Nclex New Final

SATA The nurse is collecting data from a client with an acute Myocardial infraction (MI) . Which of the following findings would be consistent with an acute MI? SATA 1) 2) 3) 4) 5) 6)

Nausea and vomiting Diaphoresis – sweating Dyspnea – shortness of breadth Nailbed splinter hemorrhages Petechiae Dizziness and fatigue

A nurse is collecting data with COPD patient. Which of the following findings would be a priority to report to the charge nurse ?

1.

The client reports getting tired easily – normal

2.

The client reports having increased sputum production in the morning – normal

3.

The client's breathing is shallow

4.

The clients sputum is yellow – most likely cause its infection

Yellow + Green + PINK = Infection

The nurse is preparing for a client for an emergency surgery to repair a depressed skull fracture. Which of the following for actions are essential for the nurse to make ?

1.

Determining the time that the client last ate – most likely = client should remain NPO 8 hrs before surgery , no NSAIDS

2.

Showing the client a picture of the postoperative would drainage system

3.

Telling the client what will occur in the post anesthesia care unit (PACU)

4.

Checking the client's corneal reflex = 1 st then 2

Surgery = NPO , NO NSAIDS

The nurse is assisting to admit a client with active pulmonary tuberculosis TB. Which of the following actions should the nurse take prior to the client’s arrival?

1) Assign the client to room with client who has pertussis if a private room is not available 2) Have a particular respirator mask available for client transport - surgical mask 3) Have a particular respirator mask available for staff who care for the client 4) Post a sign outside the room restricting pregnant women from entering the room = only for varicella zoster - again post

The nurse is contributing to staff education conference about advance directives. Which of the following information should the nurse recommend including ? SATA 1) Advance directives support a client’s ethical right autonomy = Client wishes 2) A client’s may designate another person to make health care decisions for the client

3) Health care facilities must ask clients if they have completed an advance directive

4) Advance directives indicates a client; s treatment wishes for acute diagnoses = chronic illness 5) A living will must be witnesses by a client’s attorney Patient doesn’t have consult HCP for advance directives , or the person listed, another second nurse is okay

The nurse is talking with the parent of 3 month old client . The client expresses concern that the infant in unable to roll over. Which of the following would be an appropriate response for the nurse to make ? 1) 2) 3) 4)

We should inform your child’s primary health care provider about this delay Most infants are able to roll over between ages 4 to 6 months Does your infant smile in response to your smile ? Is your infant able to pick up objects

The nurse is caring for client with pertussis . Which of the following infection control precautions should the nurse implement ? 1) 2) 3) 4)

Place a stethoscope in the client’s room to be used for the client only Wear gloves when checking the client’s pulse Wear a protective gown when bathing the client Wear a surgical mask when assisting the client to eat or giving medications Pertussis = Droplet precautions

UAP directions 1) 2) 3) 4)

Client’s who are unable to ambulate should be assisted to ambulate after meals Notify me if any pts develops an abnormal temperature Check the meal trays distributed to client’s with DM type 1 Obtain vital signs first for the client with Hypertension and report the results to me Time and minutes are important

The nurse is caring for client who has active TB . Which of the following infection control precautions should the nurse implement ? 1) Put on sterile gloves to administer prescribed medications to the client = No need , just the clean gloves 2) Perform hand hygiene prior to checking the client’s vital signs 3) Wear a particular respirator mask when assisting the client’s to bathe 4) Wear a protective gown if clothing may be soiled = contact isolation 5) Close the door after entering client’s room

The nurse has reinforced teaching with a client who has an ileal conduit. Which of the following statements by the client would indicate a correct understanding of the teaching ? 1) 2) 3) 4)

I will need to awaken several times at night to empty the pouch I can expect mucus in my urine = ileal conduit. The stoma should be a dark purple color I will need to limit by fluid intake

UAP 1) 2) 3) 4)

Record your assigned client’s vital sign before you take mid-morning break Weigh your assigned client’s before breakfast with the scale used 1 day ago- could be Help the clients who eat their meals in the dining room with breakfast Measure the amount of your assigned client intake and output regularly = no time, no min provided

The nurse is caring for client who is prescription of darbepoetin 0.45mcg/kg , subcutaneously. The client weighs 190lb (86KG) . The nurse has 100 mcg.ml solution available. How many ML should the nurse administer with each dose ? 0.4 0.45mcg kg Kg 2.2lb 0.38 = 0.4

190 LB mL X 100MCG

The nurse is reinforcing teaching with the parents of a child who is scheduled for surgical repair of hypospadias. The nurse should reinforce that intended outcomes of the procedure include. 1) 2) 3) 4)

Relief from pain Relief from bladder obstruction- maybe The ability to void while standing The ability to achieve an erection

The nurse is caring for client who has just returned from the radiology department after having an upper gastrointestinal UGI series. Which of the following action should the nurse take first ? 1) 2) 3) 4)

Administer the prescribed enema Give the prescribed multiple vitamin that was withheld prior to the procedure Determine whether follow-up x-rays are to be taken Verify the preliminary test results – most likely Assess , check , collect data , Determine , verify = correct answers

The nurse is collecting data from a client who has hypovolemic shock . which findings are consistent with hypovolemic shock? SATA 1) 2) 3) 4) 5)

Confusion Hypertension Decreased urine output Elevated respiratory rate Jugular vein distention

with increased circulating blood volume/CHF Chronic health failure 1. Hyperention = CHF , coz with heart problems , you have HTN 2. Jugular vein distention

Chronic health failure = edema is present = give Furosemide , MIDE’S

The nurse has reinforced dietary teaching with a client who has esophageal varices. Which of the following food choices by the client would indicate a correct understanding of the teaching ? 1) 2) 3) 4)

1 cup vanilla yogurt 8oz of chicken broth- mostly likely clear liquid 4 oz of pretzels- hard to chew 1 fresh apple – hard to chew

1. The charge nurse in a long-term care facility has been advised that the following Assign clients with me it will be admitted during the shift the charge nurse should assign the only available private room to which client ? 1. Pneumocystis pneumonia – droplet precautions 2.A positive vericella zoster titer ( Chicken pox ) – Airborne 3.Hepatitis C 4. A positive cytomegalovirus

A nurse has received the following information about a sign clients then there should first check the client? 1. Who has right sided heart failure at and is reporting frequent urination 2. With active pulmonary tuberculosis who is reporting expectorating blood tinged mucous = expected 3. Who has a fractured femur and received a dose of pain medication intramuscular one hour ago and is reporting that the pain has not been relieved 4. With benign prostatic hyperplasia who is reporting having no bowel movement for the past three days and is requesting a does of prescribed laxative 3 – compartment syndrome Breathing and pain comes first .

A nurse is collecting data from a client with Guillian Barre . The client is experiencing paralysis and paracentesis of the lower extremity and has a respiratory rate of 18 which of the following actions should the nurse take? 1.Massage the clients legs every two hours 2. Monitor the clients respiratory rate frequently 3. Pad the side rails of the clients bed 4. Keep the head of the bed elevated at 30° Paracentesis = Sitting up with legs dangling Thoracentesis = Sitting up in the bed , leaning on the table Lumber puncture = lateral position , knees flexed After = lie flat

The nurse is caring for a client who has been diagnosed with a hookworm infestation. The clients parent asks how can I prevent my other children from getting hookworm? Which of the following would be appropriate response for the nurse to make? 1. Cook all the meet is thoroughly 2. Have your pets treated for the worms = its not worm related 3.  Encourage your children to wear shoes when outside 4. Wash all clothing in hot water – pediculosis ( LICE)

The nurse In an ambulatory care facility has been advised that several clients have arrived for scheduled appointment the nurse should ask a client with which of the following concerns to come to a private examination room first 1. A productive cough with night sweats = nagging cough means cancer 2. Diabetes mellitus with tingling in both feet = expected 3. Red eyes with moderate Tearing = The word moderate / mild used is okay 4. Emphysema with clubbing of the fingernails

7. A nurse is caring for a client with pediculosis Which of the following infection control precautions should the nurse implement? 1. Place a thermometer in the clients room to be use for the client only 2. Where is surgical mask when assisting the client to bathe – this is for droplet precautions 3. Keep the door to the clients room closed = not necessary 4. Remove the gloves after leaving the clients room = before leaving the clients room Pediculosis = Contact isolation Contact isolation = used dedicated items

8. The nurse is assisting with the plan of care of a client with moderate Alzheimer’s disease which of the following intervention should the nurse suggest including in the clients plan of care? Select all that apply 1.  Avoid the use of restraints 2. Avoid reminiscing about happy times in the clients life = why avoid 3. Use the distraction when the client becomes anxious or agitated 4. Provide the client with a wide selection of food choices at mealtime = patient is confused, no need 5. Speak slowly and use short simple sentences when providing the client with information 6. Ride to family members with information about community support services for respite care – maybe No need to have open questions technique = Alzheimer’s No need explaining the procedure = Alzheimer’s

9.The nurse is contributing to a staff development conference about confidentiality which of the following information should the nurse suggest including? 1.Client must wait until after discharge to review their medical records 2. Nurses on a hospital unit must may review the medical records for all clients on the unit 3. Certain information in the clients medical record may not be considered confidential 4. Clients must disclose all personal information order to receive care = no need

assign the UAP? 1. Obtain vital signs from the client with major depression 2. Provide medication teaching to the client with schizophrenia = RN 3. Monitor medication side effects of the client with bipolar disorder = RN 4. Telephoning the primary care provider to report the intake and output information from the client with anorexia nervosa = RN

Teaching , Monitoring , Telephoning x-ray/family members/provider , Evaluating , checking Quality, Care plan ,newly/first = RN role

provide the best directions to the UAP about the assignments? 1.Your clients will need assistance to ambulate once in the morning and once in the afternoon 2.Obtain vital signs for clients every four hours and report any abnormal measurements 3.Assist clients who are on special diets to eat their meals 4. Turn clients who are on bed rest onto the left side for two hours/ 2 hrs and then on to the right side for two hours until lunch is served – 1 ST To prevent pressure ulcers

The nurse is contributing to a staff education conference about advance directive which of the following information should the nurse recommend including? select all that apply 1. Advance directive support a clients ethical ride to autonomy = client wishes 2. A client may designate another person to make healthcare decisions for the client  3. Healthcare facilities must ask clients if they have completed an advance directive 4. advanced directives indicate a clients treatment wishes for acute diagnosis 5. A living will must be witnessed by a clients attorney The word must be / only are doughy

And nurses assisting to admit a client with active pulmonary tuberculosis. Which of the following actions should the nurse take prior to the clients arrival? 1. Assign the client to room with a client who has pertussis if a private room is not available 2. Have a particulate Respiratory mask available for a client transport 3.  Have particulate respiratory mask available for staff will care for the client 4.  Post a sign outside the room restricting Pregnant women from entering the room

new UAP? 

