2022 exit V2 answered; attempt score 100% distinction level verified.. Graded A

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2022 exit V2 answered; attempt score 100% distinction level verified. The nurse knows that which statement by the mother indicates that the mother understands safety precautions with her four month... -old infant and her 4 year-old child? >>> "I have the 4 year-old hold and help feed the four month-old a bottle in the kitchen while I make supper." Upon completing the admission documents, the nurse learns that the 87 year-old client does not have an advance directive. What action should the nurse take? >>> Give information about advance directives A nurse administers the influenza vaccine to a client in a clinic. Within 15 minutes after the immunization was given, the client complains of itchy and watery eyes, increased anxiety, and difficulty breathing. The nurse expects that the first action in the sequence of care for this client will be to >>> Administer epinephrine 1:1000 as ordered Which of these children at the site of a disaster at a child day care center would the triage nurse put in the "treat last" category? >>> A toddler with severe deep abrasions over 98% of the body When admitting a client to an acute care facility, an identification bracelet is sent up with the admission form. In the event these do not match, the nurse's best action is to >>> Notify the admissions office and wait to apply the bracelet The nurse is having difficulty reading the health care provider's written order that was written right before the shift change. What action should be taken? >>> Call the provider for clarification An adult client is found to be unresponsive on morning rounds. After checking for responsiveness and calling for help, the next action that should be taken by the nurse is to: >>> open the client's airway A client has an order for 1000 ml of D5W over an 8 hour period. The nurse discovers that 800 ml has been infused after 4 hours. What is the priority nursing action? >>> Auscultate the lungs Following change-of-shift report on an orthopedic unit, which client should the nurse see first? >>> 72 year-old recovering from surgery after a hip replacement 2 hours ago A nurse observes a family member administer a rectal suppository by having the client lie on the left side for the administration. The family member pushed the suppository until the finger went up to the second knuckle. After 10 minutes the clientwas told by the family member to turn to the right side and the client did this. What is the appropriate comment for the nurse to make? >>> That was done correctly. Did you have any problems with the insertion? A client with a diagnosis of Methicillin resistant Staphylococcus aureus (MRSA) has died. Which type of precautions is the appropriate type to use when performing postmortem care? >>> contact precautions The nurse is reviewing with a client how to collect a clean catch urine specimen. Which sequence is appropriate teaching? >>> clean the meatus, begin voiding, then catch urine stream The provider orders Lanoxin (digoxin) 0.125 mg PO and furosemide 40 mg every day. Which of these foods would the nurse reinforce for the client to eat at least daily? >>> watermelon A nurse is stuck in the hand by an exposed needle. What immediate action should the nurse take? >>> Immediately wash the hands with vigor As the nurse observes the student nurse during the administration of a narcotic analgesic IM injection, the nurse notes that the student begins to give the medication without first aspirating. What should the nurse do? >>> Walk up and whisper in the student's ear "Stop. Aspirate. Then inject." A client with Guillain Barre is in a non responsive state, yet vital signs are stable and breathing is independent. What should the nurse document to most accurately describe the client's condition? >>> Glascow Coma Scale 8, respirations regular A client enters the emergency department unconscious via ambulance from the client's work place. What document should be given priority to guide the direction of care for this client? >>> A notarized original of advance directives brought in by the partner The charge nurse has a health care team that consists of 1 PN, 1 unlicensed assistive personnel (UAP) and 1 PN nursing student. Which assignment should be questioned by the nurse manager? >>> An admission at the change of shifts with atrial fibrillation and heart failure - PN A mother brings her 3 month-old into the clinic, complaining that the child seems to be spitting up all the time and has a lot of gas. The nurse expects to find which of the following on the initial history and physical assessment? >>> Restlessness and increased mucus production As the nurse takes a history of a 3 year-old with neuroblastoma, what comments bythe parents require follow-up and are consistent with the diagnosis? >>> ) "Clothes are becoming tighter across her abdomen." A 16 year-old enters the emergency department. The triage nurse identifies that this teenager is legally married and signs the consent form for treatment. What would be the appropriate action by the nurse? A) Ask the teenager to wait until >>> The correct answer is D: Proceed with the triage process in the same manner as any adult client A newly admitted elderly client