A nurse is caring for a client who is experiencing cerebral edema. Which of the
following actions should the nurse take?
Perform multiple nursing care activities at one time.
A nurse is admitting an adolescent who has rubella. Which of the following
actions should the nurse take?
Droplet
A client is requesting information from a nurse about a nitrazine test. Which of
the following statements should the nurse?
"This test will determine if there is leaking amniotic fluid.
A nurse is reviewing the laboratory results of a client who has rheumatoid
arthritis? Which of the following findings should the nurse report to the provider?
Erythrocyte sedimentation 75 mm/hr
A nurse is suctioning the airway of a client who is receiving mechanical
ventilation via an endotracheal tube. Which of the following findings should the
nurse identify that the suctioning has been effective?
Presence of a productive cough
A nurse is caring for a client who is in a seclusion room following violent
behavior. The client continues to display aggressive behavior. Which of the
following actions should the nurse take?
Speak assertively to the client.
A charge nurse is observing a newly licensed nurse insert an indwelling urinary
catheter for a female client. Which of the following actions by the nurse requires
intervention by the charge nurse?
Opens the sterile kit by unfolding the flap closet to her first
A nurse is caring for a client who is scheduled for a surgical procedure and
states, " I don't want to have this surgery anymore." Which of the following
responses should the nurse make?
You have the right to refuse the procedure
A nurse is teaching a group of school-age children about healthy snack options.
Which of following snacks should the nurse include?
Air popped Popcorn
A nurse is providing teaching to a client who has new prescription for
enoxaparin. Which of following medication for pain relief should the nurse
include in the teaching that can be taken concurrently with enoxaparin?
Acetaminophen
A nurse is caring for a client who has fibromyalgia and requests pain medication.
Which of the following medications should the nurse plan to administer?
Pregablin
A nurse is caring for a client who has fracture of the left hip and is in skeletal
traction. Which of the following actions should the nurse take?
Provide a trapeze for the client to aid movement in bed
A nurse is caring for a client who had an embolic stroke and has a new
prescription for alteplase. Which of the following in the client's history should the
nurse identify as a contraindication to receiving alteplase?
, Hip arthoplasty 1 week ago
A nurse is providing discharge teaching for a client who has a new implantable
cardioverter defibrillator. Which of the following client statements demonstrates
understanding of the teaching?
"I will wear loose clothing over my ICD."
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?
Obtain a urine specimen for culture and sensitivity
A nurse is caring for a client who has experienced a stillbirth. Which of the
following actions should the nurse take during the initial grieving process?
Offer to take pictures of the newborn for the client
A nurse is caring for a client who has a major burn injury. Which of the following
actions is the nurse's priority to prevent wound infections?
Maintain consistent hand washing by staff.
A nurse is caring for a client who is 1 hr postpartum and unable to urinate. Which
of the following actions should the nurse take?
Place the client's hands in warm water
A nurse on a med-surgical unit is preforming medication reconciliation for a
newly admitted client. Which of the following actions should the nurse take?
Compare the client's list of home medications to the admission prescriptions written for
the client.
A nurse is preparing to administer betamethasone to the client who is 25 weeks
of gestation and has preterm labor. Which of the following findings should the
nurse identify as an adverse effect of this medication?
Hyperglycemia
A nurse is providing dietary teaching to a client who had an exacerbation of
COPD. Which of the following information should the nurse include in the
teaching?
"During meals, you should eat foods with a high-calorie content first
A nurse is preparing to perform a dressing change on a preschooler. Which of the
following actions should the nurse take to prepare the child for the procedure?
Explain in simple terms how the procedure will affect the child.
A nurse is performing wound care for a client who has an abdominal incision.
Which of the following techniques should the nurse implement?
Irrigate the wound with a low-pressure flow of solution.
A nurse on an antepartum unit is prioritizing care for multiple clients. Which of
the following clients should the nurse see first?
A client who has preeclampsia and reports a persistent headache.
A nurse is caring for a clients who is recovering from an amputation of her right
arm below the elbow. Which of the following information should the nurse report
to the occupational therapist?
The client who has small children at home
A nurse is caring for a client who has major depression disorder, The client tells
the nurse, " No one cares about me. I'm completely alone." Which of the following
responses should the nurse make?