Bathing the client who has an altered mental status = RN



Assisting the client who uses a walker to Ambulate



Check in the vital signs of a client who has a peripheral vascular access device



Adjusting the prescribed oxygen flow rate for the client based on oxygen saturation levels = RN



Measuring the oral intake and urine output for a client who has an indwelling urethral catheter = RN



Checking the client using correct gait= RN

Ambulate , Bathing , Input and output , vitals stable clients , Alzheimer’s pts= UAP

The nurse is contributing to the plan of care for a client who had a stroke three days ago and has right sided hemiplegia and dysphasia ( Difficulty swallowing).Which of the following nutritional outcomes would be most appropriate for the nurse to recommend including in the clients plan of care? 1. The client will eat 90% of each meal 2. The client will eat without episodes of coughing 3.  The client will drink for ounces of juice or water with each meal 4. The client will drink liquids without drooling

Charge nurse provide the best information to a UAP about the assignments? 1. The client needs assistance to get out of bed = no time given 2.The client needs to have food cut into bite sized pieces – safety first 3.  The client needs range of motion exercises every four hours – time frame given 4. The client needs frequent perineal care = no time given The word frequent in an answer = means wrong answer , no time frame give

And the nurse is collecting data from a client who had a kidney transplant five days ago which of the following findings would require immediate intervention? 2. Blood pressure 154/96- BP Should be low 3. 2.Blood urea nitrogen 20 MG/DL = Range 6 – 20 4. You’re in output of 120 ml in the past four hours - Normal as 30/hr 5. Incisional pain rated five on a scale of 0 (no pain) to 10 (severe pain) – 5 is Normal pain rating Before kidney surgery or after the surgery = check BP

The nurse is collecting data from a client with sickle cell anemia which of the following statements by the client will it be essential to follow up/ further teaching ? 1. I usually drink 4 L of water or juice daily 2. I am scheduled to receive the influenza vaccine 3. I may need to receive a prescribed anti-infective if I develop a fever 4. I have been applying ice/cold packs daily to help relieve the pain in my knees Sickle cell anemia/diseases = No ICE , COLD packs

The nurse is observing a coworker suctioning a client with a tracheostomy the Nurse should intervene if the coworker - sterile technique 1. Appliance suction as the catheter is being withdrawn  2.  Wears a face shield throughout the procedure 3. Applies suction for 10 seconds at each pass of the catheter 4. Wears clean non-sterile gloves throughout the procedure = suctioning a client with a tracheostomy = sterile gloves technique

The nurse is talking with a client who has schizophrenia the client states I just returned from Mars which of the following responses would be appropriate for the nurse to make? 1. I need to tell you that you cannot talk about silly things here = never 2.  Why do you think you made that trip? = never asked why questions 3.  How does it feel to be back = also good response 4.  I am here to listen to your concerns

UAP with the best directions about an assignment? 5. The client is weak on the right side so please assist the client with dressing and bathing 6. Please check the clients capillary blood glucose level and tell me the results by 7 o’clock = time frame given 7. We need to document vitals signs for the client every four hours today = time frame given 8. Please encourage the client to change positions frequently = no time frame Eliminate frequently answers

The nurse is collecting data from an 85 or older male client which of the following statements would be essential to follow up? 1.  I feel that it takes longer to do task such as balancing my checkbook= old age 2. I feel some stomach discomfort after eating a large meal = some/mild/moderate = normal answers 3. I have awakened from sleep because of shortness of breath = Breathing 1 st 4. I have a problem starting a strong stream of urine = normal in old age

The nurse is collecting data from a client with a preliminary diagnosis of abdominal aortic aneurysm which of the following findings would be consistent with an abdominal aortic aneurysm? 1. Urinary retention 2.  Back pain 3. Neck vein distention 4. Dysphasia abdominal aortic aneurysm ( AAA) = Back pain

A nurse is assisting to admit a client who has Streptococcal (Strep throat) pharyngitis which of the following actions should the nurse take? 1.  Wear a surgical mask when checking the clients vital signs/giving meds – droplet precautions 2. Ensure the assigned a room has the monitor negative air pressure = airborne 3. Obtain particulate respiratory mask for staff members to use one providing Client care = airborne 4. Request the dietary department Provide disposable dishes and utensils for the clients meals

The orientation of new staff members to the care of postpartum client 1. I would encourage a client to wear gloves when the client applies a prescribed medication cream to the hemorrhoids- rectum area 2. I would wear gloves to assist a client who is breast-feeding her newborn = never 3. I would wear a mask when checking a clients lochia = never 4. I would offer a clean gloves to wear doing formula feeding of the clients newborn develops a fine white rash or the nose and chin

No gloves = Breast feeding , checking lochia , white rash or the nose and chin

The nurse is contributing to a staff education program about caring for a client in active pulmonary tuberculosis TB of the following information should the nurse suggest including 1. It is mandatory to report a client positive TB test results to the public health department 2. It is necessary to isolate a hospitalized client for 24 hours after initiating anti tubercular Therapy 3. Antitubercular therapy is continued until the client provide three sputum cultures that test negative for TB = maybe 4. Droplet precautions must be implemented as soon as a hospitalize client is suspected of active TB = Airborne precautions

The nurse is contributing to the plan of care for a client with gestational hypertension who is at 32 weeks gestation which of the following should the nurse recommend be included in the plan of care 1.  Monitoring the client urinary output 2. Instructing the client to report any increase in fetal activity 3. Instructing the client to use relaxation techniques to relieve a headache 4. Minimizing the clients and dietary intake of high calcium foods

The nurse has reinforced teaching with a client with phenochromocytoma Who is scheduled for adrenal arteriography. Which of the following statements by the client would indicate a correct understanding of the teaching? 1. I may experience numbness or tingling in my legs during the procedure 2. I may be a risk for severe hypertension during the procedure 3. I will need to remain flat in bed for 10 hours After the procedure 4. I will need to have coagulation studies prior to the procedure

The nurse is reinforcing teaching with a client who is scheduled for a thoracentesis which of the following information should the nurse reinforce ? 1.  You should be on the affected side for four hours after the procedure 2.  You will be placed in a sitting position with your arms resting on a bedside table doing the procedure 3. You will be given a does of a prescribed Sedative/hypnotic before the procedure 4.  You should not have anything to eat or drink for 24 hours before the procedure No need CONSENT / NPO

The nurse is caring for a client who has Mycoplasma pneumonia. Which of the following infection control precautions should the nurse Implement 1. Where a surgical mask when checking the clients breath sounds = 1 st 2. Place a client in a private room with monitored negative air pressure = airborne prections 3.Place a stethoscope in the clients room to be used for that client only= 2 nd 4. Remind Visitors to put on a productive gown before entering the clients room = contact precautions   Pneumonia = Droplet precautions

The nurse is caring for assigned clients the nurse should recognize that the client at highest of for developing peritonitis is a client who had 1) An appendectomy for ruptured appendix 12 hours ago 2) A nasal gastric tube inserted five hours ago for gastrointestinal bleeding 3) An abdominal cholecystectomy 16 hours ago and has 300 ml of greenish brown drainage in the drainage tube 4) A subtotal gastrectomy eight hours ago and is reporting pain rated seven on a scale of 0 to 10

A nurse is talking with a client who has borderline personality disorder which of the following statements Would the nurse expect the client to make?  1) 2) 3) 4)

I often feel bored and empty I hear voices others are unable to hear I need to go to my room to wash my hands again I am worried the food on the meal tray has been poisoned

The nurse is collecting data from a client with the right sided heart failure which of the following findings would be consistent with right sided heart failure? 1) 2) 3) 4) 5)

Edema  Dyspnea Dry cough Weight gain Jugular vein distention

The nurse is contributing to a staff development conference about clients who are pregnant and rubella non Immune. Which of the following information should the nurse suggest including? Live VACNINES = MMR + Influenza nasal 1.Fetal effects from the mothers exposure to rubella tend to be mild 2.Exposure to Rubella during pregnancy is only harmful in the first trimester  3. Clients that are not immune to rubella should be vaccinated postpartum 4.  Antibiotics administered after exposure eliminate the risk of Rubella in the fetus 5. Pregnancy should be prevented for four weeks after receiving the rubella vaccine Take rubella 1 month / 3 months prior to getting pregnant Frequently / only / must = wrong answers

The nurse is caring for a client with disseminated intravascular coagulation which of the following statements by the client would be essential to follow up? 1) I prefer to receive my medication subcutaneously rather than intramuscularly 2) I have been taking one aspirin every day since I had an MI one year ago No NSIADS with MI 1) I held pressure on the puncture site for five minutes after the nurse drew blood from my arm = good 2) I have avoided blowing my nose today because I have had two episodes of epistaxis (Nosebleeds)

Disseminated intravascular coagulation is a condition in which small blood clots develop throughout the bloodstream, blocking small blood vessels

The nurse is in a rehabilitation facility caring for a client who had a right knee arthroplasty eight days ago and has been diagnosed with pneumonia.  The client is being transferred to an acute care facility it would be essential for the nurse to communicate in the transfer report that ? The discharge to home is anticipated for the client after one more week of physical therapy The client lives in a ranch home that requires climbing to stairs to get to the house The most recent focused data collection reveals bilateral crackles auscultated in the clients lungs The client spouse will be visiting the client at the hospital later today after leaving work 3-5 days = The client can fully bear weight Bilateral crackles auscultated = Pneumonia

The nurse is caring for a client with moderate Alzheimer’s disease the nurse should immediately intervene if a staff member is observed 1) Providing the client with a sandwich to eat while wandering in the hallway . 1st 2) Offer the client several ounces of fluid at regular intervals 3) Securing the client a shower chair before the shower begins 4) Letting the client to choose What sweater to wear = patient is confused Securing is not restraining

The nurse is caring for assigned clients the nurse should recognize that the client at highest of for developing peritonitis is a client who had 1) An appendectomy for ruptured appendix 12 hours ago = Mark k 2) A nasal gastric tube inserted five hours ago for gastrointestinal bleeding 3) An abdominal cholecystectomy 16 hours ago and has 300 ml of greenish brown drainage in the drainage tube 4) A subtotal gastrectomy eight hours ago and is reporting pain rated seven on a scale of 0 to 10

A nurse is talking with a client who has borderline personality disorder which of the following statements Would the nurse expect the client to make? 1) I often feel bored and empty = borderline personality disorder ( They try to being suicidal) 2) I hear voices others are unable to hear = auditory hallucination 3) I am worried the food on the meal tray has been poisoned = Paranoia

1.  The nurse is reinforcing teaching about sleep and rest at home for a client who had a vaginal delivery 24 hours ago which of the following information to the nurse reinforce? 1.  Take a nap when your baby is sleeping = 1ST 2. Perform all of the household chores in the morning when you have more energy 3. Wake up and go to sleep at the same time every day 4. On the weekend plan and prepare all meals for the week to prevent fatigue

2. The nurse is talking with the spouse of a client who has Malignant melanoma and is terminally ill on the following statements by the spouse would be essential to follow up? 1. I give my spouse the prescribed pain medication regularly even though the medication causes my spouse to become drowsy 2. I feel as though there is so much happening now and I have been relying on my adult children to help care for my spouse 3. I sometimes feel bad because I often have one or two glasses of wine to help me relax and sleep at night 4. I tried to keep my spouse’s window open and the weather is nice because my spouse and I was listening to birds

The nurse is collecting data from a client with a plural effusion Who had a thoracentesis 30 minutes ago which of the following findings will require immediate follow up? 1. Pulse 108 = Tachycardia , could be hypotension , bleeding 2. Decreased pain with inspiration 3. Temperature 100.4 (38 ) 4. Absence of drainage at the puncture site

The nurse is caring for a client who had an abdominal paracentesis one hour ago which of the following statements by the client would be priority to follow up 1. The urine in my drainage bag looks pink 2. I will avoid sleeping on my left side for two days = GOOD 3. I feel dizzy when I change positions in bed too quickly 4. It is easier for me to breathe when I’m sitting up in bed

The nurse is reinforcing teaching with a client who has iron efficiency and anemia which of the following information should the nurse reinforce? 1) Continue to take your prescribed iron supplement after your symptoms resolve 2) Consult with a genetic counselor to establish inheritance patterns 3) Alternate periods of activity and rest throughout the day 4) Increase your dietary intake of food such as legumes  5) Take the prescribed iron supplement with a glass of milk if you experience gxcxastric upset No Milk , No Calcium = IRON SE: Black stools

The nurse is contributing to the plan of care for a client with gestational hypertension who is at 32 weeks gestation which of the following should the nurse recommend be included in the plan of care 1. Monitoring the client urinary output = good way to check for kidney problem 2. Instructing the client to report any increase in fetal activity = 1 st 3. Instructing the client to use relaxation techniques to relieve a headache 4. Minimizing the clients and dietary intake of high calcium foods

The nurse is reinforcing teaching by the parents of a nine-year-old child who is receiving prescribed methylphenidate which of the following information should the nurse reinforce? 1) Give me child Methylphenidate no more than three hours before bedtime 2) Your child will need to visit the primary healthcare provider periodically 3) Check your child’s pulse daily before administering methylphenidate 4) Increase your child intake of foods that are high in iron and potassium

The nurse is caring for a 17-year-old client with Guillian Barre syndrome who is beginning to have return of sensation and motor function the client states I’m going to miss my senior dance it’s not fair which of the following responses would be appropriate for the nurse to make? 1) You will be able to have your friends visit and tell you about the dance 2) You should be happy that you are getting some movement back 3) You will graduate from high school soon and they will be dances at the college you plan to attend next time  4) You are sad because you will miss something you have looked forward to for a long time