is severely dehydrated. When planning care for this client, which task is appropriate to assign to an unlicensed assistive personnel (UAP)? >>> The correct answer is B: Report output of less than 30 ml/hr The nurse has admitted a 4 year-old with the diagnosis of possible rheumatic fever. Which statement by the parent would cause the nurse to suspect an association with this disease? >>> The correct answer is B: Strep throat went through all the children at the day care last month. A nurse assigned to a manipulative client for 5 days becomes aware of feelings for a reluctance to interact with the client. The next action by the nurse should be to >>> The correct answer is A: Discuss the feeling of reluctance with an objective peer or supervisor A client is being treated for paranoid schizophrenia. When the client became loud and boisterous, the nurse immediately placed him in seclusion as a precautionary measure. The client willingly complied. The nurse's action >>> The correct answer is A: May result in charges of unlawful seclusion and restraint A client has been admitted to the Coronary Care Unit with a myocardial infarction. Which nursing diagnosis should have priority? >>> The correct answer is A: Pain related to ischemia The provisions of the law for the Americans with Disabilities Act require nurse managers to >>> The correct answer is B: Provide reasonable accommodations for disabled individuals A 42 year-old male client refuses to take propranolol hydrochloride (Inderal) as prescribed. Which client statement s from the assessment data is likely to explain his noncompliance? >>> The correct answer is C: "I have diminished sexual function." A school-aged child has had a long leg (hip to ankle) synthetic cast applied 4 hoursago. Which statement from the mother indicates that teaching has been inadequate? >>> The correct answer is D: "I think I remember that standing cannot be done until after 72 hours." Which statement best describes time management strategies applied to the role of a nurse manager? >>> The correct answer is C: Set daily goals with a prioritization of the work The pediatric clinic nurse examines a toddler with a tentative diagnosis of neuroblastoma. Findings observed by the nurse that is associated with this problem include which of these? >>> The correct answer is D: Abdominal mass and weakness A 15 year-old client has been placed in a Milwaukee Brace. Which statement from the adolescent indicates the need for additional teaching? >>> The correct answer is A: "I will only have to wear this for 6 months." The nurse manager has been using a decentralized block scheduling plan to staff the nursing unit. However, staff have asked for many changes and exceptions to the schedule over the past few months. The manager considers self scheduling knowing that this method will >>> The correct answer is D: Improve team morale A client is admitted to the emergency room following an acute asthma attack. Which of the following assessments would be expected by the nurse? >>> The correct answer is A: Diffuse expiratory wheezing The nurse manager hears a health care provider loudly criticize one of the staff nurses within the hearing of others. The employee does not respond to the health care provider's complaints. The nurse manager's next action should be to >>> The correct answer is D: Request an immediate private meeting with the health care provider and staff nurse A client is admitted to a voluntary hospital mental health unit due to suicidal ideation. The client has been on the unit for 2 days and now states "I demand to be released now!" The appropriate action is for the nurse to >>> The correct answer is C: Let's discuss your decision to leave and then we can prepare you for discharge A client is admitted with infective endocarditis (IE). Which symptom would alert the nurse to a complication of this condition? A) Dyspnea >>> The correct answer is B: Heart murmur Large, soft, rapidly developing vegetations attach to the heart valves.A nurse admits a premature infant who has respiratory distress syndrome. In planning care, nursing actions are based on the fact that the most likely cause of this problem stems from the infant's inability to >>> The correct answer is B: Maintain alveolar surface tension An 18 year-old client is admitted to intensive care from the emergency room following a diving accident. The injury is suspected to be at the level of the 2nd cervical vertebrae. The nurse's priority >>> The correct answer is C: Respiratory function The nurse is caring for a client who was successfully resuscitated from a pulseless dysrhythmia. Which of the following assessments is CRITICAL for the nurse to include in the plan of care? >>> The correct answer is A: Hourly urine output The charge nurse on the night shift at an urgent care center has to deal with admitting clients of a higher acuity than usual because of a large fire in the area. Which style of leadership and decision-making would be best in this circumstance? >>> The correct answer is A: Assume a decision making role The nurse admitting a 5 month-old who vomited 9 times in the past 6 hours should observe for signs of which overall imbalance? >>> The correct answer is B: Metabolic alkalosis Which activity can the RN ask an unlicensed assistive personnel (UAP) to