NURSING MISC Exam (elaborations) Comprehensive Form A

A nurse is caring for a client who states, "My boss accused me of stealing yesterday. I was so angry I went to the gym and worked out." The nurse should recognize the client is demonstrating which of the following defense mechanisms? A nurse is caring for a client who has generalized anxiety disorder and is to begin taking alprazolam. Which of the following actions should the nurse take? A nurse on a med surg unit is caring for a client prior to a surgical procedure. Which of the following findings should indicate to the nurse that the client has the ability to sign the informed consent? An assistive personnel (AP) and a nurse are turning a client onto the right side. Which of the following actions by the AP requires the nurse to intervene? A nurse is providing dietary teaching to the parents of a 6-month-old infant. Which of the following instructions should the nurse include? A nurse is caring for a client who has MRSA in an abdominal wound. Which of the following precautions should the nurse implement? A nurse is caring for a client who is 4 hr postpartum and has a boggy uterus with heavy lochia. Which of the following actions should the nurse take first A nurse is providing discharge teaching to a new parent about car seat safety. Which of the following statements should the nurse include in the teaching? A nurse is providing discharge teaching to a client who has colorectal cancer and a new colostomy. The client states, "I'm worried about being discharged because I live alone, and my insurance doesn't cover ostomy supplies. "Which of the following actions should the nurse take? (SATA) A nurse manager is reviewing unit records and discovers that client falls occur most frequently during the hours of 0530 and 0730. Which of the following actions should the nurse take when conducting a root cause analysis? A nurse is caring for a client who has terminal illness and requests lifesaving measures if a cardiac arrest occurs. Which of the following statements should the nurse make? A nurse is assessing a client who has delirium. Which of the following manifestations should the nurse expect? A night shift nurse is giving a change of shift report to the day shift nurse on a client who is ready for discharge. Which of the following information is the priority for the nurse to communicate to the oncoming nurse? A nurse is assessing a client during the immediate postpartum period. Which of the following findings requires immediate intervention by the nurse? A nurse in an emergency department is preparing to discharge a client who has experienced intimate partner violence. Which of the following actions should the nurse take first? A client is receiving lorazepam IV for panic attacks and develops a respiratory rate of 6/min and a blood pressure of 90/44 mm Hg. Which of the following medications should the nurse anticipate administering. A home health nurse is planning care for an older adult client who has impaired vision. Which of the following interventions should the nurse include in the plant of care to prevent injury in the home? A nurse manager is planning to make changes to the current scheduling system on the unit. To facilitate the staff's acceptance of this change, which of the following actions should the nurse manager take first? A nurse is teaching a group of guardians about child safety measures. Which of the following statements by guardian indicates an understanding of the teaching? An RN is planning care for a group of clients and is working with a licensed practical nurse (LPN) and an assistive personnel (AP). Which of the following tasks should the RN delegate to the LPN? A nurse is assessing a newborn who is 2 hr old. Which of the following findings should the nurse report to the provider? A nurse is caring for a newborn whose parent asks why the baby is receiving vitamin K. The nurse should explain to the parent that the newborn should receive vitamin K to prevent which of the following? The nurse should explain to the parent that newborns are deficient in vitamin K and should receive it following birth because this deficiency can lead to bleeding. A nurse is caring for a client who requires physical therapy following discharge. Which of the following actions should the nurse take? A nurse in an emergency department is assessing a client who reports taking MDMA. Which of the following should the nurse expect? A nurse is caring for a client who vomits on a reusable BP cuff. Which of the following actions should the nurse take? A nurse is reviewing the medical record of a client who has schizophrenia and is to start taking clozapine. Which of the following findings should the nurse identify as a contraindication for the client to receive clozapine? - A nurse is providing teaching to an adolescent following insertion of a tunneled central venous catheter without a pressure sensitive valve. Which of the following information should the nurse include in the teaching? A nurse is conducting visual acuity testing when using the Snellen letter chart for a school age child who has eyeglasses. Which of the following instructions should the nurse give to the child? When caring for a child, a nurse plans to use non-pharmacological interventions to enhance the effectiveness of pain medication. Which of the following strategies incorporates visualization techniques to help decrease the child's discomfort? - A nurse is preparing to administer heparin 5,000 units SQ. Available