6. The nurse has reinforced discharge teaching with a parent of a newborn which of the following statements by the parent would require follow-up? 1) I will leave my babies diaper off when possible if the diaper area starts to become red 2) I will secure my baby in a rear facing infant seat in the front seat of the car since there is an airbag there 3) I should give my baby a pacifier at bedtime to reduce the risk of sudden infant death syndrome 4) I should squeeze the bulb syringe before inserting it into my baby’s mouth when I suction access secretions  Should be rear- facing seat in the back seat

The nurse is caring for adolescence recently Diagnosed with diabetes Mellitus Type one. The client states you don’t understand what it’s like to have to give yourself injections every day which of the following responses would be appropriate for the nurse to make? 1) I have cared for many clients who are the same age as you and they have adjusted 2) There are many athletes who have the same diagnoses and are very healthy 3) I can teach one of your parents how to give the injections  4) It must be difficult to self administer an injection every day = address anger ,sadness , difficulty

The nurse has reinforced teaching with a client who had a colostomy created five days ago which of the following statements by the client indicates correct understanding of the teaching? 1) I will begin an aerobic exercise program since I will not be able to go swimming 2) I should avoid emptying the pouch more than two times a day so that It do not loosen the seal around the appliance 3) I will notify the primary healthcare provider if I develop a fever or redness around the drainage from the incision 4) I can expect to experience a burning sensation around the stoma until the incision is completely healed Fever , redness , edema , numbness = Reporting

A nurse who is pregnant as a sign to the care of a three-month-old client with respiratory syncytial virus pneumonia. The client it is receiving ribavirin therapy Which of the following actions would be most appropriate for the nurse to take? 1. Maintain strict isolation precautions while caring for the client 2. Discuss the assignments with the client’s physician  3. Request a change of assignment from the charge nurse 4. Switch the client assignments with a coworker

3 RSV can be transmitted to the unborn baby RSV = Contact precautions 1st , then droplet

The nurse is preparing to administer prescribed regular insulin to a client the nurse should understand that regular insulin is administered which of the following routes? Select all that apply 1. 2. 3. 4. 5.

Subcutaneous Oral = NEVER Intravenous ( IV) Intermuscular –  vastus lateralis muscle = Baby Intradermal = TB RN = IV only NPH = NO IV

The nurse is contributing to a staff education conference about the stages of grief in client with a terminal illness. Which of the following information should the nurse suggest including? 1. The nurse should confront the client in the denial phase and emphasize that the client illness will indeed result in death 2. The nurse should leave the client alone as much as possible if feelings are misdirected toward the nurse during the anger phase 3. The client may openly express feelings of sadness during the depression phase or withdraw from friends and family members 4. The client avoid making plans during the acceptance face

The nurse has reinforced teaching with a client who had a colostomy created five days ago which of the following statements for the client would indicate a correct understanding of the teaching? 1. I will begin an aerobic exercise program since I will not be able to go swimming 2. I should avoid emptying the pouch more than two times a day so that I do not loosen the seal around the appliance 3. I will notify my primary healthcare provider if I develop a fever or redness and drainage from the incision C - infection

Redness, cough , fever, edema 4. I can expect to experience a burning sensation around the stoma until the incision is completely healed

The nurse is checking a client with disseminated Herpes Zoster who is in a private room the nurse should understand the client maybe developing a sensory isolation if the client reports the onset of 1. 2. 3. 4.

Photophobia = sensory Headache Anxiety Tremors

The nurse has received the following information about assigned clients. The nurse should first check the client who ? 1. Has gastroenteritis is reporting nausea and vomiting 100 ML of green liquid 2. Has a Long cast and is sitting in a chair with the casted leg elevated on a stool 3. Had a appendectomy one day ago and has a 2 cm area of serosanguinous drainage on the incision dressing 4. Had a thyroidectomy two days ago and has muscle spasm and the wrist when the blood pressure is taken – Hypocalcemia

The nurse to assign to a UAP? 1. Removing/applying a condom catheter for the male  client who had a fractured pelvis 2. Providing discharge teaching to the client with COPD 3. Evaluating the pain level for the client who had an abdominal hysterectomy several hours ago 4. Determining the effectiveness of an anti-anxiety medication for a client with moderate Alzheimer’s disease Discharge teaching , Evaluating , Determining , instructing , first/newly , monitoring = RN

The nurse assign to a UAP 1) Administer an enema to the client with a fractured right hip 2) Removing sutures from the client who had an abdominal hysterectomy 3) Instructing the client with irritable bowel syndrome about dietary restrictions 4) Conducting a home safety assessment for the client with moderate Alzheimer’s disease

The nurse is contributing to the plan of care for a client who sustained a spinal cord injury at T1 five days ago. Which of the following interventions should the nurse recommend including in the clients plan of care? 1. Limit new clients fluid intake to 1 L daily = never , 2/3 Liter daily 2. Encouraged the client to increase the intake of foods high in carbohydrates 3. Request a prescription for a stool softener to be administered to the client daily  4. Perform a lower extremity passive range of motion exercises for the client once daily

The nurse is caring for a client who had an abdominal paracentesis one hour ago which of the following statements by the client would be priority to follow up 1. The urine in my drainage bag looks pink = Injury 2. I will avoid sleeping on my left side for two days 3. I feel dizzy when I change positions in bed too quickly 4. It is easier for me to breathe when I’m sitting up in bed

The nurse is talking with the spouse of a client with left-sided Hemiplegia.  The spouse tell the nurse I scheduled the appointment because I noticed a sore had developed on my spouses hip. I feel so guilty because I caused this to happen I do not know what to do which of the following would be appropriate initial response for the nurse to make? 1. Have you been been offering your spouse fluid at regular time intervals? 2. How often do you change your spouses position? 3. The type of care that you have undertaken is not easy 4. We will make sure that you have help if this requires special dressings

A nurse who is pregnant as a sign to the care of a three-month-old client with respiratory syncytial virus pneumonia. The client it is receiving ribavirin therapy Which of the following actions would be most appropriate for the nurse to take? 1.Maintain strict isolation precautions while caring for the client 2.Discuss the assignments with the client’s physician 3.Request a change of assignment from the charge nurse 4.Switch the client assignments with a coworker

The nurse has received the following information about assigned clients the nurse should first 1. Who has right sided heart failure and is reporting frequent urination  2. With active pulmonary tuberculosis who is reporting expectorating blooc tinted mucus 3. Who has a fractured femur and receiving a dose of pain medication intramuscularly one hour ago and is reporting that the pain has not been relieved Acute over chronic , new admit 4. With benign prostatic hyperplasia who is reporting no bowel movement for the past three days and is requesting a dose of prescribed laxative

The charge nurse should assign the only available Private room to the client with  1. 2. 3. 4.

cytosis pneumonia A positive vericella zoster titer – airborne , needs a private room Hepatitis C  A positive cytomegalovirus titer

The nurse is reinforcing discharge instructions with client for taking prescribed isosorbide dinitrate. The nurse should reinforce that the client should avoid 1. 2. 3. 4.

Exposure to sunlight Sudden position changes – orthostatic hypotension Vigorous exercise Taking antacids HTN , Pyche meds = orthostatic hypotension

Isosorbide < 60 , Hold meds

The nurse is caring for a client who has been diagnosed with hook worm infestation the clients parent asks how can I prevent my other child getting hookworm which of the following would be appropriate response by the nurse to make 1. Cook all meals thoroughly = tapeworm 2. Have your pets treated for worms = round worms 3. Encourage your children to wear shoes when outside = hook worm infestation 4. Wash all clothes in hot water

The nurse is collecting data from a client with guillan barre the client is experiencing paralysis and paresthesias of the lower extremity and has a respiratory rate of 18 which the following actions should the nurse take 1. Massage the clients legs every two hours 2. Pad the side rails of the clients bed 3. Monitor the clients respiratory rate frequently 4. Keep the head of the clients bed elevated at 30°

The nurse is preparing a client for emergency surgery to repair a depressed skull fracture which of the following actions would be essential for the nurse to take 1. Determining the time that the client last ate 2. Showing the client a picture Of the postoperative wound drainage system 3. Telling the client What will occur in the post anesthesia care unit 4. Check in the clients corneal reflex = assessment/ check with head injury patient 1st

The nurse is assisting with the plan of care for a client who is scheduled to have a right mastectomy which of the following would be most important for the nurse recommend to be included to maintain the clients positive body image 1) Encourage the client to explore her feelings 2) Provide the client with a calm quiet environment  3) Discuss the types of prostheses available 4) Reinforce information on coping mechanism

The nurse is contributing to a staff development conference about confidentiality which of the following information should the nurse and suggest including 1. Client must wait until after discharge to review the medical records 2. Nurses on the hospital Unit may review the medical record for all clients on the unit 3. Certain information in the clients medical records may not be considered confidential 4. clients may disclose all information in order to receive care

The nurse is assisting with the plan of care for a client with moderate Alzheimer’s disease which of the following interventions should the nurse suggest including in the Clients plan of care SATA 1. Avoid the use of restraints 2. Avoid reminiscing about happy times in the clients life- always do 3. Use a distraction when the client becomes anxious or agitated 4. Provide the client with a wide selection of food choices at meal times – never 5. Do not asked open ended questions as it will confused the client 6. Speak slowly and use short simple sentences and providing the client with information 7. Provide family members with information about community support service for respite care

The nurse is caring for a client with pediculosis Which of the following infection control precautions Should the nurse implement? 1. Place a thermometer in the clients room to be used for the client only – contact isolation 2. Wear a surgical mask when assisting the client to bathe 3. Keep the door to the client room closed – ebola 4. Remove the gloves after leaving the room - should always remove before leaving the room

The nurse in an ambulatory Care facility has been advised that several clients have arrived for scheduled appointment the nurse should ask a client with which of the following concerns to come to a private examination room first 1. 2. 3. 4.

A productive cough with night sweats – infection Diabetes Mellitus with tingling in both feet Red eyes with moderate tearing Emphysema with clubbing of the finger nails

A- to prevent the others from contracting in case it is TB

The nurse is caring for a client who has right sided Hemiplegia and is ambulating using a walker it would indicate a correct understanding of how to use a walker if the client is observed 1. Taking steps forward with the left leg and then advancing the right leg and the walker 2. Moving the Walker forward 12 inches then swinging both legs forward together 3. Moving the walker and the right leg forward 6 inches and then move in the left leg forward  4. Placing the rear legs of the walker and the Right leg forward and then moving the left leg forward

The nurse is caring for a five-year-old client who sustained burns over 10% of the body one week ago which of the following between meals snacks would be appropriate to offer The client? 1) 2) 3) 4)

Slices of red Apple  - finger foods cheese sticks 1st Strawberry gelatin Frozen juice bar 

The nurse on the maternity unit is talking with a staff member from another unit.  The staff member asks the nurse about a mutual friend who had a baby at the healthcare facility which of the following would be an appropriate response for the nurse to make  select all that apply 1. You should give her a call on the telephone to see how she is doing 2. I saw her this morning and she is going to be discharged home today 3. I understand the delivery went well and her spouse is with her 4. I cannot give you any information about her condition 5. I will take a look in the computer system to find out which room she is in so you can visit

Atenolol 1) Atenolol block the vasoconstrictor and aldosterone producing affects of angiotensin  II 2) Atenolol blocks the conversion of angiotensin l to angiotensin ll  3) Atenolol blocks the stimulation of beta 1 adrenergic receptors 4) Atenolol blocks the post synaptic alpha 1 adrenergic receptors

The nurse is collecting data from a client who has hypovolemic shock which of the following findings would be consistent with hypovolemic shock 1. Confusion 2. Hypertension – HYPOTENSION 3. Decreased urine output 4. Elevated respiratory rate

The nurse is caring for a client who has just returned from the radiology department after having an upper gastrointestinal series which of the following actions should the nurse take first ? 1) Administer the prescribed enema 2) Give the prescribed multiple vitamin that was withheld prior to the procedure 3) Determine whether follow up x-rays are to be taken 4) Verify the preliminary test result

The nurses is caring for a client who is scheduled to have an arterial blood gas sample obtained the nurse should anticipate that which of the following tests would be performed prior to the procedure 1) 2) 3) 4)