perform? >>> Which activity can the RN ask an unlicensed assistive personnel (UAP) to perform? A child is injured on the school playground and appears to have a fractured leg. The first action the school nurse should take is >>> The correct answer is C: Assess the child and the extent of the injury When interviewing the parents of a child with asthma, it is most important to gather what information about the child's environment? >>> The correct answer is A: Household pets An 80 year-old client admitted with a diagnosis of possible cerebral vascular accident has had a blood pressure from 180/110 to 160/100 over the past 2 hours. The nurse has also noted increased lethargy. Which assessment finding should the nurse report immediately to the health care provider? >>> The correct answer is A: Slurred speech A 3 year-old child is brought to the clinic by his grandmother to be seen for "scratching his bottom and wetting the bed at night." Based on these complaints, the nurse would initially assess for which problem? >>> The correct answer is D: Pinworms A 72 year-old client with osteomyelitis requires a 6 week course of intravenous antibiotics. In planning for home care, what is the most important action by the nurse?A) Investigating the client's insurance coverage for home IV antibiotic therapy >>> The correct answer is C: Assessing the client's ability to participate in self care and/or the reliability of a caregiver The mother of a child with a neural tube defect asks the nurse what she can do to decrease the chances of having another baby with a neural tube defect. What is the best response by the nurse? >>> The correct answer is A: "Folic acid should be taken before and after conception A PN is assigned to care for a newborn with a neural tube defect. Which dressing if applied by the PN would need no further intervention by the charge nurse? >>> The correct answer is B: Moist sterile non adherent dressing A nurse is providing a parenting class to individuals living in a community of older homes. In discussing formula preparation, which of the following is most important to prevent lead poisoning? >>> The correct answer is C: Let tap water run for 2 minutes before adding to concentrate A client is admitted to the rehabilitation unit following a CVA and mild dysphagia. The most appropriate intervention for this client is >>> The correct answer is A: Position client in upright position while eating The nurse explains an autograft to a client scheduled for excision of a skin tumor. The nurse knows the client understands the procedure when the client says, "I will receive tissue from... >>> THe correct answer is C: my thigh." The nurse is caring for a newborn with tracheoesophageal fistula. Which nursing diagnosis is a priority? >>> The correct answer is B: Ineffective airway clearance A client has been hospitalized after an automobile accident. A full leg cast was applied in the emergency room. The most important reason for the nurse to elevate the casted leg is to >>> The correct answer is D: Improve venous return During the initial home visit a nurse is discussing the care of a newly diagnosed client with Alzheimer's disease with family members. Which of these interventions would be most helpful at this time? >>> The correct answer is D: Suggest communication strategies The nurse is teaching a client with non-insulin dependent diabetes mellitus about the prescribed diet. The nurse should teach the client to >>> The correct answer is D: Keep a regular schedule of meals and snacks The mother of a 2 month-old baby calls the nurse 2 days after the first DTaP, IPV, Hepatitis B and HIB immunizations. She reports that the baby feels very warm, cries inconsolably for as long as 3 hours, and has had several shaking spells. In addition toreferring her to the emergency room, the nurse should document the reaction on the baby's record and expect which immunization to be most associated to the findings in the infant? >>> The correct answer is A: DTaP The nurse is teaching a class on HIV prevention. Which of the following should be emphasized as increasing risk? >>> The correct answer is C: Unprotected sex The charge nurse is planning assignments on a medical unit. Which client should be assigned to the unlicensed assistive personnel (UAP)? A client with >>> The correct answer is B: an order of enemas until clear prior to colonoscopy A 6 year-old child is seen for the first time in the clinic. Upon assessment, the nurse finds that the child has deformities of the joints, limbs, and fingers, thinned upper lip, and small teeth with faulty enamel. The mother states: "My child seems to have problems in learning to count and recognizing basic colors." Based on this data, the nurse suspects that the child is most likely showing the effects of which problem? >>> The correct answer is C: Fetal alcohol syndrome The nurse has performed the initial assessments of 4 clients admitted with an acute episode of asthma. Which assessment finding would cause the nurse to call the health care provider immediately? >>> The correct answer is B: Expiratory wheezes that are suddenly absent in one lobe The nurse is planning a meal plan that would provide the most iron for a child with anemia. Which dinner menu would be best? >>> The correct answer is B: Ground beef patty, lima