A nurse is assisting with monitoring a client who is in labor and has spontaneous rupture of membranes
following a vaginal examination. The provider reports the client's cervix is dilated to 1 cm with an
unengaged presenting part. Which of the following actions should the nurse take?
Apply the external fetal heart rate monitor.
A Nurse is collecting data from a client who has bipolar disorder and is experiencing acute mania. Which
of the following findings is the nurse's priority?
lack of sleep
A nurse is reinforcing teaching with a client who has a type 2 diabetes mellitus and reports waking during
the night with tremors and anxiety. which of the following information should the nurse provide to help
the client manage his symptoms?
Eat a bedtime snack
a Nurse is reinforcing teaching for a client who has a coronary artery disease and is taking low-dose
aspirin daily. The nurse should include that this medication has which of the following therapeutic
effects for CAD?
Antiplatelet
A nurse is collecting data from a client who has an unprepared femur fracture and rates his pain as 8 on a
scale of 0 to 10. The client is talking and caught with a visitor. Which of the following of the prescribed
medication should the nurse administer?
Hydromorphone 5 mg orally.
A nurse is reinforcing preoperative teaching with a client scheduled for a bowel retention with ileostomy.
which of the following descriptions should the nurse give of the expected output from a mature
ileostomy?
liquid with little odor
A nurse is caring for a client who is 16 hr postoperative following a total hip arthroplasty. the client
reports numbness, pain, and tingling in the affected leg. Which of the following actions should the nurse
take first?
compare capillary refill in toes bilateraly
,A nurse is reinforcing teaching with a client who has acute diverticulitis. Which of the following
statements by the client indicates an understanding of the teaching about the acute phase of
diverticulitis?
"I will receive the nutrient I need through my IV Fluid"
A nurse in reinforcing teaching with a client about cancer prevention. The nurse should include that
frequent consumption of which of the following foods increases the risk of cancer?
Lamb
A nurse is assisting in teaching a group of staff nurses about hepatitis A. Which of the following modes
should the nurse include as a method of transmitting hepatitis A?
Consumption of contaminated food.
A nurse is reinforcing teaching with a client who is bottle feeding he full-term newborn with formula.
Which of the following instructions should the nurse include in the teaching?
Although is is unnecessary to be rigid about feeding times, six to eight feedings every 24 hrs should
support a full-term newborn's nutrition adequately. Fewer feedings in the initial weeks could delay the
estabilment of an adequate weight-gain pattern.
A nurse is assisting with the plan of care for a client following a transurethral resection of the prostate.
Which of the following interventions should the nurse include in the plan of care?
The nurse should irrigate the bladder using strict sterile technique and maintain closed catheter drainage
system to minimize the rick of infection.
A nurse is reviewing a client's electronic medical record and finds that an assistive personnel
recorder the client's temperature as 35.3 degrees Celsius (95.5 degrees F) 2 hrs earlier. Which of the
following actions should the nurse take firsT?
Check the client's temperature.
A nurse is receiving change-of-shift report for four clients. Which of the following clients should the
nurse see first?
A client whose urinary output was 100mL for the past 12 hrs
, A nurse in reinforcing teaching about weight loss with a female older adult client who is overweight.
Which of the following statements should the nurse include in teaching?
keep fat intake to no more that 30% of daily caloric intake.
A nurse is collecting data from a client who has iron deficiency anemia. Which of the following findings
should the nurse expect?
Difficulty concentrating.
A Nurse is collecting data from an older adult client who is 48 hr postoperative following abdominal
surgery. The provider writes a prescription to advance the client to a regular Diet. For which of the
following findings should the nurse notify the provider?
The client has absent bowel sounds.
A nurse is reinforcing discharge teaching with a client who is postoperative following transurethral
resection fo the prostate. Which of the following instructions should the nurse include in the teaching?
perform Kegel exercises daily.
A nurse is reinforcing teaching about ways to reduce solid fat consumption with a client who has an
elevate cholesterol level. which of the following strategies should the nurse include in the teaching?
purchase beef that is a loin cut.
A nurse is reinforcing teaching with a client who has a new prescription for prednisone for the
treatment of Addison's disease. which of the following instructions should the nurse include in the
teaching?
You will need to schedule a bone density test.
A nurse is collecting data from a client who has type 2 diabetes mellitus and is concerned about weight
gain during pregnancy. Which of the following responses should the nurse make?
You weight gain should be the same as for someone without diabetes.