Coombes test Schilling test Ham test Allen test = ABG

The nurse is measuring a client for crutches which of the following actions should the nurse take 1. Measure the Client’s height and subtract 8 inches to obtain the correct crutch length 2. Ask the client to stand upright and position the shoulder rest of the crutch 6 inch below the axilla 3. Adjust the crutches so the clients elbows are at 30° angle while the clients hands are resting on the handgrips 4. Measure  from the interior fold of the axillae to the toes of the clients feet and add 1 inch while the client is in a supine position

The nurse is contributing to the plan of care for a client Who sustained full thickness burns on 30% of the body three days ago which of the following interventions to the nurse suggest including in the clients plan of care ? select all that apply 1. Discourage movement of the affected body parts 2. Offer the client prescribed opioids analgesics prior to providing wound care 3. Wear a hair covering and a surgical mask when the bum wounds are exposed 4. used ice and other cold therapy as an adjunct to pharmaceutical pain relief 5. Stress the importance of strict intake and output recording for the client with the unlicensed assistive personnel

The nurse is caring for a client who has a prescription to remove the NG tube which of the following actions should the nurse take ? 1)With draw the tube steadily while the client takes shallow breaths 2)Have a client hyper extend the neck before withdrawing the tube 3)Withdraw the tube quickly while the client holds a deep breath = CORRECT 4)Have the client flex the neck before withdrawing the tube

The nurse has reinforced teaching with a female client who will receive prescribed oxytocin for induction of labor which of the following statements by the client would indicate the correct understanding of the teaching?  1. The breathing exercises that I learned will not help manage labor pain 2. I will have my blood pressure checked every 60 minutes 3. The oxytocin infusion can result in uterine hyper stimulation and fetal harm 4. I can expect to have a headache and vomiting because of the oxytocin infusion

3 uterine stimulation- no longer 90 sec closer to 2 mins

The nurse is caring for a client who had a thoracentesis one hour ago which of the following findings would require immediate follow-up 1. Respiration of 24= MOSTLY 2. Tenderness of the puncture site 3. Temperature of 99.6°F 4. Small amount of bleeding at the puncture site

The nurse is caring for a client who has just been told that the cancer has metastasized The nurse into the room and observed the client crying or the following response would be appropriate for the nurse to make first 1. You seem upset may I sit with you for a while 2. I can telephone a family member to come and stay with you 3. Do you have a spiritual advisor that you would like me to notify 4. I will give you some time alone and will come back soon

The nurse is caring for a client who is experiencing new onset profuse epistaxis. which of the following action should the nurse take ? Select all that apply 1. Check the clients vital signs = No need 2. Apply a warm compress to the clients nose = Never 3. Assist the client to apply pressure to the Nares 4. Encourage the client to spit out blood instead of swallowing it 5. Play the client in an upright position with the head Tilted forward 6. Encourage the client to blow their nose periodically until the epistaxis resolves= do not blow the nose in epistaxis

The nurse has reinforced teaching with a client who is scheduled for Electro convulsive therapy which of the following statement for the client would indicate a correct understanding of the teaching? 1. I will experience a tonic clonic seizure for approximately 15 minutes during the ECT procedure 2. ECT is commonly used to treat depression when several antidepressants have not been effective 3. ECT is effective because it Decreases the level of Nero transmitters in the central nervous system 4. Common side effects of ECT are diarrhea a low-grade fever and short term memory loss

The nurse is caring for a client who sustained a closed head injury which of the following findings would require immediate intervention? 1. Ecchymotic area or the left temple = 1st = battle 2. Glasgow coma scale score of 13 = Normal …. <7 3. Blood pressure of 136/76 4. Headache that worsens with coughing

The nurse is preparing to administer prescribed regular insulin and NPH insulin to an assigned client select in the correct order the steps the nurse should take. Arrange in order 1. Aspirate a volume of air equal to the prescribed dose of NPH insulin and inject the air into the vial 2. Withdraw the prescribed amount of regular insulin into the syringe 3. With draw the prescribed amount of NPH insulin into the syringe 4. Administer the injection to the client 5. Aspirate a volume of air equal to the prescribed dose of regular insulin and inject the air into the vial

15234

The nurse is assisting with the admission of a client who is scheduled for a colon resection Which of the following statements made by the client would be most important for the nurse to clarify 1. I take acetaminophen for occasional headache 2. I had successful cataract surgery two years ago 3. I usually have a few glasses of wine in the in the evening- mostly 4. I have urinary incontinence when I sneeze

The  nurse and Unlicensed assistive personnel are caring for assigned clients which of the following activities would be appropriate for the nurse to assign to a UAP? 1. Applying a condom catheter to the male client with a hip fracture who is in continent – mostly 2. Applying pressure dressing to the right hand of the client who Has a stab wound 3. Inserting a NG tube for the client with anorexia nervosa 4. Obtaining vital signs from the client who is experiencing delirium Tremens = delierum confusion

The nurse is contributing to a staff education conference about inform consent which of the following information to the nurse suggest including? Select all that apply 1. The nurse witnessing the consent is responsible for explaining the procedure to the client - HCP will explain 2. Consent is implied for care required to treat the clients condition in a lifethreatening emergency situation 3. The client signature on the consent form is documentation that the client has no question about the procedure counseling when the nurse signed the consent form the nurse is confirming that the client appears competent to give consent 4. When the client refuses to give consent for a procedure the nurse a document refusal in the medical record

The nurse is reinforcing teaching with the parents of a child who is scheduled for surgical repair of hypospadias. The nurse should reinforce that intended outcome of the procedure includes 1. 2. 3. 4.

Relief from pain Relief from bladder obstruction The ability to void while standing – mostly That ability to achieve an erection Follow up = Further education – which answer is wrong Reinforce = Retell the correct answer

The nurse is reinforcing teaching with the client with Lymphocytic leukemia Who is a risk for developing thrombocytopenia (Bleeding disorder ) which of the following information should the nurse reinforce ? 1. You should use a disposable razor rather than an electric razor when shaving 2. Frequent deep breathing exercises should be performed but avoid coughing and blowing your nose 3. Frequent oral hygiene should be performed including flossing your teeth and using alcohol-based mouthwashes 4. You may take over the counter ibuprofen for any discomfort but avoid using OTC acetaminophen = No NSAIDS

The nurse is contributing to the plan of care for a client with multiple sclerosis which of the following should the nurse recommend to be included? 1. 2. 3. 4.

Encouraging the client to perform aerobic exercises several times daily Limiting the amount of time that the client spends in a hot environment Offering the client between meals snacks that are high in vitamin C Keeping the clients legs elevated when sitting upright in a chair multiple sclerosis- NO Hot wheather , heat intolerance

The nurse is caring for a client with a panic disorder. Which of the following findings should the nurse expect to observe 1. 2. 3. 4.

Dry skin Chest pain – mostly Decrease bowls Delusional thinking Breathing , Hypoxia, restlesness , pain , SOB 1ST

The nurse is caring for a client with diabetes type two who has been disoriented to play sometime and has a capillary blood glucose level of 60 mg/dL Before administering oranges to the client it would be priority for the nurse to 1. Recheck the clients blood glucose levels using a different glucometer = no need to recheck 2. Check the clients gag reflex – mostly 3. Determine the availability for a glucagon on the nursing unit  4. Notify the primary healthcare provider Normal is 70-110

UAP about the assignments ? 1. The client with heart failure should be weighed and have vital signs checked before breakfast is served – heart failure unstable 2. You will need to assist the client with mild Alzheimer’s disease with activities of daily living 3. You need to follow proper infection control precaution assisting the client in active pulmonary Tuberculosis 4. The client with paraplegia should have the monthly safety check completed in the wheelchair – paraplegia/ hemiplegia avoid it

The client is admitted with severe pain In the left lower extremity the client is scheduled for a complete blood count urinalysis, chest x Ray and X-ray of the lower extremities. The client asked the nurse why do I have to have all these test the pain is in my leg which of the following responses by the nurse will best help the client deal with feelings of anxiety? 1. The test will not take long to complete 2. These tests are part of the admission procedure 3. It must be difficult not understanding what is happening to you = go with the feeling 4. Perhaps this is something you need to discuss with your physician

The nurse is observing a newly hired nurse administrator. A clients transdermal patch the nurse should intervene if the newly hired nurse is observed 1. Instructing the Client to avoid massaging the patch 2. Cleansing the client skin with soap and water after removing the old patch 3. Initialing the patch and writing the date and time the patch was applied on the patch 4. Omitting (not) documentation about the location on the clients body where the patch was applied

Electronic medical records SATA 1. An advantage of using electronic medical records is improved legibility in documentation 2. The nurse should log off the computer system before leaving a computer terminal 3. And issue surrounding computerized documentation is access to secure information = maybe 4. A nurse with experience documentation in 1 electronic medical record system can use another system without training – never Saint nurse , needs training for EBS medical record system 5. The nurse should not share security passwords for the electronic medical record system 6. A disadvantage of the use of electronic medical record’s is that departments are unable to interact with the system = train them , they will

Best directions to a UAP regarding the assignments 1. Record your assigned clients vital signs before you take a midmorning break 2. Weigh your Assigned client before breakfast with scale used one day ago  3. Help the clients who eat their meals in the dining room with the breakfast 4. Measure of the amount of your assigned client intake and output regularly

The nurse is caring for a 6 Year old client who is receiving prescribed Skeletal traction for the following would be priority for the nurse to monitor? 1. The distance between the clients knees  2. The pull of the traction on the clients pins 3. The degree of flexion of the clients ankles 4. The position of the clients cervical spine on the bed

The nurse in an outpatient care facility has received the following telephone message from the client who were previously seen at the facility the nurse should first telephone the client who is reporting 1. No memory of the post procedure instructions following an EGD 2. A sore throat and cough following a bronchoscopy 3. shortness of breath following a bronchoscopy 4. Abdominal cramping following a colonoscopy

3,. AIRWAY/ BREATHING.

The nurse is caring for a client with a panic disorder. Which of the following findings should the nurse expect to observe 1. Dry skin 2. Chest pain – mostly 3. Decrease bowls 4. Delusional thinking

The nurse is reinforcing teaching with a client who has an ileal conduit, Which of the following statements by the client indicates correct understanding of the teaching 1. I will need to awaken several times at night to empty the pouch 2. I can expect to have mucus in my urine 3. The stoma should be a dark purple color 4. I will need to limit my fluid intake

An adolescent client is prescribed lispro (Humalog) and glargine (Lantus) insulins for the treatment of diabetes mellitus. When reinforcing teaching with the client about how to administer the insulins, the nurse should instruct the client to 1. 2. 3. 4.

Adjust the glargine dose based on blood glucose readings. Administer the lispro 1 hr after breakfast= before 30 mins Give the glargine in three divided doses during the day= given once only Draw up the lispro and glargine in separate syringes.

A nurse is caring for a client who is newly diagnosed with type 1 diabetes mellitus. The nurse should recognize that the client needs a referral for diabetic education when the client 1) draws up Regular insulin before NPH when demonstrating injection technique. 2) says that he will see a primary care provider to treat corns on his feet. 3) states that he will treat hypoglycemic reactions with 15 g of carbohydrates. 4) lists sweating, shaking, and palpitations as symptoms of hyperglycemia.

A client receives a new prescription for warfarin (Coumadin). Which of the following should the nurse reinforce (Correct) with this client? 1) 2) 3) 4)

Use a safety (manual) razor for shaving. Avoid the use of salicylates, including aspirin. = Bleeding risk Eat foods that are high in vitamin K content. Do not take over-the-counter laxatives. INR 2-3 , Hold warfarin if INR is above 4,5,6

A nurse is reinforcing discharge instructions to the mother of a newborn. Which of the following statements by the mother indicates an understanding of the teaching? 1) "I will notify my doctor if my baby sleeps more than 5 hr at a time." =they sleep 12-16 hrs 2) "I will check my baby when she cries." 3) "I will change my baby's diaper every 4 hr." 4) "I will limit my baby's feedings so she does not become overweight."

A nurse is reinforcing foot care instructions to a client with diabetes mellitus. Which of the following client statements indicates proper understanding of the teaching? 1) 2) 3) 4)

"I should shake out my shoes before I put them on." "I can remove my own calluses with a pumice stone." "I should wear the same shoes all day." "I should not use moisturizers on my feet."

