A home health nurse is caring for a child who has Lyme disease. Which
of the following is an appropriate action for the nurse to take?
A. Ensure the state health department has been notified.
B. Administer antitoxin.
C. Educate the family.
D. Assess for skin necrosis.
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Select the 5 actions the nurse should take:
A. Provide frequent rest periods
B. Restrict the clients sodium intake
C. Advise the client to avoid the use of soap and alcohol
D. Place the client on a low-carbohydrate diet
E. Place the client under contact isolation
F. Instruct the client to avoid blowing their nose forcefully
G. Assess the client's level of orientation
A nurse is caring for a client who has a vented NG tube set to low intermittent suction and has vomited. Which of the following actions should the nurse perform first?
A. Administer antiemetic medication
B. Evaluate functioning of the suction device
C. Provide oral hygiene care
D. Replace the NG tube
While performing a routine assessment, a nurse notices fraying on the electrical cord of a client's continuous passive motion (CPM) device. Which of the following actions should the nurse take first?
A. Initiate a requisition for a replacement CPM device
B. Report the defect to the equipment maintenance staff
C. Remove the device from the room
D. Ensure the device inspection sticker is current
A nurse is setting up a sterile field to perform wound irrigation for a client. Which of the following actions should the nurse take when pouring the sterile solution?
A. Remove the cap and place it sterile side up on a clean surface.
B. Place sterile gauze over areas of spilled solution within the sterile field
C. Hold the bottle in the center of the sterile field when pouring the solution
D. Hold the irrigation solution bottle with the label facing away from the palm of the hand
A nurse is creating a plan of care for a female client who has recurrent urinary tract infections. Which of the following interventions should the nurse include in the plan?
A. Wear loose-fitting underwear
B. Take a bubble bath after intercourse
C. Drink four 240 ml (8 o) glasses of water each day
D. Void every 5 to 6 hr during the day
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The client is at risk for developing _______ and _________
A. hypoglycemia
B. tachycardia
C. bronchopulmonary dysplasia
D. transient tachypnea of the newborn
A nurse is caring for an infant who has gastroenteritis. Which of the following assessment findings should the nurse report to the provider?
A. Pale and a 24-hour fluid of 30 mL
B. Sunken fontanels and dry mucous membranes
C. Decreased appetite and irritability
D. Temperature 38C (100.4F) and pulse rate 124/min
A nurse is conducting health promotion education regarding contraindications to combination oral contraceptive use to a group of women. Which of the following conditions should the nurse include in the teaching?
A. Hypertension
B. Fibromyalgia
C. Renal calculi
D. Fibrocystic breast disease
A nurse is providing teaching to a client who has depressive disorder and a new prescription for amitriptyline. Which of the following statements by the client indicates an understanding of the teaching?
A. "I can continue to take St. John's wort while taking this medication."
B. "I know it will be a couple of weeks before the medication helps me feel better."
C. "I expect this medication to raise my blood pressure."
D. "I should take this medication on an empty stomach."
A nurse is caring for a client who is immobile. Which of the following interventions is appropriate to prevent contracture?
A. Position a pillow under the client's knees.
B. Place a towel roll under the client's neck.
C. Align a trochanter wedge between the client's legs.
D. Apply an orthotic to the client's foot.
A nurse is assessing a client who is postoperative following abdominal surgery and has an indwelling urinary catheter that is draining dark yellow urine at 25 mL/hr. Which of the following interventions should the nurse anticipate?
A. Initiate continuous bladder irrigation.
B. Administer a fluid bolus
C. Clamp the catheter tubing for 30 mins
D. Obtain a urine specimen for culture and sensitivity
A nurse is reporting a client's laboratory tests to the provider to obtain a prescription for the client's daily warfarin. Which of the following laboratory tests should the nurse plan to report to obtain the prescription for the warfarin?
A. Fibrinogen level
B. aPTT
C. INR
D. Platelet count
A nurse is assessing a client who is taking haloperidol and is experiencing psuedoparkinsonism. Which of the following findings should the nurse document as a manifestation of pseudoparkinsonism?
A. Serpentine limb movement
B. Shuffling gait
C. Nonreactive pupils
D. Smacking lips
A nurse is caring for a client who is experiencing expressive aphasia and right hemiparesis following a stroke. Which of the following actions by the nurse best promotes communication among the staff caring for the client?
A. Posting swallowing precautions at the head of the client's bed
B. Noting changes in the treatment plan in the client's medical record
C. Recording the client's progress in the nurses' notes
D. Having interdisciplinary team meetings for the client on a regular basis
A nurse is caring for a 2-year-old toddler. Which of the following food choices should the nurse recommend to promote independence in eating?
