Practice

70問 • 2年前

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A nurse is reinforcing information with a client who wishes to complete their advance directives. Which of the following statements should the nurse make?

You can decline to have certain medical procedures performed in your living will.”

A nurse is reinforcing teaching with a client who is premenopausal. Which of the following statements by the client indicates in understanding of the teaching?

“I might have headaches due to a decline in my estrogen levels.”

A nurse in a provider's office is calculating a client's BMI. Which of the following pieces of the client data should the nurse use as a part of the calculation?

Height

A nurse is reinforcing teaching with a client about the use of a peak flow meter. Which of the following actions should the nurse make first?

Determine the client's knowledge of the use of the peak flow meter.

A nurse is collecting data about a client's oral care. The client wears dentures and reports having mouth sores. The nurse should identify which of the following oral care practices by the client as a possible cause of the mouth sores?

Wears dentures while sleeping at night.

A nurse is preparing to administer a medication from an ampule. Which of the following is an appropriate action for the nurse to make?

Use a filter needle to aspirate the medication.

A nurse on a medical-surgical unit is caring for a group of clients. Which of the following findings should the nurse identify as a safety hazard?

An assistive personnel raises all four side rails of a client's bed before leaving the room.

A nurse is caring for a client who is 2 days postoperative following a below-the-knee amputation. Which of the following statements by the client should the nurse identify as indicating an acceptance of the limb loss?

"I need to learn how to perform a dressing change on my leg."

A nurse on a medical-surgical unit is collecting data from a client who is postoperative following abdominal surgery. The client's BP was 126/72 mm Hg 15 min ago. The nurse now finds that the client's BP is 176/96 mm Hg. Which of the following actions should the nurse make?

Measure the client's BP in the other arm.

A nurse is assisting with the admission of a client who has streptococcal pharyngitis. Which of the following precautions should the nurse make?

Wear a surgical mask when giving the client direct care.

A nurse is caring for a client who has dyspnea with an oxygen saturation of 88%. Which of the following images indicates the type of face mask the nurse should use to deliver the client a 90% oxygen concentration?

non-rebreather mask with bag

A nurse working in a rehabilitation unit is caring for a client who has dysphagia and has difficulty swallowing during meals. Which of the following actions should the nurse take to prevent the client from aspiration while eating?

Add liquid to foods to thin consistency.

A nurse in a provider's office performs a fecal occult blood test with a positive result on a client. Which of the following clients may have a false positive result?

A client who takes an iron supplement

A nurse is caring for a client who is flushed and has temperature of 38.7 C (101.7 F). Which of the following actions should the nurse take?

Remove blankets from the client.

A nurse is caring for a client who has a hip fracture and plans to administer a pain medication prior to turning the client. Which of the following ethical principles is the nurse implementing?

Beneficence.

A nurse is caring for a client who was recently admitted to hospice care and tells the nurse "I am going to die, and my family is hoping for a cure. I am mad that they behave like everything will be fine." Which of the following responses should the nurse make?

"You are feeling angry that your family continues to wish for a cure?"

A nurse in a provider's office is reviewing the medical record of an older adult who report's having nausea and vomiting for the last 48 hrs. Which of the following findings indicate fluid volume deficit? (Select all that apply.)

Dry mucous membranes., Decreased skin turgor., Blood pressure 88/62 mm Hg.

A nurse is caring for a client who refuses a prescribed medical procedure. Which of the following actions should the nurse take to act as the client's advocate?

Evaluate the client's concerns and communicate them to the provider.

A nurse is assisting with scoliosis screenings for students at a public school. Which of the following findings should the nurse recognize as an indication of scoliosis?

Unequal height of the shoulders.

A nurse is disinfecting the room of a client who has a Clostridium difficile infection. Which of the following solutions should the nurse use?

Chlorine bleach.

A nurse is preparing to administer sucralfate 80 mg/kg/day to divide into four doses per day to a child who weighs 35 kg. The amount available is sucralfate oral suspension 1 g/ 10 mL. How many mL should the nurse administer per dose? (Round to the nearest whole number.). _mL

(80x35÷1*1000 x10) /4 =7 mL

A nurse is reinforcing teaching with a client who follows a vegan diet and is interested in ways to increase protein to promote healing after a recent surgery. Which of the following suggestions is appropriate?