A nurse is caring for an older adult client who was admitted with dehydration. Which of the following is the nurse's priority for data collection? 1) 2) 3) 4)

Deep tendon reflexes Skin turgor Intake and output Blood pressure and pulse

A nurse is reinforcing teaching with the parent of a child who has hypothyroidism and is to start taking levothyroxine. Which of the following information should the nurse include? 1 )Administer a calcium supplement with this medication." 2) Expect your child to take this medication for his lifetime." 3) Your child will have permanent hair loss due to this medication." 4) Avoid giving this medication on an empty stomach." 5) Take this meds in the morning before breakfast on empty stomach

A nurse at an urgent care clinic is caring for a child who hit her head on the playground at school 30 min ago. Which of the following findings is the nurse's priority?

 Nasal discharge negative for glucose  2 cm (0.8 in) scalp laceration  Asymmetric pupils  Negative Babinski reflex

A nurse is caring for an infant who has heart failure and a new prescription for digoxin. Which of the following findings should the nurse report to the provider?

1. Vomiting twice in 4 hr Vomiting and diarrhea = Dehydration 2. Respiratory rate 30/min = 30-60 3. Heart rate 130/min – 110-160 4. Weight loss 0.25 kg (0.55 lb)

Digoxin < 90 for infant , < 60 for adult , Hold meds

Fall prevention 1. 2. 3. 4.

Raise the side rails for a client with memory impairment Encourage the client with impaired balance to avoid ambulation Instructed client with orthostatic hypotension to ambulate slowly = RN Place a commode at the bedside of a client with urinary frequency 

The nurse is reinforcing teaching with client my preventing skin cancer which of the following statements by client would indicate a correct understanding of the teaching?  1. I can wear hat rather than the sunscreen if I am a outdoor for a short period of time 2. I will gradually increase the amount of time I am exposed to the sun to put on sunburn 3. I will wear sunscreen with the sun protection factor of at least 15-20 mins when before spending time in the sun 4. I do not need to wear sunscreen on cloudy days because clouds provide natural protection = Still need to wear sunscreen

The nurse is reinforcing teaching with a client who is receiving Prescribe insulin gargline which of the following information should the nurse reinforce ( Correct statement )? 1. After administering the insulin gargline the same syringe can be used to administer regular insulin = use different syringes 2. Extra vials of insulin gargline that have not been open can be stored in the freezer 3. Insulin gargline does not have a peak action time 4. Insulin gargline should be administered three times each day 15 minutes before meals = once daily

Best directions to a UAP about the assignment? 1. The client with a UTI should drink two pitchers of water this shift 2. The client with mild dementia need assistance with bathing  3. The client who had a stroke needs to ambulate in the hallway 4. The client with peripheral neuropathy should receive good skin care

The nurse is caring for a client with the dysthymic disorder What are the following behaviors without the nurse expect to observe? 1. 2. 3. 4.

Grandiose actions  Reports of Auditory hallucinations Expansive pressured speech Inability to experience joy or pleasure in life

The nurse in a pediatric outpatient care facility receive telephone message from parents the client who is previously seen at the facility. The nurse should first telephone the parent of a client who has  1. Acute otitis media and reports insomnia after taking prescribed amoxicillin six hours ago 2. A fracture of the left tibia and has placed a crayon in the cast 3. A colostomy and reports skin irritation around the stoma – normal 4. Epilepsy and has pink frothy sputum = pulmonary Edema Yellow , Green , PINK sputum = Infection

The nurse in a Rehabilitation facility is admitting a client who had a stroke the client has an advance directive which of the following actions should the nurse take? SATA 1. 2. 3. 4. 5.

Obtain a do not resuscitate prescription for the client Make the healthcare team aware of the advanced directive Notify the client family that the emergency care will not be given  Witnessed a client signature on the advanced directive – nurse cant witness Document in the Medical record that the client has an advanced directive 

The charge nurse in a long-term care facility has been advised of the following clients will be admitted during the shift. The charge nurse should assign the only available private room to the client with 1. 2. 3. 4.

Scabies – contact precaution, private room Salmonellosis  Hepatitis Cytomegalovirus

The nurse has reinforced teaching with the client about non-pharmacological pain management techniques which of the following statements by the client would indicate a correct understanding of the teaching?

Select all that apply 5. Massage can be performed to decrease pain intensity 6. I will read a book to distract my attention from the pain 7. Analgesics will not be necessary if I use non-pharmacological techniques

8. I will use a heating pad on Low temperature 5. The nurse should provide me with a topic if I use guided imagery

The nurse is preparing to assist a client who has recently developed a visual impairment to ambulate to ensure the client safety it would be appropriate for the nurse to 1. Hold the clients hand while walking next to the client 2. Place one hand on the clients shoulder and walk in front of the client 3. Apply a gait belt around the clients waist and walk at the client side 4. Instruct the client to hold onto the nurses upper arm while the nurse walks slightly ahead of the client

The nurse has reinforced teaching with a client Who is receiving prescribed Alendronate which of the following statements about the client would indicate a correct understanding – osteoporosis 1. 2. 3. 4.

I should take the medication with orange juice I can take the medication at any time of the day I will avoid taking over-the-counter vitamin D supplements I must set up right for 30 minutes after taking the medication – dronates

 Fosamax –

1) Before breakfast 2) keep the client stay upright for 30 minutes.

The nurse has reinforced teaching about sexually transmitted infections with a group of clients are the following statements about client indicated good understanding of the teaching? 1. Gonorrhea and has no symptoms in female clients until the infection has entered the pelvis 2. A Watery gray discharge from the penis is associated with gonorrhea 3. Frothy green vaginal discharge is an indication of an infection caused by chlamydia trachomatis 4. A mail client with chlamydia trachomatis will have a faint rash on the testicles

Green , yellow , pink sputum/discharge = infection / injury

The nurse is caring for a sign clients who have closed chest drainage system the nurse should first check the client 1. Who reports thick drainage in the system tubing  2. Who’s chest tube has become disconnected from the drainage system 3. Who reports pain at the incision site reading five on a scale of zero no pain to 10 severe pain 4. Who’s chest tube is clamped in accordance with a prescription from the primary health care provider 

A client is scheduled to have a Glucose tolerance test at 8 o’clock to ensure the accuracy of the test results the nurse should make which of the following statements to the client prior to the test? 1. Do not smoke during the test 2. Tell me if you get nauseated during the test 3. Discard your for your example after the blood test sample is taken 4. Let me know if you begin to feel hungry during the test

The nurse is collecting data from the client who is receiving continuous Ambulatory peritoneal dialysis or the following statements by the client would be essential to follow up 1. My abdomen feels very full after the fluid has infused 2. The drainage at the end of the dwell time is greater than the amount of fluid that has infused 3. My food taste bland to me since I have been receiving CAPD 4. The drainage at the end of the dwell Time is cloudy

The nurse is collecting data from a client who sustained a fracture of the femur 24 hours ago. Which of the following findings would be a priority to follow up? 1. Petechiae on the chest 2. Ecchymosis of the affected extremity 3. Pain rated five on a scale of zero no pain to 10 severe pain 4. Reports of muscle spasms in the affected extremity

Electronic medical records Select all that apply 1. Do not document sensitive information such as positive HIV status in the electronic Medical record – maybe 2. You may view the electronic medical record for any client as long as you do not Modify the record= Never , only your own client 3. Do not leave the computer unattended while you are logged in the computer 4. Tell your password to your supervisor for use in case of emergencies = never share passwords 5. Never share passwords with anyone 6. Change your password frequently

A nurse is preparing to administer enoxaparin 1.5mg/kg subcutaneously to a client who has pulmonary embolism. The client weighs 132 lbs. The amount available to enoxaparin solution for injection 100mg /ml. How many should the nurse administer? Round the answer to the nearest tenth. Use a leading zero if it applies . 0.9 ml

Nurse to assign to a UAP SATA 1. Performing pharyngeal suctioning for the client who has a newly created tracheostomy 2. Measuring and documenting Intake and output for the client with diabetes insipidus 3. Weighing the client with anorexia nervosa at the same time daily 4. Giving a back rub for a client was experiencing preterm labor 5. Check in the vital signs for the client with stable angina pectotis

 Measuring and documenting Intake and output  Vitals for stable patients  Weighing patients  Bathing clients  Ambulating Alzheimer patients

. The charge nurse should assign the only available private room to the client with 1. Human immunodeficiency virus (HIV) and bacterial pneumonia – Droplet and contact 2. Hepatitis B and acute gastritis – DROPLET – private room 3. End stage renal disease and cellulitis of the left leg 4. Acute pulmonary tuberculosis and osteoarthritis- Airborne 1st

Client confidentiality. 1. Written consent is not needed to acknowledge the hospitalization of the client to a visitor 2. Personal information will be revealed to the public from volunteers who participate in research study = Never , no police, security ,driver , no volunteers 3. The client may see and copy the clients medical record and may have amendments made to the document 4. Nurses may share a computer password with other team members who are assigned to care for the same client 5. Clients medical records should not be displayed on a monitor where others may see the medical record

The nurse assisting with the admission of a client with active pulmonary tuberculosis which of the following actions should the nurse take? Airborne precautions SATA 1. Provide a supply of sterile gloves outside the clients room = Clean gloves 2. Keep the client in the room and the door closed 3. Inform visitors that plants are restricted from the clients room = For neutropenic precautions 4. Place the client in a private room with monitor negative air pressure 5. Place a surgical mask on the client when preparing the client for transport to the radiology department 6. N95 mask on the nurse , remove it when out of the room

The nurse is caring for a client with schizophrenia which of the following clients behaviors with the nurse expect to observe? 1. Disorganized speech- most likely 2. Hand tremors 3. Mood swings – depression 4. Binge eating

The nurse is collecting data from a client with a plural effusion Who had a thoracentesis 30 minutes ago which of the following findings will require immediate follow up? 1. 2. 3. 4.

Pulse 108 Decreased pain with inspiration Temperature 100.4 (38 ) ….. Fever Absence of drainage at the puncture site

The nurse is contributing to the plan of care for a client with peptic ulcer disease the nurse should suggest monitoring for which of the following as part of the clients plan of care? 1. 2. 3. 4.

Dysphagia Heartburn after eating – Not Symptoms of Barrett’s syndrome Hematemesis – RECHECK …………… vomiting blood Hema = Blood

Leopold maneuvers help determine 1. The location of the Placenta 2. Whether the fetus moves with stimulation 3. The location of the presenting part 4. Whether cervical dilation has started

The nurse is collecting data from a client who had percutaneous transluminal coronary angioplasty Via right femoral artery two hours ago. Which of the following findings would require immediate intervention? 1. Diminish right dorsalis pedis pulse 2. Nausea after drinking a cup of  water 3. 2 cm area of serosanguinous drainage on the right groin dressing 4. Right groin pain rated three on the scale of zero no pain to 10 severe pain = Never

The home health nurse has collected data from a client with diabetes Mellitus type 1 recently diagnosed with retinopathy. The nurse should recognize that the client may have increased risk for injury if 1. Outdoor steps have a railing on only one side of the steps 2. Skid resistant rugs are covering the wood floor = Good 3. Carbon monoxide detectors are batteryOperated = Good 4. Prescribe medication have standard labels

The nurse is reinforcing teaching with a client with osteoarthritis which of the following information should the nurse reinforce? 1. Balance periods of exercise with periods of rest 2. Increase your intake of foods that are high in calcium 3. Isotonic exercises place less stress on your joints than isometric exercise better 4. Limit your alcohol consumption to one drink per day while taking prescribed nonsteroidal anti-inflammatory drugs – Never drink Calcium and Vitamin D is good for client with osteoarthritis

The nurses working in the emergency department received information that several clients are being transported by a radiologist emergency response team after exposure to radiation. When the clients arrives which of the following actions should the nurse take first? 1. Bag and tag each client clothing and place the clothing in the appropriate BioHazard receptacle 2. Irrigate any wounds and cover each with a water resistant dressing 3. Have the client shower thoroughly with soap and water 4. Determine whether each client has been decontaminated

Clostridium difficile and Scabies SATA 1. Place a blood pressure cuff in the clients room to be used for the client only 2. Wear a particulate respiratory mask when assisting the client with meals = Airborne precautions 3. Place the client in a private room with monitor negative air pressure = Airborne precautions 4. Limit visits by the clients family members to 30 minutes each day 5. Remove the gloves prior to leaving the clients roommate 6. Use soap and water only 7. No alcohol wipes 8. Single client/ Private room only 9. Gown and clean gloves only

Preparing to administer prescribed nasal drops 1. Ask the client to blow her nose 2. Instill the prescribed number of drops 3. Encourage the client to breathe through the mouth 4. Hold the medication dropper above 0.5 inches above the Nares 5. Assist the client to Tilt the head back over the edge of the bed 6. Encourage the client to remain supine for five minutes

1,5,4,2,3,6

Long-term care facility, Gives a UAP the best directions about the assignments 1. The client with quadriplegia should receive a complete bed bath before the client goes to the physical therapy at noon 2. All clients should have a vital signs taken and documented on the flowsheet let me know if anything needs follow up 3. The client who had a stroke should perform exercises twice daily before the client attended recreation therapy 4. All clients should be assisted with meals make a list of what they eat at each meal

Input and output/ bed bath

The nurse is contributing to a staff education program about impaired nurses and nurse should recommend including the nurses who abuse substance typically 1. 2. 3. 4.