A. Banana pieces
B. Grapes
C. Hot dog
D. Popcorn
A nurse on a medical-surgical unit is notified that a mass casualty event has occurred in the community. Which of the following actions should the nurse plan to take?
A. Act as a liaison between the facility and the media
B. Recommend to the provider specific acute care clients for discharge
C. Determine the medical needs of incoming clients through the emergency department
D. Call in additional medical-surgical unit nursing care staff
A nurse has just received change-of-shift report for four clients. Which of the following clients should the nurse assess first?
A. A client who is scheduled for a procedure in 1 hr.
B. A client who received a pain medication 30 min ago for postoperative pain
C. A client who was just given a glass of orange juice for low blood glucose level
D. A client who has 100 mL of fluid remaining in his IV bag
A nurse is performing postmortem care for a recently deceased client prior to the client's family visit. Which of the following actions should the nurse plan to take?
A. Cross the client's arms across their chest
B. Hold the client's eyes shut for a few seconds
C. Place the client in a high-fowlers position
D. Remove the client's dentures from their mouth
A nurse is admitting a client who has schizophrenia. The client states, "I'm hearing voices." Which of the following responses is the priority for the nurse to state?
A. "What are the voices telling you?"
B. "I realize the voices are real to you, but I don't hear anything."
C. "Have you taken your medication today?"
D. "How long have you been hearing the voices?"
A nurse is administering furosemide IV bolus to a client who has fluid volume excess. The nurse should recognize which of the following findings as an indication that the medication has been effective?
A. Increased blood pressure
B. Weight loss
C. Decreased inflammation
D. Decreased pain
A nurse is caring for a client who requires nasotracheal suctioning. Identify the sequence the nurse should follow to perform suctioning.
A. Apply suction while rotating the catheter
B. Rinse the catheter to remove secretions
C. Don sterile gloves
D. Insert the catheter during the client's inspiration
E. Turn on the suction and set the pressure.
A nurse is caring for a client who is in a coma and is scheduled for a surgical procedure. Which of the following actions should the nurse take?
A. Send the unsigned informed consent form to the facility's risk manager.
B. Determine if the client's health care surrogate is aware of the risks and benefits of the procedure
C. Ensure that the client's family supports the provider's decision for surgery
D. Determine if the procedure is medically necessary for the client
A nurse is preparing to administer vancomycin IV to an adult client. The client asks the nurse if the medication can be given 2 hr earlier. Which of the following statements should the nurse make?
A. "I can start the medication 30 minutes earlier."
B. "I can adjust the time and schedule for when it's convenient for you."
C. "I can infuse the medication at a faster rate."
D. "I have up to 2 hours after the usual schedule time to give you this medication."
A nurse is caring for a client who requires seclusion to prevent harm to others on the unit. Which of the following is an appropriate action for the nurse to take?
A. Document the client's behavior prior to being placed in seclusion.
B. Assess the client's behavior once every hour
C. Offer fluids every 2 hr
D. Discuss with the client his inappropriate behavior prior to seclusion
A nurse is caring for an adolescent who has hyperthermia. Which of the following actions should the nurse take?
A. Administer oral acetaminophen
B. Cover the adolescent with a thermal blanket
C. Submerge the adolescent's feet in ice water
D. Initiate seizure precautions
A nurse is caring for a client who asks for information regarding organ donation. Which of the following responses should the nurse make?
A. "I cannot be a witness for your consent to donate."
B. "You must be at least 21 years of age to become an organ donor."
C. "Your desire to be an organ donor must be documented in writing."
D. "Your name cannot be removed once you are listed on the organ donor list."
A parish nurse is leading a support group for clients whose family members have committed suicide. Which of the following strategies should the nurse plan to use during the group session?
A. Encourage clients to establish a timeline for their own grieving process.
B. Initiate a discussion with client's about ways to cope with changes in family dynamic
C. Assist client's in identifying ways suicide could have been prevented
D. Discourage client's from sharing negative aspects of their relationship with the deceased persons
A nurse is developing a care plan for a client who is in Buck's traction and is scheduled for surgery for a fractured femur of the right leg. Which of the following interventions should the nurse delegate to an assistive personnel?
A. Ask the client to describe her pain.
B. Check the client's pedal pulse on the right leg.
C. Observe the position of the suspended weight
D. Remind the client to use the incentive spirometer
A nurse is caring for a client who repeatedly refuses meals. The nurse overhears an assistive personnel (AP) telling the client, "If you don't eat, I'll put restraints on your wrists and feed you." The nurse should intervene and explain to the AP that this statement constitutes which of the following torts?
A. Battery
B. Assault
C. Negligence
D. Malpractice
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