A nurse is reviewing information about advance directives with a newly admitted client.
Which of the following statements by the client indicates an understanding of the information?
Advance directives include a living well
A nurse on a medical surgical unit is assisting with the admission of a client who has
advanced lung cancer. Which of the following actions regarding advance directives should the
nurse take? Document the client's decision about end-of-life care in the medical record
A nurse is reinforcing teaching with a client about advance directives and a
healthcare proxy which of the following client statements and the kids and
understanding of the teaching? I do not need to name a relative as my designee in my health
care proxy
A nurse is reinforcing teaching about advance directives with a client who has end-stage heart
failure. Which of the following statements by the client indicates an understanding of the
teaching? I know I can change my advance directives if I need to in the future."
A nurse is caring for a client who speaks a different language than the nurse. Which of
the following actions should the nurse take? Supplement spoken language with pictures. Or
review the facility policy about the use of an interpreter
A nurse is caring for a client who speaks a different language than the nurse. The clients
partner tells the nurse that the client would like to go home against medical advice (AMA) .
Which of the off actions should the nurse take?
Request the services of an interpreter to determine the clients wishes
A nurse at long term care facility is reviewing the plan of care who has a prescription for mitten
restraints. Which of the following tasks should the nurse assign to assistive personnel? Assist
the client with range of motion exercises of the hands
A nurse in an acute mental health facility is caring for an adolescent who is exhibiting
destructive behavior. Which of the following actions should the nurse take after applying
physical restraints to the client? Plan to remove the restraints as soon as the clients is calm
A nurse in a mental health facility receives a change of shift report on 4 clients. Which of the
following clients should the nurse plan to assess first? A client placed in restraints for
aggressive behavior
A nurse on a mental health unit is caring for a client who is in restraints. Which of the
following actions should the nurse take? Check the client's status every hour.
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 rate
75mm
,A nurse is caring for a client who has generalized petechiae and ecchymoses. The nurse should
expect a prescription for which of the following laboratory tests? platelet count
A nurse is caring for a client following application of a cast. Which of the following actions
should the nurse take first? palpate the pulse distal to the cast
A nurse is caring for a client who has vision loss. Which of the following actions should the
nurse take? SATA
keep objects in the clients room in the same place.
ensure there is high-wattage lighting in the clients room.
touch the client gently to announce presence
A nurse in the emergency department is assessing newly admitted client who is experiencing
drooling and hoarseness following a brain injury. Which of the following actions should the
nurse take first? Administer 100% humidified oxygen
A nurse is planning care for a client who has unilateral paralysis and dysphagia following a right
hemispheric stroke. Which of the following interventions should the nurse include in the plan?
Place the client's left arm on a pillow while he is sitting.
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?
Confront the client about this behavior
A nurse is caring for a client who is receiving brachytherapy for treatment of prostate cancer.
Which of the following actions should the nurse take? Limit the client's visitors to 30 min per
day.
A nurse is caring for a client who has severe preeclampsia and is receiving magnesium sulfate
intravenously. The nurse discontinues the magnesium sulfate after the client displaces toxicity.
Which of the following actions should the nurse take? Administer calcium gluconate IV
A charge nurse is teaching new staff members about factors that increase a client's risk to
become violent. Which of the following risk factors should the nurse include as the best
predictor of future violence? Previous violent behavior
A nurse is preparing to perform a sterile dressing change. Which of the following actions should
the nurse take when setting up the sterile field? Place the cap from the solution sterile side
up on clean surface
Open the outermost flap of the sterile kit flap AWAY from the body's first
Set up the sterile field 5 cm (2 in) ABOVE waist level
, Place the sterile dressing 2.5 cm (1-inch) border around any sterile drape or wrap
that is considered contaminated
A nurse is providing teaching to an older adult client about methods to promote nighttime
sleep. Which of the following instructions should the nurse include? Eat a light snack before
bedtime
A home health nurse is preparing for an initial visit with an older adult client who lives alone.
Which of the following actions should the nurse take first? Identify environmental hazards in
the home
A nurse is assessing the remote memory of an older adult client who has mild dementia. Which
of the following questions should the nurse ask the client? "What high school did you graduate
from”
A nurse is providing teaching to an adolescent who has type 1 diabetes mellitus. Which of the
following goals should the nurse include in the teaching? HbA1c level less than 7%
A nurse is caring for a client who is receiving phenytoin for management of grand mal seizures
and has a new prescription for isoniazid and rifampin. Which of the following should the nurse
conclude if the client develops ataxia and incoordination? The client is showing evidence of
phenytoin toxicity
A nurse is caring for a client who is 1 hr postoperative following rhinoplasty. Which of the
following manifestations requires immediate action by the nurse? Increase in frequency of
swallowing→ may indicate bleeding
A nurse is planning care for a preschool-age child who is in the acute phase Kawasaki disease.
Which of the following interventions should the nurse include in the plan of care? Monitor the
child's cardiac status
A nurse is planning an educational program for high school students about cigarette smoking.
Which of the following potential consequences of smoking is most likely to discourage
adolescents from using tobacco? Use of tobacco decreases the level of athletic ability
A nurse is assessing a client who is prescribed spironolactone. Which of the following laboratory
values should the nurse monitor for this client? Serum potassium- diuretic that retains
potassium= hyperkalemic risk
A nurse has agreed to serve as an interpreter for an older adult client who is assigned to
another nurse. Which of the following statements by the nurse indicates an understanding of
this role? "I will let the client know that I am available as the interpreter."
A nurse in a pediatric unit is preparing to insert an IV catheter for 7-year- old. Which of the
following actions should the nurse take? Tell the child they will feel discomfort during the
catheter insertion.