Deny that there is a problem with substances Have been practicing nursing less than five years Abstain from using substances while at work Do not hold a management position

The nurse has reinforced teaching on a client who is receiving prescribed NPH and regular insulin which of the following statements by the client would indicate a correct understanding of the teaching 1. I should increase the dose of NPH incident if I am planning to have dessert for dinner 2. I should administer regular insulin into my arm if I am planning to exercise with in one hour 3. I will withhold regular insulin if I’m vomiting but I will administer NPH  insulin as prescribed 4. I will draw regular insulin into the syringe first and then draw npH into this same syringe

The nurse is reinforcing teaching with a female client who is at 24 weeks gestation and is scheduled for a glucose tolerance test which of the following information should the nurse in reinforce  1. Fasting is required for four hours prior to the test 2. A serum glucose level will be obtained 1 hour after the test 3. A written consent form is required before the test is perform 4. A second test will be performed if your serum  glucose level is below 140 MG/DL 

 The nurse is reinforcing teaching with a client who has Giardiasis.  Which of the following statements by the Client would indicate a correct understanding of the teaching? 1. 2. 3. 4.

I should drink only bottled water I will avoid using Using a public washroom I should keep my eating utensils separate from those of other family members I will avoid drinking water from the streams or lakes while I’m camping

The nurse is changing the dressing over a clients infected wound.  The client tells the nurse I would not need all of this care if someone in the staff here had taken care of Me correctly.  Which of the following responses would be most appropriate for the nurse to take 1. It sounds like you’re angry = addresses it feeling 2. I will arrange to have the wound care specialist busy 3. Let me see how the infection is responding to the treatment 4. Tell me what I can do to help you at the time

The nurse is caring for assigned clients the nurse should first evaluate the equipment of a client who has 1. A patient controlled analgesia device and reports that the medication is not received each time that the button on the pump is activated 2. A pulse oximeter sensor attached to the finger and reports that the numbers on the pulse oximeter screen change every few seconds = normal 3. A nasogastric tube connected to low intermittent section and reports that Bubbles appear in the NG tube when the machine turned on = 1 st 4. A sequential compression stocking and reports that the stockings have remained inflated for the past several minutes

The nurse is assigned in developing a plan of care for an older adult client with visual impairment which of the following modifications in the clients home environment would be appropriate for the nurse to recommend 1. Encourage the client to place a bright light next to the chair the client uses while reading magazines 2. Rearranging the clients furniture so that the bed faces the window 3. Obtaining polish brass colored handles for the use on exit doors 4. Using contrasting colors like black and white to mark the edge of stairs

The nurse is talking with a parent of a four month old infant the parent is concerned that the infant may have been exposed to measles the nurses response should be based on the understanding that the infant 1. May have passive immunity for rubeola measles based on the mothers immune status 2. Needs to be isolated from other children for 4 to 5 days 3. Needs to receive immunoglobin to prevent rubeola ( measles ) 4. May need to have blood test completed to determine whether exposure occurred – mostly Determine/ asses/ check personally / collect data 1 st

The nurse is caring for a five-year-old client with pertussis which of the following infection control precautions will the nurse implement 1. Place a surgical mask on the client during transport out of the clients room 2. Place a client in a private room with monitor negative air pressure – Airborne 3. Restrict family members who are pregnant from Visiting the client – No need 4. Keep the doors of the clients room closed at all times – for Ebola patient Pertussis – (Whopping cough ) = Droplet precautions

Change a sterile dressing 1. 2. 3. 4. 5.

Remove the old dressings with clean gloves/ non-sterile gloves Secure dressing with tape Put on sterile gloves Apply sterile dressing Clean the wound

1,3,5,4,2

The nurse is collecting data about a client sleep and rest patterns which of the following statements by the client would be a priority to follow up/ further teaching ? 1. 2. 3. 4.

I take a nap in the afternoon if I feel tired after work = Normal I watch television at night when I have difficulty falling asleep – maybe I wake up feeling tired even though I sleep 7 to 8 hours each night I often wake up once or twice during the night but fell back to sleep quickly = Normal

The nurses is going to perform perform an EKG for assigned client which of the following actions should the nurse take? 1. Assist the client in semi Fowler’s position 2. Applied a gel to the clients chest before applying the transducer  3. Place electrodes to all four extremities and on the clients chest  4. Ensure the client had a patent Peripheral venous access device

The nurse is caring for a client who has been receiving nalbuphine, Which of the following should the nurse plan to have available as an antagonist/ antidote for the medication? 1. 2. 3. 4.

Sodium bicarbonate Magnesium sulfate Naloxone Methadone 

The nurse is caring for assigned clients. the nurse should recognize that the client at risk for developing hypothyroidism is a client who 1. 2. 3. 4.

Has a pituitary tumor Has a parathyroidectomy  has a small cell lung cancer Has been receiving prolonged corticosteroid therapy

The nurse has received the following information about assign clients the nurse should first check the client 1. With diverticulitis who has had four episodes of diarrhea in the past 12 hours 2. Who has a long leg cast and is reporting that the toes feel numb – compartment syndrome 3. With right sided heart failure who has 3+ pitting Edema of the lower extremities 4. Who has pleurisy and is reporting right sided chest pain while deep breathing 

The nurse is preparing to administer an intramuscular injection to a client. The client ask why the medication is being administered in the ventrogluteal site Instead of the deltoid site. The nurse’s response should be based on which understanding 1. The Ventrogluteal site provides a large muscle mass for injection- best muscle as large tissue is there 2. Intramuscular injections are not painful when given in the ventrogluteal site 3. The deltoid muscle should be used only for immunizations 4. There is a risk for injuring the sciatic nerve when injecting the deltoid muscle

Diphenhydramine – treats rashes Miconazole – maybe 1st

Nurse to assign to a UAP SATA 1. Providing telephone instructions to the client with posttraumatic stress disorder who is experiencing a flashback – RN 2. Measuring and recording intake and output for the client with major depression who has refused to eat for several days 3. Monitoring the client with moderate Alzheimer’s disease so the client will not wander from the facility – monitoring is RN 4. Transporting the client with schizophrenia to receive electro convulsive therapy 5. Taking a urine specimen to the laboratory for the client with anorexia nervosa 6.

The nurse is preparing a newly admitted client with meningococcal meningitis for a magnetic resonance imaging scan of the chest which of the following actions would be appropriate for the nurse to take? 1. Cleanser clients test where they povidone iodine solution 2. Place a surgical mask over the clients Mouth and nose 3. Where a protective gown when assisting the client onto a stretcher = its droplet precaution questions 4. Put the clients dentures in a container with water

The nurse is reinforcing teaching about nutrition and preventing infection at home with a client newly diagnosed with acquired immune deficiency disorder ( AIDS) which of the following information should the nurse reinforce? SATA 1. 2. 3. 4. 5. 6.

Consult with a registered dietitian Monitored for weight loss or weight gain Wash all produce thoroughly before eating Use separate sets of dishes and utensils Consume a diet high in calories and protein Eat large meals when you are not feeling nauseated

The nurse has reinforced teaching with a client with pheochromocytoma Who is scheduled for adrenal arteriography. Which of the following statements by the client would indicate a correct understanding of the teaching? 1. I may experience numbness or tingling in my legs during the procedure  2. I may be a risk for severe hypertension during the procedure 3. I will need to remain flat in bed for 10 hours After the procedure 4. I will need to have coagulation studies prior to the procedure

The nurse is caring for a five-year-old client who sustained burns over 10% of the body one week ago which of the following between meals snacks would be appropriate to offer The client? 1. 2. 3. 4.

Slices a red Apple  cheese sticks Strawberry gelatin Frozen juice bar  Kids, toddler = Cheese option is always SAFE

There is caring for a client who has streptococcal Pharyngitis. Which of the following infection control precautions should the nurse implement 1. Place a particulate respirator mask on the client during transport – surgical mask 2. Insert the client to cover the mouth with a reusable cotton cloth when coughing  3. Ensure that the door to the client room remains closed at all times – Ebola 4. Where a surgical mask when administering medications to the client

The nurse is collecting data from a client with a major depression. The clien tells the nurse yesterday I felt like killing myself but today I feel better which the following statements will be essential for the nurse to make 1. This information will help us to plan further treatments for you 2. Do you think your treatment has been effective 3. I’m glad you’re feeling better 4. Will you promise to contact someone if these feelings happen again = no promises and persuading clients

The nurse has reinforced teaching with the client about nonpharmacological pain management techniques which of the following statements by the client would indicate a correct understanding of the teaching? Select all that apply 1. Massage can be performed to decrease pain intensity 2. I will read a book to distract my attention from the pain 3. Analgesics will not be necessary if I use non-pharmacological techniques 4. I will use a heating pad on Low temperature 5. The nurse should provide me with a topic if I use guided imagery

Informed consent select all that apply 1. The client may not withdraw consent once the informed consent form has been signed = Client can 2. The student nurse assigned to the client may witness and sign and form consent form if a staff nurse is not available = Never 3. The nurses responsible for explaining the procedure to the client prior to asking for the informed consent form to be signed  Explaining the procedure only by HCP 4. The client who is minor and enlisted in the military is considered legally capable of signing their own informed consent form 5. The nurses signature on informed consent form indicate that the client has voluntary given consent for the treatment or procedure 6. Verify if the client is eligible to give consent 18 most states 7. The nurse can act as a witness only

The nurse is observing a client who has been receiving diphenoxylate hydrochloride with atropine Sulfate which following would be the best indication that the medication is effective? 1. The client no longer strains at stool 2. The client has an increase in flatulence 3. The client has an increase in bowl sounds 4. The client has more solidly formed stools = brown stools

The nurse is reinforcing teaching with a client who is receiving prescribed metronidazole which of the following information to the nurse reinforce/ CORRECT ANSWER? 1. You may consume one glass of wine = NEVER 2. You may experience metallic taste while taking the medication – Normal side effects 3. Notify your primary healthcare provider if urine becomes dark in color  4. Take the medication with food to increase the rate of absorption Metronidazole = Metallic taste

The nurse is assisting with the plan of care for a client who is scheduled to have a right mastectomy which of the following would be most important for the nurse recommend to be included to maintain the clients positive body image 1. Encourage the client to explore her feelings 2. Provide the client with a calm quiet environment  3. Discuss the types of prostheses available 4. Reinforce information on coping mechanism

Vitamin D deficiency which of the following dietary modifications to the nurse reinforce? 1. 2. 3. 4.

