze. A nurse is reviewing medical record of a client who is taking acetaminophen to relieve headache pain. Which of the following conditions in the clients history should the nurse identify as a contraindication? .b. Hepatitis C. A nurse is reinforcing teaching about passive range of motion exercises with the family of a client who has had a stroke. Which of the following instructions should the nurse include in the teaching? .d. Support the extremity. A nurse is caring for a client who is unable to perform ADL's and wears dentures. Which of the following actions should the nurse take when providing denture care? .Place a towel in the sink when cleaning the dentures. A nurse is caring for a client who has peptic ulcer disease and is scheduled to undergo an esophagogastroduodenoscopy. Which of the following actions should the nurse take prior to the procedure? .a. Ensure that the client gave informed consent. A nurse is monitoring a client who has received external radiation for throat cancer. Which of the following findings should the nurse expect? .b. Loss of taste. A nurse is reinforcing teaching with a client who has GERD and a prescription for pantoprazole. Which of the following statements indicate an understanding of the teaching? .b. I have to take this medication on an empty stomach. A nurse is caring for an older adult client who has acute delirium. Which of the following actions should the nurse take first? .c. Determine the client's level of consciousness. A nurse is reinforcing teaching with a client who is scheduled to have a colonoscopy in 1 week. Which of the following client statements indicates an understanding of the teaching? .d. I'll have my friend drive me home after the procedure. A nurse at a long-term care facility is reviewing the plan of care for a client who has a prescription for mitten restraints. Which of the following tasks should the nurse assign to assistive personnel? .Assist the client with range of motion exercises of the hands. A nurse is caring for a client who has anorexia nervosa and a behavioral management plan in place. Which of the following findings should the nurse identify as an indication that the behavioral plan is effective? .c. Potassium 3.5. A nurse is collecting data from a client who has pyelonephritis and is receiving gentamicin via iv infusion. Which of the following manifestations should the identify as an adverse effect of the treatment? .c. New onset of hearing loss. A nurse is caring for a preschooler who recently experienced the death of a parent. Which of the following findings should the nurse identify as consistent with this age group? .a. Believes the death is punishment for bad behavior. A nurse is caring for a client who has toxoplasmosis and asks the cause of the infection. Which of the following responses should the nurse make? .a. Handling cat feces. A nurse is administering hydromorphone to a client who is experiencing postoperative pain. Which of the following findings is an adverse effect of this med? .c. Urinary retention A nurse is providing pre op care to a client who reports he has no one at home to help him after his outpatient surgery. Which of the following actions should the nurse take? .a. Assist with a referral to a home health care agency. A nurse is assisting with monitoring a client who is receiving a unit of packed RBC's. Which of the following findings indicates the client is experiencing a transfusion reaction? .a. Temperature 38.8C (101.8F). A nurse is reinforcing teaching with a client who is postop following a partial gastrectomy. Which of the following instructions should the nurse include to prevent dumping syndrome? .a. Include one serving of protein with each meal. A nurse is reinforcing teaching with a client who has a new prescription for a cervical cap as a form of contraception. Which of the following statements by the client indicates an understanding of the teaching? .c. I need to keep the cap in place for at least 6 hours after intercourse. A nurse is preparing to apply a thigh length sequential compression device for a client who is post op. Which of the following actions should the nurse take? .a. Measure the circumference of the client's upper leg. A nurse is collecting data from a client during a routine prenatal visit. The client is in their second trimester of pregnancy and reports feeling dizzy, has a racing heart, and becomes pale while lying on their back. Which of the following actions should the nurse take? .d. position the client on their left side. A nurse in an acute setting is assisting in collecting client information to include in a referral for a physical therapist. Which of the following information should the nurse plan to include? .b. Physical assessment findings. A nurse is collecting data from a client who has acute cholecystitis. which of the following findings should the nurse expect? .b. Pain in the right upper abdomen. A nurse is reinforcing teaching about newborn care with a new guardian. Which of the following statements by the guardian indicates an understanding of the teaching? .c. I will wash my baby's face with a warm wet washcloth without soap A nurse is reinforcing teaching with new parents about car seat safety. Which of the following instructions should the nurse include? .d. Place the shoulder harness at the level of the infants shoulders A nurse is reinforcing teaching with a client who has a new prescription for albuterol PRN. The nurse should reinforce with the client that the medication can help treat which of the following manifestations? .a. Shortness of breath. A nurse is contributing to an in service for newly licensed nurses about situations requiring an incident report. Which of the following examples should the nurse include? .a. A nurse discovers that an electronic Iv pump delivered twice the prescribed amount of fluid to a child A nurse is assisting with the care of a client who is receiving chemotherapy and radiation for advanced breast cancer. The client states I am thinking about stopping the treatment. which of the following responses should the nurse make? .b. tell me more about what you are thinking. A charge nurse is monitoring a group of assistive personnel regarding the use of gloves in contact isolation. For which of the following actions by an AP should the charge nurse intervene? .a. Removes gloves last after other personal protective equipment. A nurse is reinforcing teaching with a client who is at 12 weeks of gestation and has hyperemesis gravidarum. which of the following client statements indicate an understanding of the nurses instructions? .a. I will eat or drink something every 2 to 3 hours throughout the day. A nurse is assisting with the care of a client who is receiving a continuous iv infusion. which of the following indicates fluid volume excess? .c. Distended neck veins. A nurse is caring for a client who has a femur fracture with the leg in bucks traction. which of the following actions should the nurse take? .c. Compare bilateral pedal pulses. A nurse is caring for a client who is 2 days post op following an above the knee amputation. which of the following actions should the nurse take to promote progression toward independence and mobility for the client? .d. Encourage the client to use the overbed trapeze. A nurse is reinforcing teaching with the guardian of a 2-month-old infant about immunizations. which of the following statements by a guardian indicates an understanding of the teaching? .a. My baby will receive the rotavirus immunization orally. A nurse is reinforcing teaching about palliative care to a client who has cancer. Which of the following statements should the nurse make? .a. It enhances quality of life by promoting comfort. A nurse is reinforcing teaching with a client who has cystocele. Which of the following statements by the client indicates an understanding of the teaching? .d. I will practice perineal exercises to decrease urinary leakage. A nurse is caring for a client who suddenly develops chest pain and dyspnea. which of the following actions should the nurse take first? .Elevate the head of the client's bed. A nurse is caring for a client who has dementia. which of the following findings should the nurse expect? .b. Acute onset of confusion. A nurse is caring for a client who was admitted for observation following a head injury. which of the following findings by the nurse indicates the client is experiencing increased ICP? .Irritability. A nurse is caring for a client who has recently died. which of the following actions should the nurse take? .b. Place a pillow under the client's head. A nurse on a med surgical unit is assisting with the admission of a client who has advanced lung cancer. which of the following statements regarding advance directives should the nurse take? .b. Document the clients decisions about end-of-life care in the med record. A nurse is collecting data from a client who is 12 hours post op following intestinal surgery. which of the following findings should the nurse report to the charge nurse prior to the clients ambulation? .Oxygen saturation@ 90 degrees. A nurse is caring for a client who speaks a different language than the nurse. the client's partner tells the nurse that the client would like to go home against medical advice. which of the following actions should the nurse take? .Request the services of an interpreter to determine the client's wishes. A nurse in a providers office is caring for a group of clients who have communicable diseases. Which of the following infections should the nurse report to the state health department? .c. Neisseria gonorrhoeae. A nurse is preparing to delegate the client care to an ap which of the following information should the nurse verify prior to delegations? .b. The ap's job description. [Show More]

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