beans, wheat roll, raisins, milk A 10 year-old client is recovering from a splenectomy following a traumatic injury. The clients laboratory results show a hemoglobin of 9 g/dL and a hematocrit of 28 percent. The best approach for the nurse to use is to >>> The correct answer is C: Plan nursing care around lengthy rest periods The nurse planning care for a 12 year-old child with sickle cell disease in a vasoocclusive crisis of the elbow should include which one of the following as a priority? >>> The correct answer is B: Client controlled analgesia As the nurse provides discharge teaching to the parents of a 15 month-old child with Kawasaki disease. The child has received immunoglobulin therapy. Which instruction would be appropriate? >>> The correct answer is D: The measles, mumps and rubella vaccine should be delayed The nurse is giving instructions to the parents of a child with cystic fibrosis. The nurse would emphasize that pancreatic enzymes should be taken >>> The correct answer is C: With each meal or snackThe nurse is assessing an 8 month-old infant with a malfunctioning ventriculoperitoneal shunt. Which one of the following manifestations would the infant be most likely to exhibit? >>> The correct answer is B: Irritability The nurse is performing a physical assessment on a toddler. Which of the following should be the first action? >>> The correct answer is B: Use minimal physical contact A client has been tentatively diagnosed with Graves' disease (hyperthyroidism). Which of these findings noted on the initial nursing assessment requires quick intervention by the nurse? >>> The correct answer is C: The appearance of eyeballs that appear to "pop" out of the client''s eye sockets Which serum blood findings with diabetic ketoacidosis alerts the nurse that immediate action is required? >>> The correct answer is C: HCT of 60 The nurse is preparing the teaching plan for a group of parents about risks to toddlers. The nurse plans to explain proper communication in the event of accidental poisoning. The nurse should plan to tell the parents to first state what substance was ingested and then what information should be the priority for the parents to communicate? >>> The correct answer is D: The affected child''s age and weight A 2 year-old child is brought to the health care provider's office with a chief complaint of mild diarrhea for 2 days. Nutritional counseling by the nurse should include which statement? >>> The correct answer is B: Continue with the regular diet and include oral rehydration fluids The nurse is teaching an elderly client how to use MDI's (multi-dose inhalers). The nurse is concerned that the client is unable to coordinate the release of the medication with the inhalation phase. What is the nurse's best recommendation to improve delivery of the medication? >>> The correct answer is B: Adding a spacer device to the MDI canister Which of the following manifestations observed by the school nurse confirms the presence of pediculosis capitis in students? >>> The correct answer is D: Whitish oval specks sticking to the hair When parents call the emergency room to report that a toddler has swallowed drain cleaner, the nurse instructs them to call for emergency transport to the hospital. While waiting for an ambulance, the nurse would suggest for the parents to give sips of which substance? >>> The correct answer is B: Water A client is scheduled for an IVP (Intravenous Pyelogram). Which of the followingdata from the client's history indicate a potential hazard for this test? >>> The correct answer is B: Allergic to shellfish The nurse is preparing a handout on infant feeding to be distributed to families visiting the clinic. Which notation should be included in the teaching materials? >>> The correct answer is A: Solid foods are introduced 1 at a time beginning with cereal The nurse is caring for a client with sickle cell disease who is scheduled to receive a unit of packed red blood cells. Which of the following is an appropriate action for the nurse when administering the infusion? >>> The correct answer is C: Limit the infusion time of each of the unit to a maximum of four hours A client with a documented pulmonary embolism has the following arterial blood gases: PO2 - 70 mm hg, PCO2 - 32 mm hg, pH - 7.45, SaO2 - 87%, HCO3 - 22. Based on this data, what is the first nursing action? >>> The correct answer is C: Administer oxygen A client diagnosed with hepatitis C discusses his health history with the admitting nurse. The nurse should recognize which statement by the client as the most important? >>> The correct answer is D: I had a blood transfusion A client is recovering from a thyroidectomy. While monitoring the client's initial post operative condition, which of the following should the nurse report immediately? >>> The correct answer is A: Tetany and paresthesia A client is admitted with a right upper lobe infiltrate and to rule out tuberculosis. The most appropriate action by the nurse to protect the self would be which of these? >>> The correct answer is C: Particulate respirator mask A client had 20 mg of Lasix (furosemide) PO at 10 AM. Which would be essential for the nurse to include at the change of shift report? >>> The correct answer is C: The client's urine output was 1500 cc in five hours The nurse