RN concept-based assess level 1

RN concept-based assess level 1 RN concept-based assess level 1 which of the following statements shows understanding of the breast self-exam - ANS I should expect to feel a firm ridge along the bottom curve of each breast Which of the following actions should the nurse take to provide emotional support to the parent - ANS inform the parent that anger is a natural response when dealing with loss Accessing electronic resources- which should the nurse include - ANS websites endin gin .gov are reliable pt had knee "lock" and is lying on the floor. Which action - ANS check the pt. for injuries RA about chronic pain. Which indicates understanding - ANS I should use a warm paraffin dip for the hands and feet preventative hypertension. Which ethnic group is at greatest risk - ANS African americans Estinguishing fire, which should the nurse take using the fire extinguisher - ANS slide the pin on top of the fire extinguisher straight out enteral nutrition in NG tube. Put steps in order - ANS 1. high fowler's 2. verify with aspirating 5 ml gastric contents 3. test pH 4. check for gastric residual volume 5. flush with 30 ml water nurse caring for 47 year old female, urinary incontinence. Why action? - ANS obtain a specimen from client for culture (rule out UTI) a nurse is talking with a client who has major depressive disorder "nobody cares if I'm around" - ANS "it feels as though you are hopeless" a charge nurse is teaching a group of newly licensed nurses how to prevent errors during admin of blood transfusions. which should include? - ANS use a new blood admin tubing set for each blood bag infused C. diff infection and is incontinent of stool. which action do you take - ANS wear a gown a nurse is providing discharge teaching about nutrition manage who has COPD. Which instruction - ANS have a high calorie protein drink after meals b/c anorexia is a manifestation of COPD nurse has pt. who has dysphagia. which action facilitates safe swallowing - ANS delay meal time if he is tired toddler home injury prevention. snacks - ANS watermelon but remove seeds invasive procedure. why actions to ensure in scope of practice - ANS check the state's nurse practice act before performing leg wound. age related in older adults that impaired wound healing - ANS elastin fibers separate and thicken long-term care facility small fire. move client and then what? - ANS pull alarm isolation precautions. which actions when removing tied surgical mask - ANS remove mask by holding ties and moving it away from face electronic data about behavior indicators of pain in infant. which online source should be used to research infant care issue - ANS cumulative index to nursing and allied health lit a nurse is preparing to administer three medications to a client who has an NG tube: a levothyroxine tablet, an ibuprofen gel cap, and a delayed release omeprazole capsule. which actions - ANS crush the levo tablet into a powder and dissolve in 30 mL of warm water indwelling urinary Cath. prevent UTI - ANS secure to leg 2 yr old toddler who is post op. which scale to assess pain - ANS FLACC scale. 2 months to 7 years client w cancer and planning discharge with hospice. which indicates spiritual distress - ANS I wish God didn't let cancer happen breast cancer. nausea and vomiting. which to include? - ANS administer ondansetron long-term care facility in acute care. joint commission national patient safety goals regarding medication admin. which action - ANS compare list of client's medications with the ones he will take in long term care timed up and go test. tripod cane for ambulation. which action - ANS observe client ambulating a distance of 3 m during TUG test orthopedic clinic about several clients. which action complies with HIPAA - ANS log off when he leaves parent of a child who is receiving chemo. which action - ANS have child rest with head elevated after meals joint commission national patient safety goals regarding communication - ANS client mediated with morphine 5 mg for pain med sure unit. which client should nurse monitor for reflex urinary incontinence - ANS spinal cord injury which abbreviation should nurse clarify - ANS SQ reduce infection drug use. tertiary prevention - ANS needle-exchange chronic pain due to fibromyalgia. which question for quality - ANS describe pain assist her when interviewing a client who does not speak the same language as the nurse. which action - ANS ensure compatibility healthy people 2020 initiatives - ANS determine level of health equity among groups in community haemophilus flu. which infection control - ANS place mask when transporting pt. planning care for newly admitted school age child who has rubella. which isolation precautions - ANS airborne a nurse is admin. ophthalmic solution to a client who has bacterial conjunctivitis. which action - ANS supine sleep hygiene - ANS exercise in morning sub Q - ANS B nutrition manage to the parent of an 18 mo old toddler who has phenylketonuria. which foods recommend - ANS potato med sure unity. which pain is neuropathic - ANS neuralgia, phantom, spinal nerve acute pain in a client who is post op. dementia and nonverbal. which for PRN pain med? - ANS rapid breathing nurse is teaching client about strategies to prevent recurrent constipation. which instructions - ANS exercise, whole grains, fluids developing facility policy about fax machine to communicate information about a client's electronic medical record. which action policy - ANS use cover sheet when sending fax from health care unit plan of care for older adult who is fall risk. which measure - ANS demonstrate use of call light car seat for newborn - ANS rear facing screening for scoliosis - ANS bend forward at waist and let arms dangle restraints - ANS can be in mechanical restraint up to 4 hours diarrhea - ANS increase intake of potassium rich foods while experiencing implement bladder retraining who has urge urinary incontinence - ANS gradually length time between void times fibromyalgia. which prescription should be expected for pain - ANS pregabalin po twice daily (depression) which food/beverage should be liberally (a lot) included in diet for colorectal cancer - ANS fruit a hospice nurse. hindu religion, which supports beliefs - ANS allow time for a family member to perform a ritual bath after client dies 16 yo mother and maternal grandfather. which action should the nurse take when assisting with informed consent - ANS witness consent obtained from infant's mother a nurse is beginning nutrition counseling with a client who has BMI of 34.2. why question - ANS Are you ready to make a lifelong commitment to a healthier lifestyle contact dermatitis due to poison ivy. prevent further reactions - ANS wash child's exposed clothing with hot water and detergent enoxaprin subq who is post op and is at risk of thromboembolic events. which action - ANS pull up a small amount of skin using thumb and forefinger of non dominant hand nurse is talking who report difficulty adjusting to death of her partner. which of the following demonstrates good communication - ANS what do you think would help you cope with your loss use of smokeless tobacco. which information - ANS smokeless tobacco provides a higher dose of nicotine than cigarettes a nurse is preparing to administer an immunization via IM injection in deltoid. which action - ANS select a 1 inch needle for the injection newly licensed nurse prepare medications for a client. which is safe - ANS nurse compares medication label with the client's medication administration record nurse is preparing to administer a medication via intermittent IV bolus. incompatible with the bolus. which action - ANS stop the continuous IV infusion nurse is providing teaching to the parent of 6 year old girl about preventing urinary tract infections. which of the following statements by the parent indicates understanding - ANS I will increase her intake of foods high in fiber plan of care for an older adult client who is experiencing functional incontinence following hip arthroplasty - ANS place grab bars by the toilet planning the menu for a client who practices seventh day adventism. which food selections - ANS scrambled eggs electronic health record with assistive personnel asks to enter the morning blood glucose for client - ANS request the AP uses another computer to enter the data a nurse is developing a plan of care for a client who has urinary incontinence - ANS apply a moisture barrier stool specimen who has had diarrhea for 3 days with fever and abdominal cramping. which medication increases risk of c diff - ANS ciprofloxacin (causes diarrhea) electronic medical record system for client care. which action should the nurse manager take to promote interoperability - ANS recommend a single coding system for each department to use a nurse is reviewing the medication record of a client who is 2 days post op. which medication delays wound healing - ANS prednisone nurse is prepping contact a client's provider regarding the need for a prescription for pain medication. background, assessment, recommendation communication tool - ANS the client is in audible distress and rates her pain as 8/10 a nurse is prepping morphine 5 mg IM from 10 mg/mL to help. which action - ANS have a second nurse witness and initial the disposal of the remaining medication client that practices judaism. which dietary practices - ANS the client is permitted to eat fish that have scales a nurse at a provider's office is counseling a client who reports insomnia. which of the following statements should the nurse include in sleeping plan - ANS sleep in the location of your home where you feel you best rest a nurse is preparing to admit a client in the hospital. which of the following actions should the nurse take first - ANS determine the need for an interpreter a nurse is caring for a pt. with violent activity who is placed in seclusion. which action - ANS document the client's status every 15 min a nurse is caring for a child who has celiac disease. which of the following items should the nurse REMOVE from the child's meal tray - ANS oatmeal with raisins a nurse is using therapeutic communication to attempt de-escalation with a client who is yelling at staff members. which of the following statements - ANS tell me what is causing your anger at this moment a nurse is caring for a client who is morbidly obese and is 3 days post op after bariatric surgery. which of the following dits - ANS eat foods that are high in protein a nurse is preparing to administer a unit of packed RBCs to a client. in adherence with the joint commission national patient safety goals regarding blood admin, which of the following plan - ANS verify the client and blood component using a two person process a nurse is providing teaching to a client who has chronic fatigue syndrome. which of the following statements should the nurse make - ANS take NSAIDs for body aches and pain male client who just turned 50 years old. the client has no significant health problems or family history. which of the following screenings should he get - ANS initial screening for colonoscopy, digital rectal, monthly testicular self exam, annual skin examination a nurse on pediatric unit is admitting an infant who has pertussis. which of the following isolation precautions should the nurse initiate - ANS droplet a nurse is assessing a preschooler for a UTI. which of the following should the nurse expect - ANS abdominal pain a nurse is teaching about advance directives with an adult client who has a terminal illness. which statement - ANS your advance directives can designate a friend to make your health care decisions a nurse is preparing a client for an elective vaginal hysterectomy when the client states "my doctor said there are more conservative ways..." which response - ANS you have the right to refuse this procedure even after you sign a nurse is planning community health program for substance use. which guidelines - ANS a healthy woman of any age should consume no more than seven drinks in a week. a nurse is assessing the spiritual and development of a preschooler. why is it wrong to kick your baby sister. which response should the nurse expect - ANS it's wrong because my dad said I can't kick her a nurse is providing a change of shift report about a group of clients. which statement - ANS the client has been very tearful since finding out about DM a nurse is caring for an older adult who has osteoarthritis and plans to go to an assisted living facility due to decreased mobility. which action should nurse say as an advocate - ANS research facilities for the client that best meet her specific needs charge nurse is educating staff about culture - ANS the body of a client who practices islam is washed and wrapped in a cloth following death a nurse is admitting a client who has pulmonary tb. which transmission - ANS airborne