is heparin injection 10,000 units/mL. How many mL should the nurse administer per dose? - A charge nurse is observing a newly licensed nurse performing a physical assessment on a client. Which of the following actions by the nurse indicates that the charge nurse should intervene? A nurse is assessing a client who has schizophrenia. The nurse should identify the following alteration in speech as which of the following? (Audio) - A nurse is assessing a school age-child who has cystic fibrosis. Which of the following findings is the priority for the nurse to report to the provider? - A nurse is caring for a client who ha bipolar disorder. The nurse observes that the client is becoming increasingly restless. The client is pacing the unit and speaking rapidly, frequently using profanities and sexual references. Which of the following actions should the nurse take first? A nurse is providing colostomy care for a client using a two-piece pouching system. Which of the following actions should the nurse take? A nurse is teaching the parent of a school-age about administering ear drops. Which of the following response by the parent indicates an understanding of the teaching? A nurse is assessing a client who is 2 hr postoperative following a cardiac catheterization. Which of the following information should the nurse report to the provider? A nurse is caring for a client who is receiving total parenteral nutrition (TPN) solution by continuous IV infusion at 60 mL/hr. The nurse discovers the infusion pump has stopped working. Which of the following actions should the nurse take while waiting for a new infusion pump? . A nurse is caring for a client who has an STI that must be reported to the state health department. Which of the following actions should the nurse take? A nurse is caring for a group of clients. For which of the following events should the nurse complete an incident report? A nurse is caring for a client who has hypertension and is taking captopril. Which of the following tasks should the nurse delegate to an assistive personnel (AP)? - A nurse is assessing a client who is receiving a blood transfusion. Which of the following findings should indicate to the nurse that the client is having a hemolytic transfusion reaction? A nurse is caring for a toddler who has infectious gastroenteritis. Which of the following actions should the nurse take? A nurse is administering medications to a client who has percutaneous gastrostomy tube for enteral feedings. Which of the following actions should the nurse take to prevent clogging of. the tube? A nurse is teaching home wound care to the family of a child who has a large wound. Which of the following interventions should the nurse recommend? - A nurse is teaching the parents of a toddler about snacks. Which of the following foods should the nurse recommend? A nurse is assessing a preschooler who has cystic fibrosis and has been receiving oxygen therapy for the past 36 hr. Which of the following findings should the nurse identify is an indication that the client has developed oxygen toxicity? - A charge nurse is observing a newly licensed nurse administer enteral feedings via NG tube. Which of the following actions by the newly licensed nurse indicates an understanding of the procedure? A nurse is assessing a client who has Raynaud's disease. Which of the following findings should the nurse expect? A nurse is talking with the partner of a client who attempted suicide. Which of the following statements by the client's partner should the nurse identify as the priority? A nurse in a clinic receives a call from a guardian whose child has varicella. The guardian asks when the child can return to school. Which of the following responses should the nurse make? A nurse is caring for a toddler who is admitted to the pediatric unit for surgery. Which of the following should the nurse include in the toddler's plan of care? - A nurse is caring for an older adult client in the PACU following general anesthesia. Which of the following findings should the nurse report to the provider? A nurse is preparing to insert an indwelling urinary catheter for a client. The nurse should assess the client for which of the following conditions prior to starting the procedure? A home health nurse is providing teaching about infection prevention to a client who has cancer and is receiving chemotherapy. Which of the following statements by the client indicates an understanding of the teaching? pulmonary stasis and prevent the development of respiratory infections A nurse is caring for a client who has end-stage Alzheimer's disease. The adult child of the client says to the nurse, "I don't know why I bother to visit my mother anymore." Which of the following responses should the nurse make? A charge nurse assigns a newly licensed nurse to care for a client who has a chest tube. The nurse expresses concern about having limited experience with monitoring chest tube drainage. Which of the following actions should the charge nurse take first to provide teaching about chest tubes? A nurse is caring for an adolescent client who has a new diagnosis of terminal cancer. When discussing the client's prognosis with the parents, the nurse should recognize which of the following responses by the parents as an example of rationalization? A nurse is caring for a client who is at 28 weeks of gestation. The client asks the nurse to explain what causes the nurse to explain what causes her to have constipation. Which of the