is caring for a client with a colostomy. During a teaching session, the nurse recommends that the pouch be emptied >>> The correct answer is A: When it is 1/3 to 1/2 full Lactulose (Chronulac) has been prescribed for a client with advanced liver disease. Which of the following assessments would the nurse use to evaluate the effectiveness of this treatment? >>> The correct answer is C: A decrease in lethargy The mother of a 3 month-old infant tells the nurse that she wants to change fromformula to whole milk and add cereal and meats to the diet. What should be emphasized as the nurse teaches about infant nutrition? >>> The correct answer is B: Whole milk is difficult for a young infant to digest The nurse is assessing a 55 year-old female client who is scheduled for abdominal surgery. Which of the following information would indicate that the client is at risk for thrombus formation in the post-operative period? >>> The correct answer is A: Estrogen replacement therapy The nurse is planning discharge for a 90 year-old client with musculoskeletal weakness. Which intervention should be included in the plan and would be most effective for the prevention of falls? >>> The correct answer is A: Place nightlight in the bedroom An 8 year-old client is admitted to the hospital for surgery. The child's parent reports the following allergies. Of these allergies which one should all health care personnel be aware of? >>> The correct answer is C: Balloons The nurse is caring for a client who is post-op following a thoracotomy. The client has 2 chest tubes in place, connected to 1 chest drain. The nursing assessment reveals bubbling in the water seal chamber when the client coughs. What is the most appropriate nursing action? >>> The correct answer is C: Continue to monitor the client to see if the bubbling increases The nurse is reinforcing teaching to a 24 year-old woman receiving acyclovir (Zovirax) for a Herpes Simplex Virus type 2 infection. Which of these instructions should the nurse give the client? >>> The correct answer is B: Begin treatment with acyclovir at the onset of symptoms of recurrence An 8 year-old child is hospitalized during the edema phase of minimal change nephrotic syndrome. The nurse is assisting in choosing the lunch menu. Which menu is the best choice? >>> The correct answer is C: Chicken strips, corn on the cob, milk The nurse is teaching parents about accidental poisoning in children. Which point should be emphasized? >>> The correct answer is B: Empty the child''s mouth in any case of possible poisoning Which of the following findings contraindicate the use of haloperidol (Haldol) and warrant withholding the dose? >>> The correct answer is C: Rash, blood dyscrasias, severe depression The nurse is planning care for a 14 year-old client returning from scoliosis corrective surgery. Which of the following actions should receive priority in the plan? >>> The correct answer is C: Assess movement and sensation of extremitiesA 3 year-old child diagnosed as having celiac disease attends a day care center. Which of the following would be an appropriate snack? >>> The correct answer is C: Potato chips A client with moderate persistent asthma is admitted for a minor surgical procedure. On admission the peak flow meter is measured at 480 liters/minute. Post-operatively the client is complaining of chest tightness. The peak flow has dropped to 200 liters/minute. What should the nurse do first? >>> The correct answer is B: Administer the PRN dose of Albuterol What finding signifies that children have attained the stage of concrete operations (Piaget)? >>> The correct answer is C: Makes the moral judgment that "stealing is wrong" The nurse is caring for a 17 month-old with acetaminophen poisoning. Which of the following lab reports should the nurse review first? >>> The correct answer is D: Liver enzymes (AST and ALT) The nurse is teaching parents about diet for a 4 month-old infant with gastroenteritis and mild dehydration. In addition to oral rehydration fluids, the diet should include >>> The correct answer is A: Formula or breast milk The nurse instructs the client taking dexamethasone (Decadron) to take it with food or milk. What is the physiological basis for this instruction? >>> The correct answer is B: Stimulates hydrochloric acid production The nurse is planning care for a 3 month-old infant immediately postoperative following placement of a ventriculoperitoneal shunt for hydrocephalus. The nurse needs to >>> The correct answer is A: Assess for abdominal distention The mother of a 2 year-old hospitalized child asks the nurse's advice about the child's screaming every time the mother gets ready to leave the hospital room. What is the best response by the nurse? >>> The correct answer is C: "Keep in mind that for the age this is a normal response to being in the hospital." When caring for a client receiving warfarin sodium (Coumadin), which lab test would the nurse monitor to determine therapeutic response to the drug? >>> The correct answer is C: Prothrombin time The nurse is caring for a 4 year-old 2 hours after tonsillectomy and adenoidectomy. Which of the following assessments must be reported immediately? >>> The correct answer is D: Increased restlessness [Show More]

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