A nurse is reinforcing teaching with the parent of a preschooler who has lactose intolerance. Which of
the following statements by the parent indicates an understanding of the teaching?
following a vaginal examination. The provider reports the client's cervix is dilated to 1 cm with an
unengaged presenting part. Which of the following actions should the nurse take?
Apply the external fetal heart rate monitor.
A Nurse is collecting data from a client who has bipolar disorder and is experiencing acute mania. Which
of the following findings is the nurse's priority?
lack of sleep
A nurse is reinforcing teaching with a client who has a type 2 diabetes mellitus and reports waking during
the night with tremors and anxiety. which of the following information should the nurse provide to help
the client manage his symptoms?
Eat a bedtime snack
a Nurse is reinforcing teaching for a client who has a coronary artery disease and is taking low-dose
aspirin daily. The nurse should include that this medication has which of the following therapeutic
effects for CAD?
Antiplatelet
A nurse is collecting data from a client who has an unprepared femur fracture and rates his pain as 8 on a
scale of 0 to 10. The client is talking and caught with a visitor. Which of the following of the prescribed
medication should the nurse administer?
Hydromorphone 5 mg orally.
A nurse is reinforcing preoperative teaching with a client scheduled for a bowel retention with ileostomy.
which of the following descriptions should the nurse give of the expected output from a mature
ileostomy?
liquid with little odor
A nurse is caring for a client who is 16 hr postoperative following a total hip arthroplasty. the client
reports numbness, pain, and tingling in the affected leg. Which of the following actions should the nurse
take first?
compare capillary refill in toes bilateraly
,A nurse is reinforcing teaching with a client who has acute diverticulitis. Which of the following
statements by the client indicates an understanding of the teaching about the acute phase of
diverticulitis?
"I will receive the nutrient I need through my IV Fluid"
A nurse in reinforcing teaching with a client about cancer prevention. The nurse should include that
frequent consumption of which of the following foods increases the risk of cancer?
Lamb
A nurse is assisting in teaching a group of staff nurses about hepatitis A. Which of the following modes
should the nurse include as a method of transmitting hepatitis A?
Consumption of contaminated food.
A nurse is reinforcing teaching with a client who is bottle feeding he full-term newborn with formula.
Which of the following instructions should the nurse include in the teaching?
Although is is unnecessary to be rigid about feeding times, six to eight feedings every 24 hrs should
support a full-term newborn's nutrition adequately. Fewer feedings in the initial weeks could delay the
estabilment of an adequate weight-gain pattern.
A nurse is assisting with the plan of care for a client following a transurethral resection of the prostate.
Which of the following interventions should the nurse include in the plan of care?
The nurse should irrigate the bladder using strict sterile technique and maintain closed catheter drainage
system to minimize the rick of infection.
A nurse is reviewing a client's electronic medical record and finds that an assistive personnel
recorder the client's temperature as 35.3 degrees Celsius (95.5 degrees F) 2 hrs earlier. Which of the
following actions should the nurse take firsT?
Check the client's temperature.
A nurse is receiving change-of-shift report for four clients. Which of the following clients should the
nurse see first?
A client whose urinary output was 100mL for the past 12 hrs
, A nurse in reinforcing teaching about weight loss with a female older adult client who is overweight.
Which of the following statements should the nurse include in teaching?
keep fat intake to no more that 30% of daily caloric intake.
A nurse is collecting data from a client who has iron deficiency anemia. Which of the following findings
should the nurse expect?
Difficulty concentrating.
A Nurse is collecting data from an older adult client who is 48 hr postoperative following abdominal
surgery. The provider writes a prescription to advance the client to a regular Diet. For which of the
following findings should the nurse notify the provider?
The client has absent bowel sounds.
A nurse is reinforcing discharge teaching with a client who is postoperative following transurethral
resection fo the prostate. Which of the following instructions should the nurse include in the teaching?
perform Kegel exercises daily.
A nurse is reinforcing teaching about ways to reduce solid fat consumption with a client who has an
elevate cholesterol level. which of the following strategies should the nurse include in the teaching?
purchase beef that is a loin cut.
A nurse is reinforcing teaching with a client who has a new prescription for prednisone for the
treatment of Addison's disease. which of the following instructions should the nurse include in the
teaching?
You will need to schedule a bone density test.
A nurse is collecting data from a client who has type 2 diabetes mellitus and is concerned about weight
gain during pregnancy. Which of the following responses should the nurse make?
You weight gain should be the same as for someone without diabetes.
A nurse is reinforcing teaching with the parent of a preschooler who has lactose intolerance. Which of
the following statements by the parent indicates an understanding of the teaching?