Which of the following statements by the client indicates an understanding of the information?
Advance directives include a living well
A nurse on a medical surgical unit is assisting with the admission of a client who has
advanced lung cancer. Which of the following actions regarding advance directives should the
nurse take? Document the client's decision about end-of-life care in the medical record
A nurse is reinforcing teaching with a client about advance directives and a
healthcare proxy which of the following client statements and the kids and
understanding of the teaching? I do not need to name a relative as my designee in my health
care proxy
A nurse is reinforcing teaching about advance directives with a client who has end-stage heart
failure. Which of the following statements by the client indicates an understanding of the
teaching? I know I can change my advance directives if I need to in the future."
A nurse is caring for a client who speaks a different language than the nurse. Which of
the following actions should the nurse take? Supplement spoken language with pictures. Or
review the facility policy about the use of an interpreter
A nurse is caring for a client who speaks a different language than the nurse. The clients
partner tells the nurse that the client would like to go home against medical advice (AMA) .
Which of the off actions should the nurse take?
Request the services of an interpreter to determine the clients wishes
A nurse at long term care facility is reviewing the plan of care who has a prescription for mitten
restraints. Which of the following tasks should the nurse assign to assistive personnel? Assist
the client with range of motion exercises of the hands
A nurse in an acute mental health facility is caring for an adolescent who is exhibiting
destructive behavior. Which of the following actions should the nurse take after applying
physical restraints to the client? Plan to remove the restraints as soon as the clients is calm
A nurse in a mental health facility receives a change of shift report on 4 clients. Which of the
following clients should the nurse plan to assess first? A client placed in restraints for
aggressive behavior
A nurse on a mental health unit is caring for a client who is in restraints. Which of the
following actions should the nurse take? Check the client's status every hour.
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 rate
75mm
,A nurse is caring for a client who has generalized petechiae and ecchymoses. The nurse should
expect a prescription for which of the following laboratory tests? platelet count
A nurse is caring for a client following application of a cast. Which of the following actions
should the nurse take first? palpate the pulse distal to the cast
A nurse is caring for a client who has vision loss. Which of the following actions should the
nurse take? SATA
keep objects in the clients room in the same place.
ensure there is high-wattage lighting in the clients room.
touch the client gently to announce presence
A nurse in the emergency department is assessing newly admitted client who is experiencing
drooling and hoarseness following a brain injury. Which of the following actions should the
nurse take first? Administer 100% humidified oxygen
A nurse is planning care for a client who has unilateral paralysis and dysphagia following a right
hemispheric stroke. Which of the following interventions should the nurse include in the plan?
Place the client's left arm on a pillow while he is sitting.
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?
Confront the client about this behavior
A nurse is caring for a client who is receiving brachytherapy for treatment of prostate cancer.
Which of the following actions should the nurse take? Limit the client's visitors to 30 min per
day.
A nurse is caring for a client who has severe preeclampsia and is receiving magnesium sulfate
intravenously. The nurse discontinues the magnesium sulfate after the client displaces toxicity.
Which of the following actions should the nurse take? Administer calcium gluconate IV
A charge nurse is teaching new staff members about factors that increase a client's risk to
become violent. Which of the following risk factors should the nurse include as the best
predictor of future violence? Previous violent behavior
A nurse is preparing to perform a sterile dressing change. Which of the following actions should
the nurse take when setting up the sterile field? Place the cap from the solution sterile side
up on clean surface
Open the outermost flap of the sterile kit flap AWAY from the body's first
Set up the sterile field 5 cm (2 in) ABOVE waist level
, Place the sterile dressing 2.5 cm (1-inch) border around any sterile drape or wrap
that is considered contaminated
A nurse is providing teaching to an older adult client about methods to promote nighttime
sleep. Which of the following instructions should the nurse include? Eat a light snack before
bedtime
A home health nurse is preparing for an initial visit with an older adult client who lives alone.
Which of the following actions should the nurse take first? Identify environmental hazards in
the home
A nurse is assessing the remote memory of an older adult client who has mild dementia. Which
of the following questions should the nurse ask the client? "What high school did you graduate
from”
A nurse is providing teaching to an adolescent who has type 1 diabetes mellitus. Which of the
following goals should the nurse include in the teaching? HbA1c level less than 7%
A nurse is caring for a client who is receiving phenytoin for management of grand mal seizures
and has a new prescription for isoniazid and rifampin. Which of the following should the nurse
conclude if the client develops ataxia and incoordination? The client is showing evidence of
phenytoin toxicity
A nurse is caring for a client who is 1 hr postoperative following rhinoplasty. Which of the
following manifestations requires immediate action by the nurse? Increase in frequency of
swallowing→ may indicate bleeding
A nurse is planning care for a preschool-age child who is in the acute phase Kawasaki disease.
Which of the following interventions should the nurse include in the plan of care? Monitor the
child's cardiac status
A nurse is planning an educational program for high school students about cigarette smoking.
Which of the following potential consequences of smoking is most likely to discourage
adolescents from using tobacco? Use of tobacco decreases the level of athletic ability
A nurse is assessing a client who is prescribed spironolactone. Which of the following laboratory
values should the nurse monitor for this client? Serum potassium- diuretic that retains
potassium= hyperkalemic risk
A nurse has agreed to serve as an interpreter for an older adult client who is assigned to
another nurse. Which of the following statements by the nurse indicates an understanding of
this role? "I will let the client know that I am available as the interpreter."
A nurse in a pediatric unit is preparing to insert an IV catheter for 7-year- old. Which of the
following actions should the nurse take? Tell the child they will feel discomfort during the
catheter insertion.