following responses should the nurse make? A nurse is teaching a client who has opioid use disorder about methadone. Which of the following information should the nurse include in the teaching? A community health nurse is reviewing the medical records of four newly diagnosed clients. The nurse should identify which of the following clients as having a nationally notifiable infectious condition? A nurse is assessing a client who is experiencing autonomic dysreflexia. which of the following findings should the nurse expect? (SATA) A nurse is caring for a client who is 12 hr postoperative, is receiving PCA for pain control, and requires a blood pressure check every 10 min. Which of the following staff members should the nurse assign to collect this information? A charge nurse observes a staff nurse document a dressing change in a client's chart that was not performed. Which of the following actions should the charge nurse take first? the issue with the staff nurse before deciding on the next course of action. A home health nurse is providing teaching to a client who has hepatitis A. Which of the following instructions should the nurse include? A nurse manager is on a planning committee to develop an emergency preparedness plan. The nurse should recommend that which of the following actions takes place first when implementing an emergency preparedness plan? - A nurse is performing an admission assessment of a preschooler who is in the acute phase of Kawasaki disease. Which of the following findings should the nurse expect? A nurse is caring for an older adult client. Which of the following findings should the nurse recognize as a physiological change associated with aging? A nurse is providing teaching about improving nutrition for a client who has multiple sclerosis. Which of the following instructions should the nurse include? A nurse is assessing a client who has obstructive sleep apnea. For which of the following complications should the nurse monitor? A charge nurse is teaching a newly licensed nurse how to identify true labor. Which of the following should the nurse include in the teaching? A nurse is planning care for a client who is receiving hemodialysis via an established arteriovenous (AV) fistula in the right arm. Which of the following interventions should the nurse include in the client's plan of care? A nurse is planning teaching about allowable foods for a client who has a history of uric acid-based urinary calculi formation. Which of the following foods should the nurse include in the teaching? A nurse is assessing a client who has multiple sclerosis. Which of the following manifestations should the nurse expect? A nurse is preparing to administer a long-acting insulin to a client who has diabetes mellitus. Which of the following actions should the nurse plan to take first? - A nurse is caring for a client who is in the manic phase of bipolar disorder. Which of the following manifestations should the nurse expect? A case manager is reviewing the medical records of several clients. For which of the following clients should the nurse request an interprofessional care conference? A nurse working on a medical-surgical unit receives a telephone call requesting the status of a client from an individual who identifies themself as the client's parent. Which of the following actions should the nurse take? A nurse is caring for a client who is at 37 weeks of gestation and is experiencing abruptio placentae. Which of the following findings should the nurse expect? - A nurse is providing discharge instructions to a client following a total hip arthroplasty. Which of the following instructions should the nurse include? A nurse is preparing to administer enoxaparin to a client. Identify the area the nurse should use to administer the injection. A nurse in an outpatient mental health clinic is working with a client who has post-traumatic stress disorder (PTSD) and asks the nurse to recommend a nonpharmacological therapy to use to provide relief of the manifestations. Which of the following complementary therapies should the nurse teach the client to use to help alleviate the distress? A nurse is caring for four clients. Which of the following clients should the nurse assign to an assistive personnel (AP) to assist with meals? A community health nurse is assisting with the development of a disaster management plan. The nurse should include which of the following nursing responsibilities in the disaster response stage of the plan? A community health nurse is preparing a health education program for a local rural community. Which of the following actions should the nurse plan to take first? - A charge nurse is planning an educational session for staff nurses about working with parents whose terminally ill children are candidates for donating their organs. Which of the following information should the nurse plan to include? A nurse is assessing a client who has schizophrenia and is taking chlorpromazine. Which of the following findings is the priority for the nurse to report the provider? A nurse is providing discharge teaching to a client following a cataract extraction. Which of the following statements by the client indicates an understanding of the teaching? A nurse is assessing a client who has macular degeneration. Which of the following findings should the nurse expect? A nurse is planning care for a client who is receiving heparin to treat a deep-vein-thrombosis of the left lower leg. Which of the following interventions should