Increase the amount of green leafy vegetables in the diet = calcium Increase the amount of calcium in the diet Drink a glass of orange juice at breakfast = vitamin c Use fortified milk with cereal 

Milk has Vitamin D

The nurse has reinforced teaching with a client about healthy sleep patterns follow up/further teaching is required if the client reports doing which of the following before bed? 1. Performing aerobic exercises – mostly likely 2. Eating a carbohydrate containing snack  3. Taking an over-the-counter lavender supplement – improves sleep quality 4. Listening to music

Performing a breast self examination which of the following information to the nurse reinforced select all that apply 1. You should use the palm of your hand to Feel for lumps = finger pad should be used for assessment 2. Perform the BSE after your menses when your breast are less tender 3. You should notify your primary healthcare provider if you observe dimpling/ lump of the skin 4. Remain lying flat on your back and observe your breast for chain is using a Hand mirror = standing and using Face mirror best option 5. You should notify your primary healthcare provider if you have discharge from your nipples

Risk for developing malnutrition? 1. The six-year-old client who has missing front teeth 2. The 16-year-old client who has a history of kidney stones 3. The 45-year-old client who had a stroke and has right sided weakness 4. The 65-year-old client who had a stomach cancer 5. The 88-year-old client who has a history of alcohol abuse

The nurse has reinforced teaching with a client with phenochromocytoma Who is scheduled for adrenal arteriography. Which of the following statements by the client would indicate a correct understanding of the teaching? 1. I may experience numbness or tingling in my legs during the procedure 2. I may be a risk for severe hypertension during the procedure 3. I will need to remain flat in bed for 10 hours After the procedure 4. I will need to have coagulation studies prior to the procedure

The nurse is caring for a client who sustained a closed head injury which of the following findings would require immediate intervention? 1. Ecchymotic area or the left temple = battle 1 st 2. Glasgow coma scale score of 13 = < 7 NO 3. Blood pressure of 136/76 4. Headache that worsens with coughing = ICP 2 nd

Nurse assign to a UAP 1. Administer an enema/ condom catheter to the client with a fractured right hip 2. Removing sutures from the client who had an abdominal hysterectomy 3. Instructing the client with irritable bowel syndrome about dietary restrictions 4. Conducting a home safety assessment for the client with moderate Alzheimer’s disease Conduction , instructing , monitoring , evaluating , Removing sutures =RN

There is caring for a client who has streptococcal Pharyngitis. Which of the following infection control precautions should the nurse implement 1. Place a particulate respirator mask on the client during transport = surgical mask 2. Insert the client to cover the mouth with a reusable cotton cloth when coughing 3. Ensure that the door to the client room remains closed at all times = Ebola 4. Where a surgical mask when administering medications to the client = Droplet precaution

The nurse at an outpatient care facility has received the following telephone message from clients Who were previously seen at the facility then there should first telephone a client who is at ? 1. 12 weeks gestation is experiencing nausea and vomiting = Normal 2. 36 weeks gestation is reporting the leakage of yellow fluid from the nipple = Normal 3. 35 weeks gestation is reporting a gush of clear fluid from the vagina 4. 22 weeks gestation and has a burning sensation with your urination = UTI 2 nd

Yellow discharge from a Nipple from pregnant women = Normal

Breast tenderness , vaginal discharge , urinary frequency = Women is Pregnant

The nurse is obtaining a pole street for a client with Dysrhythmia which of the following actions should the nurse take 1. Count the Apical rate for 60 seconds

Confidentiality

The clients medical record is the clients property and the client may have access to the record any time 2.Unneeded computer generated work sheets must be shredded at the end of the shift to ensure client confidentiality 3.Personal computer passwords may not be shared with anyone including other members of the clients healthcare team 4.Medical information about the client may be shared with a police officer who brought the client into the emergency department = NEVER 5.Keep your voice low when speaking with the client Because direct interaction with clients must be kept as private as possible

The nurse is contributing to the plan of care for a client who sustained full thickness burns on 30% of the body three days ago which of the following interventions to the nurse suggest including in the clients plan of care ? select all that apply 1. Discourage movement of the affected body parts = MOVE IT BURN 2. Offer the client prescribed opioids analgesics prior to providing wound care 3. Wear a hair covering and a surgical mask when the bum wounds are exposed 4. Used ice and other cold therapy as an adjunct to pharmaceutical pain relief 5. Stress the importance of strict intake and output recording for the client with the unlicensed assistive personnel

The nurse is talking with a client who is exhibiting defense mechanisms which of the following statements by the client with exemplify projection? 1. 2. 3. 4.

I purchased a gift for the nurse because I was rude yesterday I became angry at my spouse and threw a glass against the wall I backed my car into a pole because my spouse was distracting me I have been informed of my poor prognosis But I know I will live a long time = denial

The charge nurse is talking with a coworker who has returned from a meal break five minutes ago the charge nurse observes that the co-workers eyes appear glassy and the speech is slurred which of the following actions should the charge nurse take SATA 1. Send a coworker to the employee health department to have a urine specimen obtained for a drug screen  = marginuna = glassy eyes , not sure about this answer 2. Suggest the coworker in the eyes with cold water and telephone the coworkers spouse to drive that coworker home 3. Re-assign the coworkers clients and ask a coworker to wait in the conference room 4. Notified the facility security officer and ask the officer to question the coworker 5. Provide assistance to the impaired colleague by reporting the behavior to the appropriate supervisor

The nurse has attended a staff development conference about the care of clients with a neurological injury the following statements by the nurse would indicate a correct understanding of the conference 1. A client who has a Neurosurgery is at risk for developing a DVT and may have anti Embolism stockings or TED hose , SCD prescribed. They put mild pressure on the legs to prevent blood from clotting and can, to some degree, prevent blood clots in the legs (DVT).

The nurse has reinforced teaching with a client who was placed in skeletal traction 24 hours ago for affected femur it would indicate a correct understanding of the following if the client 1. Rolls from side to side for linen changes 2. Reports a change in the sensation on the leg = Paresthesia: 3. Rest the feet against the end of the bed 4. Adjusts the length of the rope used for traction Paresthesia: 1) a tingling, 2) pricking, 3) chilling, 4) burning, 5) Numb sensation on the skin) with no apparent physical cause.

Yellow discharge from a Nipple from pregnant women = Normal Yellow execute from circumcision = Normal

The nurse in the pediatric clinic is caring for a five week 1 months and 1 week old infant which of the following behaviors is a nurse likely to observe in a healthy five-yearold client  1. 2. 3. 4.

Inspecting and playing with hands = No Crying when a stranger approaches  = 6 months ,10 -18 months ,3 yrs. Lifting the head when lying on the abdomen Frequent drooling – 3 months -5 months

The nurse is caring for a client who practices Orthodox Judaism and is expected to die during the shift which of the following with the nurse expect to observe after the client dies  1. One of the clients  family members will remain with the client 2. Several small drops of oil will be placed on the clients lips and forehead 3. The client spiritual advisor will fold the clients hands across the clients chest  4. The client spouse will request that staff members wrap the Client in a red cloth

The nurse is caring for a client with chronic pain who is requesting a dose of prescribed opioid analgesic every 1 to 2 hours. Which of the following statements would be appropriate for the nurse to make? 1. Using the medication to treat chronic pain may cause drug addiction 2. You are scheduled to receive a dose of the medication every four hours and you may not receive additional doses 3. You don’t seem to be experiencing relief from the medication let’s talk with your primary healthcare provider about a different medication. 4. Additional problems may be causing you pain talk with your primary healthcare provider about scheduling test to determine the source of pain

The nurse is caring for a couple who just experience a stillbirth the client’s spouse says to the nurse I’m tired I need to go home I’ll probably take the babies bassinet back to the store while I’m gone since we just started to buy furniture for the nursery. Which of the following responses would be most appropriate for the nurse to make 1. 2. 3. 4.

Your wife need you here with her  there will be plenty of time to return the bassinet = maybe I can help you talk with your wife about the nursery You need to get some rest instead of working

Nurse is caring for a five-year-old client with autism ASD which of the following behaviors would be consistent with the diagnosis ? 1. 2. 3. 4.

Frequently trips or falls when ambulating Blinks and twitches extremities uncontrollably = Bells palmy Tonic colonic muscle contractions Speech and language delays

The nurse is talking with a dietitian who is preparing to consult with a client at 12 weeks gestation during the first prenatal visit it would be essential to inform the dietitian of the client 1. Is allergic to penicillin the client  2. is experiencing Ptyalism 3. Have a history of diabetes mellitus 4. Has a  body mass index of 22 before pregnancy 

The nurse is cooking with multiparous client who was just admitted at term in early labor stage which of the following statements by the client would be requiring immediate Notification of the RN 1. 2. 3. 4.

My back is really hurting It feels like there’s a water running down my legs I feel the emesis basin right away  My contractions make it feel like I need to have a bowl movement = baby is coming = When contractions make you feel like having a bowel movement, the baby is in the perineum. Remember they are multiparous clients. , Remember they're multiparous women.

2 (if there is watering running down her legs that means she had spontaneous rupture of membranes and needs a vaginal examination to assess for progress of labour and cord prolapse) 2 bcz RN needs to monitor FHR and look for cord prolapse

The nurse is talking with a client who has a DVT and is receiving prescribed enoxaparin. Which of the following statements about the client would require follow-up means review/ further teaching requires 1. I am scheduled for a lumbar puncture in the morning and will have to be NPO Left, later position or sitting up the edge of the bed 2. My primary healthcare provider said my serum aminotransferase ALT Levels are being monitored 3. I have been saving through specimen so the nurses can test them for blood 4. My primary health care provider said protamine selfie should be administered in the event of an aspirin overdose

1) Antidote for aspiring overdose is sodium bicarbonate 2) Protamine sulfate antidote is for heparin.

The nurse is reinforcing teaching about safety with a group of parents do the following information to the nurse reinforce? 1. School-age children are at greatest risk for ingesting toxic plants = 6-12 are smart enough 2. Toddlers are at great risk for acetaminophen poisoning 3. Toddlers who ingest honey are at greatest risk for botulism poisoning - its for infant who ingest honey is risk for botulism 0-12 months

Preschool age children living in a home built after 1978 Are at greatest risk for lead poisoning – lead poisoning is greater in toddler 18 to 24 months 1-3 years

The nurse has reinforced teaching with a client who has depression and is taking it prescribed monoamine oxidase inhibitor MAOI. Which of the following statements by the client would indicate a great understanding of the teaching? 1. Every morning I will eat a banana with my cereal for breakfast = NO BAR Banana, avocado , raisin , yogurt , chocolate, caffeine ,alcohol/wine , only cottage cheese. 2. I should not eat any type of cheese while taking the medication = only cottage cheese 3. I should avoid eating chocolate while I am taking the medication 4. I can continue to drink one glass of wine with my evening meal = No

The nurse is reinforcing teaching with a female client but early detection of breast cancer. Which of the following statements by a client would indicate a correct understanding of the teaching? 1. Digital mammography is less painful than x – ray mammography = Nothing is painful 2. Digital mammography is better at detecting tumors in dense breast tissue than X-ray mammography 3. Magnetic resonance imaging ( MRI) can be used to direct breast tumor instead of mammography – NEVER

The nurse reinforced teaching with a son of a female client who is being discharged after the stroke the client will continue rehabilitation At the sons home. The nurse is aware that one of the family members is a 10-month-old infant which of the following statement by the son would indicate the correct understanding of the teaching ? Infant safety 1. We need to schedule my mothers physical therapy during times that our baby normally is taking a nap 2. We should make sure that our mothers bed is located close to the door of her bedroom because of our baby. 3. We should remove my mothers raised toilet seat from the toilet after each use  4. If we get a hospital bed for my mother we will need to look under the bed Before we lower the height of the bed

The nurse is caring for a client who has a partial gastrectomy six hours ago the client has the NG tube attached to low intermittent suction and the drainage tube bright red blood. The nurse should first  1. 2. 3. 4.

Check the clients vital signs = patient 1st Irritate the clients NG tube as prescribed prn Determine the setting on the suction device Inform the Charge nurse about the observation = Passing bucket

Any thing happens either STOP or just the VITALS

A nurse is collecting data from a client with Bell’s palsy. Which of the following findings would the nurse expect to observe? 1. 2. 3. 4.