Cottage cheese.

A home health nurse is reinforcing teaching about dietary needs with the son of a client. The son states, "I don't know what to do because he's not eating." Which of the following responses should the nurse make?

"Tell me more about what happens at mealtime."

A nurse is coordinating care of a group of clients with an assistive personnel (AP). Which of the following tasks should the nurse assign to the AP?

Reinforce teaching with a client about crutch-gait walking.

A nurse is preparing to insert an indwelling urinary catheter and is verifying the client's express consent for the procedure. Which of the following actions should the nurse take?

Obtain verbal consent from the client.

A nurse is planning to place a client into the Sims' position. Which of the following actions should the nurse plan to take?

Place a pillow under the client's flexed leg.

A nurse is reinforcing teaching with a client about how to collect a stool specimen. Which of the following instructions should the nurse include?

Avoid placing the toilet tissue in the bedpan after defecation.

A nurse is planning to apply a belt restraint to a client who is confused and at risk for falls. Which of the following actions should the nurse make?

Fasten the client's restraint using a quick-release tie.

A nurse is collecting data from a client following lumbar puncture. For which of the following adverse effects of the procedure should the nurse monitor the client?

Headache.

A nurse is collecting data from a client who is immobile and has a potential deep-vein thrombosis. Which of the following findings should the nurse report to the provider?

Calf swelling.

A nurse is caring for a client who is postoperative and is preparing to walk for the first time in several days. Which of the following interventions should the nurse give the client to prevent orthostatic hypotension?

"dangle your legs over the side of the bed."

A nurse is caring for a client who speaks a different language than the nurse and is 6 hrs postoperative. Which of the following actions should the nurse take to determine the client's level of pain?

Use a communication board to interact with the client.

A nurse is performing a wound irrigation for a client who has methicillin-resistant. Staphylococcus aureus. When removing personal equipment, which of the following pieces should the nurse remove first?

Gloves.

While performing hygiene care for a client, a nurse notices a frayed electrical cord on the clients electronic BP monitor. Which of the following actions should the nurse take first?

Remove the device from the room.Remove the device from the room.

A nurse is reinforcing teaching with a male client about collecting a mid-stream urine specimen. Which of the following interactions should the nurse include?

Urinate into the toilet and then place the cup into the stream to collect urine.

A nurse is reinforcing teaching with a client who has a new ileostomy about nutrition therapy. Which of the following food choices by the client demonstrates an understanding of the teaching?

Bananas.

A nurse is collecting data regarding home safety from a client who is prone to falls. Which of the following findings should the nurse recognize as placing the client at additional risk?

Throw rugs over electrical cords on the floor.

A nurse is collecting data from a client who had a stroke and is unable to name common items. The nurse should recognize that the client's experiencing which of the following types of aphasia?

Expressive aphasia.

A nurse is reviewing the laboratory results for a client who reports vomiting and diarrhea for 2 days. Which of the following laboratory findings should the nurse expect?

Hyponatremia.

A nurse is collecting data from a client who has an NG tube in place for gastric decompression. Which of the following findings should the nurse report to the provider?

Gastric contents are present in the air vent.

A nurse observes an assistive personnel (AP) perform mouth care for a client who is unconscious which of the following actions by the AP requires intervention by the nurses?

Using two gloved fingers to open the client's mouth for cleaning

A nurse is assisting in creating a plan to reduce environmental stressors for clients in an acute unit. Which of the following actions should the nurse include in the plan?

Restrict the number of visitors for clients

A nurse is reinforcing teaching with a client who is learning to use a walker and his left-leg weakness. Which of the following instructions should the nurse include in the teaching?

"Move your right leg forward as you advance the walker"

A nurse is reinforcing teaching with a client about using guided imagery to manage chronic pain. Which of the following statements by the client indicates an understanding of this technique?

"I'll think about my grandfather's farm to reduce pain"

A nurse is assisting a client who is 4hr postoperative to get out of bed. The client states, "Do not touch me! I can get up by myself." Which of the following response should the nurse make?

"I will be next to you and will help if you need to"

A nurse is reinforcing teaching with a newly hired nurse about cultural sensitivity during death and dying. Which of the following information should the nurse include?

Devout practitioners of Islam prefer to have their heads turned toward Mecca at death

A nurse is reinforcing teaching about beginning an exercise program with an older adult client who is at risk for osteoporosis. Which of the following activities should the nurse recommend?