the nurse include in the plan of care? A nurse is providing teaching to a client about newborn safety. Which of the following statements should the nurse include in the teaching? A nurse manager is assisting the orientation of a newly licensed nurse. Which of the following actions by the nurse requires the nurse manager to intervene? - A nurse is assessing a 2-month-old infant during a well-baby examination. Which of the following actions should the nurse take to assess the infant's rooting reflex? - A nurse is providing client education to a postpartum client who has decided to bottle feed the newborn. Which of the following instructions should the nurse include in the teaching to help prevent the discomfort of engorgement? A nurse receives a request from a client to review the information in his medical record. Which of the following responses should the nurse give? A nurse is administering the cyclophosphamide orally to a school-age child who has a neuroblastoma. Which of the following actions should the nurse take when administering this medication? A nurse in the delivery room is caring for a newborn immediately after birth. Which of the following actions should the nurse take first? A nurse is reviewing the urinalysis report of a client who has acute glomerulonephritis. Which of the following findings should the nurse expect? - A nurse is initiating discharge planning for a client who had a stroke and is experiencing right-sided weakness. Which of the following actions should the nurse take first? A nurse is teaching the parents of a preschooler about sleep promotion. The parents report that their child is demonstrating reluctance in going to bed at night and states, "I am not tired." Which of the following statements by the parents indicate an understanding of the teaching? A clinic nurse is caring for a client who is in the first trimester of pregnancy. The client reports using acupressure bands on both wrists. which of the followings statements by the client indicates that this therapy is having the desired effect? A nurse is planning care for a client who has thrombocytopenia. Which of the following instructions should the nurse include in the client's plan of care? A nurse is preparing to administer 15 units of regular insulin along with 20 units of NPH insulin. Which of the following actions should the nurse plan to take? A nurse is caring for a client who is immediately postoperative following a total vaginal hysterectomy. Which of the following actions should the nurse take first? - A nurse is providing discharge instructions to a client who has a new prescription for amitriptyline to treat depression. The nurse should identify that which of the following client statements indicates an understanding of the teaching? A nurse is teaching a client who has a new prescription for estradiol. For which of the following adverse effects of this medication should the nurse instruct the client to monitor and report to the provider A nurse is providing teaching to a parent of a child who has a permanent tracheostomy tube. Identify the sequence of steps the parent should follow to perform tracheostomy care. A nurse is caring for a newborn who has herpes simplex virus (HSV). Which of the following isolation precautions should the nurse initiate? A nurse is assessing a client who has antisocial personality disorder. Which of the following manifestations should the nurse expect? A nurse is caring for a client who had a recent stroke. Prior to transferring the client to the bedside commode, which of the following actions should the nurse take first? A nurse is preparing to administer diazepam 0.3 mg/kg IV bolus to a toddler who weighs 22 lb and is experiencing a grand mal seizure. Available is diazepam solution for injection 5 mg/mL. How many mL should the nurse administer? A nurse is caring for a client who is in labor at 39 weeks of gestation. During the second stage of labor, the nurse observes early decelerations on the monitor tracing. Which of the following actions should the nurse take? A nurse is interviewing a client who is now without a home due to a natural disaster. After ensuring the client's safety, which of the following actions should the nurse take first? A charge nurse is planning care for a client who has mechanical restraints in place. Which of the following interventions should the nurse include in the plan? - A nurse is performing tracheostomy care for a client who is postoperative following a laryngectomy. Which of the following actions should the nurse take when suctioning the client's airway? A nurse is caring for a client who has a closed-head injury and is receiving mechanical ventilation. The nurse should expect to administer which of the following medications to reduce intracranial pressure? A charge nurse overhears two staff nurses in the hallway discussing the nutritional status of a client who has anorexia nervosa. Which of the following actions should the charge nurse take? A community health nurse is performing triage tagging following a mass casualty incident. On which of the following clients should the nurse place a black tag? A nurse is planning care for a client who has a deficit with cranial nerve II. Which of the following actions should the nurse plan to take? A nurse is teaching a client who is to start taking misoprostol and currently is on long-term therapy with NSAIDs for arthritis. The nurse should provide the client with which of the following information? A nurse is creating