A nurse is caring for a client who has a recent diagnosis of a terminal illness. The
nurse should identify which of the following as an indication of hopelessness? -
ANSWER The client has a decreased level of energy
A nurse is preparing to collect data on a preschooler. Which of the following
behaviors by the child indicates that he is ready to cooperate? (SATA-3) -
ANSWER 1. Allows the nurse to touch him on the arm
2. Answers questions asked by the nurse
3. Makes eye contact with the nurse
A nurse on a mental health unit is planning care for a group of clients. Which of the
following clients should the nurse see first? - ANSWER A client who has schizo
and is having command hallucinations
A nurse is caring for a client who recently gave birth to her first child. The newborn is
crying and the client states, "I can't seem to do anything right. What should I do?"
Which of the following responses should the nurse make? - ANSWER "Let me
show how to swaddle and cuddle him, then try."
A nurse is using a glucometer to measure a client's capillary blood glucose level.
Which of the following actions should the nurse take? - ANSWER Keep the finger
in dependent position
A nurse is reviewing the home medications with a client who recently had a transient
ischemic attacks and is to begin taking clopidogrel. The nurse should instruct the
client that which of the following otc meds interact adversely w clopidogrel? -
ANSWER Naproxen
A nurse is collecting data from a client who has a long leg cast that was applied 2
days ago. The client's foot is pale w a weak pedal pulse and the client reports foot
numbness. Which of the following actions should the nurse take first? - ANSWER
Check for pain w passive movement of the affected extremity
A nurse in a providers office is reinforcing teaching about cigarette smoking w a
client. Which of the following adverse effects should the nurse include in the
teaching? - ANSWER Somnolence
A nurse is contributing to the development of an in-service program for mental health
nursing staff. The nurse should include that the staff can medicate a client against
his will, without a court hearing in which of the following situations? - ANSWER A
client who is attempting to hurt himself or others
,A nurse is reinforcing teaching with a client who has a new prescription for digoxin.
Which of the following instructions should the nurse include in the teaching? -
ANSWER "Monitor for muscle weakness while taking the medication"
A charge nurse is discussing confidentiality requirements w a newly licensed nurse
when sharing a client's medical info. Which of the following individuals should the
charge nurse identify as appropriate with whom to share client info? - ANSWER A
social worker who's assigned an involuntary committed school-age client
A nurse is reviewing lab values for a client who is at 34 weeks of gestation. Which of
the following findings should the nurse report to the provider? - ANSWER Urine
protein plus
A nurse is collecting data from a client who is 4 hr postop following a hemicolectomy.
Which of the following findings is a nurse's priority, requiring immediate intervention?
- ANSWER O2 sat 89%
A nurse in a provider's office is collecting data from a client who has a history of
hypertension during his annual physical examination. Which of the following findings
should the nurse report to the provider immediately? - ANSWER Blurred vision
A nurse is caring for a client who suddenly develops chest pain and dyspnea. Which
of the following actions should the nurse take first? - ANSWER Elevate the client's
HOB
A nurse is reinforcing teaching on a client who has diabetes mellitus. Which of the
following lab tests is most accurate of blood glucose effective management? -
ANSWER Glycoslated Hemoglobin
A nurse charge on a mental health unit is supervising a newly licensed nurse. For
which of the following actions by the newly licensed nurse should the supervising
nurse intervene? - ANSWER Tells a client he will lose his phone privileges if he
does not take his medication
A nurse is supervising an AP obtain supplies for a client who is on seizure
precautions. Which of the following materials should the AP place in the client's
room? - ANSWER Oral suction equipment
A nurse is reinforcing discharge teaching with a family of a client who has dependent
personality disorder. What action should the nurse take? - ANSWER Encourage
client to be assertive
A nurse is reinforcing discharge teaching with a client who had a right total hip
arthroplasty. Which of the following instructions should the nurse indicate? -
ANSWER "You should avoid crossing your legs for 3 months"
A nurse is reinforcing dietary teaching with a client who has hyperemesis
gravidarum. Which of the following instructions should the nurse include in the
teaching? - ANSWER Eat a small meal every 2-3 hr
, A nurse is reinforcing teaching with a client who has GERD and a prescription for
ranitidine. Which of the following statements by the client indicates and
understanding of the teaching? - ANSWER "I should take this medication in the
morning and at night"
A nurse is assisting with the admission of a client who has pulmonary tb. Which of
the following types of isolation precautions should the nurse include? - ANSWER
Airborne
A nurse is reinforcing discharge teaching with a client who has COPD and reports
problems with maintaining adequate nutrition. Which of the following instructions
should the nurse include? - ANSWER "Perform pulmonary hygiene 1 hr before
meals"
A nurse is administering pancreatic enzymes to a client who has cystic fibrosis.
Which of the following outcomes should the nurse expect as a therapeutic effects of
the treatment? - ANSWER Reduced fat in stools
A nurse is caring for a client who has paranoid schizo and believes that she is being
followed by FBI agents who are pretending to be the psychiatric staff. Which of the
following responses should the nurse make? - ANSWER The psychiatric staff not
the FBI. They're here to help you
A nurse is assisting in the care of a client who has a fractured femur and is in Buck's
traction, which of the following actions should the nurse take? - ANSWER Ensure
the weights are hanging freely
A nurse is reviewing the med record of a client who requires continuous oxygen
saturation monitoring. Which of the following should the nurse identify as a factor
that can affect the validity of the readings? - ANSWER Peripheral Vascular
Disease
A nurse is collecting data from a group of clients. Which of the following clients
should the nurse identify as having xanthelasama? - ANSWER Lady with eyes
closed with nodule on eyelid
A nurse is assisting with the admission of a client who has VRE of the urine. Which
of the following types of precautions should the nurse implement for this client? -
ANSWER Contact precautions
A community health nurse is assisting in the development of a brochure about
hypertension. Which of the following actions should the nurse take? - ANSWER
Explain medical terminology using basic one-syllable words
A nurse is collecting data from an adolescent during an annual physical examination.
Which of the following statements by the client is the nurse's priority? - ANSWER I
would rather be alone than with my fiance