Walking

A nurse is caring for a client who has hearing loss. Which of the following actions should the nurse take to promote commucation?

Decrease background noise

A nurse is caring for a client who requires a sterile dressing change. The nurse should recognize that the surgical field has been contaminated if which of the following actions occur ?

The sterile solution is poured with the bottle held over the field

A nurse is reinforcing teaching with the adult children of a client who is receiving palliative care. Which of the following statements by one of the adult children indicates an understanding of the teaching?

"We will receive emotional support during our mother's illness"

A nurse is inserting an indwelling urinary catheter for a female client. In which order should the nurse perform the following steps? 1) Separate the labia with the nondominant hand 2) Clean around the urinary meatus from front to back 3) Insert the catheter into the urethral meatus 4) Inflate the catheter balloon 5) Secure the catheter to the client's thigh

Just read so you can know the order

A nurse is assisting with the postmortem care of a client whose partner is at the bedside. Which of the following actions should the nurse take?

Ask the partner about any rituals they would like to be performed

A nurse is reinforcing teaching plan regarding proper lifting with a client. Which of the following strategies should the nurse include to prevent back injury when lifting an object?

Tighten the abdominal muscles

A nurse in a provider's office receives a telephone call from a client's sibling requesting current information about the client's condition. Which of the following actions should the nurse take?

Ask the caller to contact the client directly for information

A nurse is caring for a client who is experiencing fecal incontinence. Which of the following actions should the nurse take?

Increase the client's intake of raw fruits and vegetables

A nurse is caring for a client who has difficulty swallowing following a stroke. Which following actions should nurse take when administering an oral medication to this client?

Place the client in high-Fowler's position

A nurse is caring for a group of clients. For which of the following situatuons should the nurse complete an incident report? (Select all that apply)

A client becomes disoriented and falls out of bed, A client's visitor becomes dizzy and faints in the client's room, A client receives burns from a heating pad

A nurse is caring for a young adult client who is postoperative and requires physical therapy, pain management, and dietary advancement. The nurse enters the client's room and finds them dressing and stating that they are going home. Which of the following actions should the nurse take?

Have the client sign an against medical advice form

A nurse is caring for a client who has experienced a cerebrovascular accident with resulting dysphagia. Which of the following therapists assists clients to learn to eat with less risk of aspiration?

Speech

A nurse is caring for a client who is postpartum. Which of the following documentations should the nurse include in the client's health record?

Oral temperature elevated at 0800

A nurse is in a long-term care facility is transcribing a prescription for a client. Which of the following abbreviations is appropriate?

mcg

A nurse is assisting with the admission of a client. Which of the following statements should the nurse make to demonstrate the principle of advocacy?

"I will speak with your provider on your behalf"

A nurse is reinforcing teaching with a client who has crutches regarding the use of the three-point gait. Which of the following instructions should the nurse include?

Bear weight on the unaffected leg

A nurse at a long-term care facility is caring for an older adult client who has dementia and is at risk for malnutrition. Which of the following actions should the nurse take to promote an increase in food intake?

Restrict visitors during meals

A nurse is monitoring a client's oxygen saturation using a pulse oximeter. The client's oxygen saturation is 88% on 2 L/min of oxygen via nasal cannula. Which of the following actions should the nurse take?

Reposition the sensor probe

A nurse is reinforcing teaching with a client who needs to increase vitamin C intake to promote wound healing. Which of the following foods should the nurse recommend as the best source of vitamin C?

1 small pink grapefruit

A nurse in an acute care center is caring for a client who just died. The client's family requests to perform the postmortem care. Which of the following is an appropriate response for the nurse to make?

"I will assist you in any way I can during this process"

A nurse is wearing sterile gloves in preparation for assisting with a client's sterile procedure. While waiting for the procedure to begin, how should the nurse position her hands?

Interlock her fingers and hold her hand away from her body above her waist

A nurse is assisting in the transfer of a client who has left-side weakness from a bed to chair. Which of the following actions should the nurse take?

Flex hips and knees when assisting the client to a standing position

A nurse is showing a newly licensed nurse how to use a mechanical lift. Which of the following statements by the newly licensed nurse indicates understanding of this assistive device?

the type of device is useful for a client who cannot assist