a plan of care for a child who has acute lymphoid leukemia and an absolute neutrophil count of 400/mm3. Which of the following interventions should the nurse include in the plan? A nurse is assessing a client who has a stage II pressure injury. Which of the following wound characteristics should the nurse expect? A nurse in an emergency department is admitting a client who has cardiac tamponade. Which of the following assessment findings should the nurse expect? - A nurse is caring for a client who has had nausea and vomiting for the past 2 days. The nurse should identify which of the following findings as an indication the client is experiencing fluid volume deficit? A nurse is assessing a client who has sickle cell anemia. The nurse should identify which of the following findings as a manifestation of vasoocclusive crisis? - A nurse is caring for a client who has a potassium level of 3 mEq/L. For which of the following manifestations should the nurse monitor? A nurse is caring for four clients at the beginning of a shift. After receiving change-of-shift report, which of the following clients should the nurse attend to first? A client who is 24 hr postoperative following abdominal surgery refuses to ambulate. Which of the following actions should the nurse take first? A nurse is teaching a client about foods high in vitamin A. Which of the following foods should the nurse recommend as having the highest amount of vitamin A? A nurse working in a long-term care facility is assessing an adult client. Which of the following findings places the client at risk for development of a pressure injurty? A nurse is teaching a client who has a new prescription for digoxin about manifestations of toxicity. Which of the following findings should the nurse include in the teaching? A home health nurse is assessing a 2-week-old newborn who had a birth weight of 3.64 kg (8 lb) and is being breastfed. Which of the following findings indicates effective breastfeeding? A nurse is reviewing the laboratory findings of a client who is experiencing chest pain. The nurse should identify that an elevation in which of the following laboratory values indicates cellular injury of myocardial tissue? A nurse is teaching a newly admitted client who has heart failure about advance directives. Which of the following statements should the nurse make? A nurse on a mental health unit is caring for a client who tells the nurse that she does not want to receive a scheduled dose of lorazepam IM. Which of the following actions should the nurse take? A nurse is preparing to administer 2 units of fresh frozen plasma to a client. Which of the following actions should the nurse plan to take ? A nurse is providing discharge instructions to a client who has a new prescription of warfarin. Which of the following client statements should the nurse identify as an indication that the client understands the teaching? A charge nurse is preparing to administer 0900 medications and is told by the pharmacy staff that the medications are not available. Medications availability has been ongoing problem, and the charge nurse has previously discussed this issue with the pharmacy staff. Which of the following actions should the charge nurse take first? A nurse is teaching about total parenteral nutrition (TPN) and IV lipid emulsions with a client who has an extensive burn injury. Which of the following information should the nurse include? A nurse is caring for a client who has a fractured femur and has had a fiberglass leg cylinder cast for 24 hr. Which of the following assessment findings should the nurse identify as the priority? A mental health nurse is conducting the first of several meetings with a client whose partner recently died. The nurse should perform which of the following actions to establish trust during the orientation phase of the nurse-client relationship? A nurse is performing gastric lavage for a client who has gastrointestinal bleeding an an NG tube in place. Which of the following actions should the nurse take? - A nurse is assessing a client who has been taking lithium carbonate for the past month to treat bipolar disorder. Which of the following assessment findings should the nurse identify as the priority? A nurse is preparing to perform an intermittent urinary catheterization for a client who has urinary retention. Which of the following images indicates the catheter the nurse should use? A nurse is reviewing the ABG results of a client who has COPD. The results include a pH of 7.3, PaO2 56 mm Hg, PaCO2 54 mm Hg, HCO 26 mEq/L, SaO2 87%. Which of the following is the correct interpretation of these values? A nurse is assessing a client who has skeletal traction for a femur fracture. Which of the following findings should the nurse identify as the priority? A nurse in an acute mental health facility is planning care for a client who has anorexia nervosa. Which of the following interventions should the nurse include in the client's plan of care? A nurse is preparing a sterile field in order to insert an indwelling urinary catheter for a male client. Which of the following techniques should the nurse use to maintain surgical aseptic technique? A nurse is caring for a child who is experiencing a tonic clonic seizure. Which of the following actions should the nurse take? A nurse manager is preparing a newly licensed nurse's performance appraisal. Which of the following methods should the nurse manager use to evaluate the nurse's time management skills? [Show less]