Cold intolerance  Positive Babinski reflex Tearing on the affected side Nystagmus

The nurse has attended a staff education conference about reminiscence therapy For clients with Alzheimer’s disease which of the following statements about Reminiscence Therapy by the nurse would indicate correct understanding of the Conference? 9. The client is encouraged to listen to familiar tunes to Induce relaxation, alter moods and improve social interaction 10.Reminiscence therapy elicits pleasant memories from the clients past through the use of sensory stimulation such as pictures

11.The client is provided with a stable and coherent social organization to facilitate individual treatment 12.Reminiscence therapy focuses the use of dolls or stuffed animals To provide tactile stimulation and comfort

The nurse is caring for a client recently diagnosed with terminal lung cancer. The clients shouts I can’t believe how terrible the food is here and are you trying to make me ill. Which of the following responses should be appropriate for the nurse to make ? 1.You are not happy with the food you have been served is there anything else you would like to discuss = best 2.Your behavior is unacceptable I will return when you are calm and rational 3.Please stop shouting at me I will be happy to help you plan your meals 4.Is there a problem with your food I will ask the register dietitian to talk with you

The nurse is reinforcing discharge instructions with a client who has heart failure the client has prescriptions for diuretic and a potassium supplement which of the the following statements for the client would indicate an understanding of the instructions? 1. I will take an extra diuretic pill with a glass of orange juice at night if I start gaining weight = doesn’t make sense 2. I will include canned soups and frozen vegetables in my diet because they’re easy to prepare and a good source of potassium = NEVER , they are source of sodium 3. I will increase my activity gradually but if I get short of breath I will stop and rest 4. I will not take my diuretic pill and I will call my doctor if my pulse is below 60 = Take it 1st

The nurse is collecting data from a client in labor who just had an amniotomy performed. The fetal heart rate is 92. Which of the following would be consistent with the findings 1. Polyhydramnios 2. Imminent delivery  3. Fetal cardiac anomaly  4. Prolapsed umbilical cord FHR = 110 -160

The nurse has reinforced teaching with a client who is scheduled for a bronchoscopy which of the following statements by the client would require follow-up/ further teaching ? 1. I should remove my dentures prior to the procedure 2. I can eat and drink immediately after the procedure Following the procedure, the client will need to be monitored for complications such as bleeding/ hemorrhage 3. I will be given a local anesthetic during the procedure  4. I will need to sign a consent prior to the procedure

The nurse Is collecting data from a client who is at 30 weeks gestation. The client tells the nurse it seems like I have been incontinent of urine for the last few days. The nurse should make sure that which of the following is available in the clients examination room 1. 2. 3. 4.

Electronic fetal monitor Sterile urine container Nitrazine paper Clean, cotton-tipped applicators

 The nurse is caring for a client with prostate cancer who is scheduled for an orchiectomy. The client states I don’t understand why I need to have this surgery. The nurse should reinforce the preoperative instructions with the client to indicate that the surgery 1. Decreases male hormones that stimulate the prostate cancer growth = orchiectomy 2. Eliminates the most common site of metastasis  3. Minimizes a need for chemotherapy 4. Remove the source of the cancer

Orchiectomy (also named orchidectomy, and sometimes shortened as orchi) is a surgical procedure in which one or both testicles are removed (bilateral orchiectomy)

The nurse is collecting data from a client with primary hypothyroidism which of the following findings would the nurse expect? 1. 2. 3. 4.

Elevated serum thyroxine Elevated serum thyroid stimulating hormone Elevated serum triiodothyronine  Elevated serum parathyroid hormone

The nurse is caring for a client who wants to leave the facility against medical advice AMA which of the following actions should the nurse take? 1. Complete an incident report and forward it to the risk management department 2. Inform the client that the client can leave after the family member is notified 3. Do not allow the client to leave until the primary healthcare provider performs a complete physical assessment 4. Permit the client to leave after the client sign the release form also notify the HCP

The nurse is reinforcing teaching with a client who is scheduled for a radical neck dissection and laryngectomy. Which of following statements by the client would indicate a great understanding of the teaching 1. After surgery I look forward to spending time alone at home doing my hobbies = needs constant monitoring.

2. I will ask my friends to make a special board with pictures of food that I like to eat – 1st 3. I need to renew my membership at the local swimming club so that I can go swimming during the recovery= you cant swim when you have a hole in your throat. 4. After surgery I will probably feel more comfortable if I am wearing a shirt that buttons around my neck = body image

Nurse is contributing to a staff education conference about advanced directive and the responsibilities of the nurse which of the following should the nurse suggest including select all that apply 1. Encourage the client to complete advance directives 2. Answer the clients legal questions regarding advanced directive = never 3. You may serve as a witness for the clients adventure asked if asked = not HCP , Not listed person, not nurse 4. Make sure a copy of the clients advance directive is in the medical record 5. Encourage the client to discuss healthcare preferences with family members 6. You may reassure the client that advance directive can be change at anytime 2 witness required , HCP , the nurse , the listed person cants witness

Isolation precautions

The nurse has attended a staff development conference about infection control precautions which of the following statements by the nurse would indicate a good understanding of the Conference 1. A gown and gloves should be worn when changing the bed linens of a client with pediculosis capitis = also wear head cap 2. Disposable towels should be used when bathing a client with bacterial conjunctivitis = contact isolation

3. Gloves should be worn when giving a back rub to a client with systemic lupus erythematosus = not even a isolation 4. Goggles and a gown should be worn when obtaining a sputum specimen from a client with active pulmonary tuberculosis  = airborne precautions

The nurse is reinforcing teaching with a client who is receiving prescribed methotrexate which of the following information to the nurse reinforce? 1. 2. 3. 4. 5.

Take over-the-counter aspirin if you have a headache Apply sunscreen prior to participating in outdoor activities Continue to take Saint johns wort for depression Notify your primary healthcare provider if your experience a sore throat Limit your intake of beverages that contain alcohol to one glass of red wine per day

Methotrexate = Sore throat

The nurse is caring for a client who is receiving prescribed oxygen a spiritual advisor is performing a ritual in the clients room. Which of the following if used doing the ritual would require the nurse to intervene ? 1. 2. 3. 4.

Special food and herbs small candles = causes fire Religious books Metals and threads

The nurse is caring for 5 year old client who has prescription for acetaminophen 12mg/kg , every 4 hrs. The client weighs 43 lb ( 19.kg). The nurse 160 mg/ 5ml of solution available. How many ML should the nurse administer to the client with each dose ? One decimal places

12MG KG 2580 352 7.3 ml

KG 2.2 LB

43 X

5ML 160MG

The nurse is caring for a client who has a prescription for tobramycin 3mg/kg/day. IM , divided doses every 8 hrs . The client weighs 115lb . The nurse has tobramycin 40mg/ml of solution available. How many ML each does ? round answer to using one decimal place . 1.3

A nurse is contributing to a staff conference program about electroconvulsive therapy which of the following information should the nurse recommend including 1. ECT is commonly used to treat depression prior to prescribing antidepressant medications = meds first 2. ECT may be administered to clients on an outpatient basis  3. Auditory hallucinations are common side effects of ECT 4. ECT lowers the level of norepinephrine in the central nervous system =

ECT increases norepinephrine

The nurse is collecting data from a client who is receiving but he prescribed antihypertensive medication which of the following would indicate a correct data collection technique to identify Orthostatic hypotension 1. Measure the clients blood pressure in each arm while the client is seated and compare the results 2. Ask the client to stand from a sitting position and then measure the clients blood pressure while standing 3. Asked the client to walk for five minutes and then measure the client blood pressure while seated 4. Measure the clients blood pressure in the supine sitting and standing position 1 to 3 minutes apart 

The nurse is caring for a client who has been vomiting and has diarrhea for the past 24 hours which of the following actions would be priority for the nurse to take ? 1. 2. 3. 4.

Measure the clients weight Obtain a 24 hour urine specimen Monitor the client for changes in mental status Check clients blood pressure in a supine and standing position

The nurse has reinforced teaching with a client who is receiving prescribe alprazolam which of the following statements by the client would require follow-up – further teaching 1. 2. 3. 4.

I will avoid drinking grapefruit juice while taking alprazolam I can divide the total daily dose of alprazolam into more frequent intervals I should Avoid Alcohol while taking Alprazolam I will need to take alprazolam for the rest of my life = short term use only Levothyroxine yes

2. You can’t divide medication doses without doctor’s prescription and just on your own. I did not pick 4 because benzodiazepines accdg to remar are for short term use only.

The nurse is caring for a client who’s wearing antiembolism stockings. The nurse should recognize that which of the following findings as likely to impede venous return 1. Sequential compression devices have been applied over the stockings – mostly likely 2. Powder was applied to the clients legs prior to application of the stockings 3. The top of the stockings have rolled down = never fold down 4. The stockings are too large for the client I would go with 1 because SCD compresses your extremity. With number 1, there are 2 types of compressions stockings one is thigh length and the other one is knee-length, so if it’s rolled down, it doesn’t mean it impedes the blood circulation but doesn’t provide the proper compression.

Provide a UAP with the best directions regarding the assignments 1. Assist the client with dementia/Alzheimer’s to ambulate to the bathroom after eating = 1st 2. Offer between meals snacks to the client with diabetes Mellitus  3. Help the client with microvalve prolapse prepare for a schedule dental appointment today 4. Encourage the client with gastroenteritis to drink one cup of liquid every two hours = reinforcing .. LVN

UAP can help with ADL, routine procedures , measure I/O, measure v/s, ambulating

Which of the following activities would be appropriate for the nurse to assign to a UAP SATA 1. Weighing the client with heart failure 2. Providing oral hygiene to the client with severe Alzheimer’s disease 3. Palpating the pedal pulses of the client who had a cardiac Catherization two hours ago = less than 12 hrs fresh operative 4. Obtaining and documenting vital signs from the client who had an appendectomy  24 hours ago – maybe not , coz post op 5. Obtaining a pulse oximetry reading from the client with chronic obstructive pulmonary disease – COPD

The nurse in a long-term care facility is making client care assignments for you a which of the following statements by the nurse would provide a UAP but the best directions about the assignment? 1. The client is at risk for infection take the vital signs and report back to me if the temperature is above 100.5 - task given , report back to me good answer but

RISK of infection

2. The client has hemiplegia assist the client to eat breakfast = risk of choking Avoid hemiplegia and quadriplegia and stoke 3. The client who had total knee replacements needs to begin physical therapy plan of the client care around the therapy = Fresh operative 4. All the clients who have been assigned to you will need to have vital signs obtained an intake and output recorded = best answer Think about what CAN DO

The nurse is reinforcing teaching with the parents of a three-year-old client about how to administer prescribed eyedrops medication and a prescribed Eye ointment which of the following should the nurse reinforced? Select all that apply 1. It is best to administer the eye ointment soon after your child awakens in the morning = During the day not first thing in the morning 2. Administer the eyedrops prior to the eye ointment  3. You can ask your spouse to help immobilize your child head and arms = maybe 4. Clean each eye from the outer canthus to the inner canthus prior to administering the medication = Never From the inner canthus to outer cantus Irrigation of the wound = center to outmost 5. Apply the ointment in a thin strip along the conjunctival sac

The nurse is caring for an adult client admitted one day ago following a stroke which of the following findings should be reported immediately 1. Negative Babinski reflex = Adults don’t have Babinski reflex 2. Breast Pupillary response 3. Irregular respirations of 22 =

Normal = 12-18

4. Capillary refill less than 2/two seconds = Normal

Cap refill <2 is normal.

The nurse is contributing to a staff education conference about informed consent which of the following information to the nurse suggest including

A clients knowledge of the procedure Include 1.Name of the procedure 2.Length of the hospital stay 3.Medications prescribed 4. nurse should ask the client if there is anyone that they would like to have present during the explanation of the procedure = no need , consent requires only the patient 5. A client could file a charge of assault if the consent is not signed before a procedure is performed 6. A nurse should avoid answering clients questions about the procedure until the consent is signed = always answer the questions by the clients

The nurse is caring for a client who has right sided Hemiplegia and is ambulating using a walker it would indicate a correct understanding of how to use a walker if the client is observed 1. Taking steps forward with the left leg and then advancing the right leg and the walker 2. Moving the Walker forward 12 inches then swinging both legs forward together 3. Moving the walker and the right leg forward 6 inches and then move in the left leg forward 4. Placing the rear legs of the walker and the Right leg forward and then moving the left leg forward

3.Walker, Affected leg, following Unaffected Leg.🤔

The nurse has received the following information about assigned clients. The nurse should first check the client who ? 1. Has gastroenteritis is reporting nausea and vomiting 100 ML of green liquid 2. Has a Long cast and is sitting in a chair with the casted leg elevated on a stool 3. Had a appendectomy one day ago and has a 2 cm area of serosanguinous drainage on the incision dressing 4. Had a thyroidectomy two days ago and has muscle spasm and the wrist when the blood pressure is taken 4.Hypocalcemia,