PN Comprehensive Predictor

A nurse is caring for four clients. Which of the following client statements should the nurse attend to first? - "My heartburn pain is going into my jaw now." A nurse is caring for a client who is receiving mechanical ventilation via an endotracheal tube. Which of the following actions should the nurse take? - Perform oral care every 2 hr. A nurse is caring for a client who is receiving warfarin 5 mg PO daily. Which of the following laboratory values should the nurse check prior to administering the medication? - - PT - INR A nurse is collecting data from a client who is at 9 weeks of gestation and has hyperemesis gravidarum. Which of the following findings should the nurse expect? - Weight loss A nurse is reinforcing teaching with a client about the importance of a low sodium diet. Which of the following foods should the nurse recommend as the best choice to include in a low sodium diet? - 2 tbsp of peanut butter A nurse is collecting data from an 18-month-old toddler at a well child visit. Which of the following findings should the nurse report to the provider? - The toddler can say four words. A nurse is collecting data from a client who has diabetes mellitus. Which of the following findings indicates that the client might be experiencing diabetic ketoacidosis? - Kussmaul respirations A nurse is reinforcing teaching with a client who has a permanent pacemaker in place. Which of the following statements by the client indicates an understanding of the teaching? - "I need to record my pulse rate daily." A nurse is caring for a client who is in mechanical restraints after becoming violent with a staff member. Which of the following actions should the nurse take? - Document in the clients medical record every 15 min. A nurse is reinforcing teaching about self-administration of nasal drops with a client. Which of the following positions should the nurse recommend for instillation of the drops? - Supine A nurse is preparing to administer furosemide to a client who has heart failure. Which of the following laboratory results should the nurse review prior to administering the medication? - Potassium A nurse is caring for a client who has methicillin-resistant staphylococcus aureus (MRSA) infection. Which of the following actions should the nurse plan to take? - Don a gown and gloves when providing perineal care A nurse is assisting with the plan of care for a client who has dementia and often wanders in the halls at night. Which of the following interventions should the nurse recommend including in the plan of care? - Labeling the clients bathroom door A charge nurse is reinforcing teaching with a newly hired licensed practical nurse about scope of practice. Which of the following responsibilities should the nurse include in the teaching? - Providing direct client care A nurse is working on a mental health unit is meeting with a client who has been in the unit for 2 days. The nurse greets the client and asks, "What has been happening with you today?" Which of the following therapeutic techniques is the nurse using? - Reflecting A nurse us reinforcing teaching with a group of expectant parents regarding the proper use of a car seat. Which of the following statements by a parent indicates an understanding of the teaching? - "I will secure the seat belt across my newborns lap." A nurse from a medical surgical unit is floating to a postpartum unit. Which of the following clients is an appropriate assignment for the nurse to accept? - A client who underwent removal of a retained placenta A nurse is assisting with planning care for a newly admitted client who has anorexia nervosa. Which of the following interventions should the nurse recommend to include in the plan of care? - Reinforce teaching about healthy eating during meals A nurse is admitting a client who is scheduled for an elective surgery. Which of he following actions should the nurse take to verify the status of the clients advance directives? - Ask the client whether they have advance directives A nurse is collecting data from a client who is receiving a continuous IV infusion of 0.9% sodium chloride. The nurse discovers the IV infusion pump was set incorrectly and the client received 200 ml more than prescribed. Data collection reveals that the client is stable. The nurse recognizes that this incident is not considered malpractice for which of the following reasons? - The client was not harmed as a result of the incident A nurse is caring for a client who has COPD. The nurse should identify that which of the following findings is the priority to report? - Productive cough with green sputum A nurse is caring for a newborn who just had a circumcision. Which of the following findings should the nurse identify as a nonverbal sign of pain? - The newborn continues to cry despite efforts to console A nurse is reinforcing teaching with a parent about appropriate snacks for a toddler. Which of the following foods should the nurse include? - Graham crackers A nurse is caring for a client who is breastfeeding their 5-day old newborn. Which of the following should the nurse identify as an indication that the newborn is breastfeeding effectively? - Makes audible swallowing sounds A nurse is reinforcing teaching with a client who has a new diagnosis of myasthenia gravis (MG) and a prescription for neostigmine. Which of the following information should the nurse include about the action of the medication? - Improves muscle strength A nurse is reinforcing teaching with the parents of a newborn who had a circumcision. Which of the following client statements indicates understanding of the teaching? - "I will apply petroleum jelly to the penis with each diaper change." A nurse is collecting data from a 3 month old infant who is 6 hr postoperative following a cleft palate repair. Which of the following pain rating tools should the nurse use? - FLACC scale A nurse is collecting data from a client who has substance use disorder and reports recently taking opioids. Which of the following findings should the nurse identify as a manifestation of opioid intoxication? - Pinpoint pupils A nurse is checking the home environment of a client for safety hazards. Which of the following items require intervention by the nurse? - The dining room table has low chairs with no armrests A nurse is preparing to administer medication to a newborn. Which of the following information should the nurse use to identify the newborn? - Name and medical record number Footprints and identification number A nurse is reinforcing teaching with a client who has a prescription for a combination contraceptive transdermal patch. Which of the following should the nurse include in the teaching? - "Start the first patch on the seventh day of the menstrual cycle." A nurse is caring for a client who attempted suicide. Which of the following actions should the nurse take? - Assign the client to a private room. A nurse is reinforcing teaching with a newly licensed nurse about the HIPAA privacy rule. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching? - "A client has the right to view their medical record." A nurse is caring for an older adult client who states, "I can't pay for my care because my kid took all my money." Which of the following actions should the nurse take? - Report the possible abuse to adult protective services A nurse us reinforcing with a client who is 12 hr postpartum and has an episiotomy. Which of the following instructions should the nurse include? - Change the perineal pad with each void. A nurse in a pediatric clinic is reviewing the urine laboratory results for an adolescent. For which of the following results should the nurse notify the provider? - Ketones positive A nurse is reviewing the laboratory results for a client who is at 32 weeks of gestation. For which of the following results should the nurse notify the provider? - Platelet count 90,000/mm3 A nurse is assisting with the admission of an older adult client who has impaired mobility and is at risk for falls. Which of the following actions should the nurse plan to perform first? - Document the client's risk in the medical record Check the clients ability to use the call light A nurse is collecting data from a newly admitted client. Which of the following questions should the nurse ask to assess the client's abstract thinking ability? - "What does the phrase 'butterflies in my stomach' mean? A nurse is reinforcing discharge teaching with an older adult client's family about safety precautions when administering a tap water enema to the client. Which of the following should the nurse include in the instructions? - Insert the rectal tube in the direction of the clients umbilicus A nurse is preparing to transfer a client who has left sided weakness from the bed to a wheelchair. Which of the following actions should the nurse take first. - Lock the wheels on the bed A nurse is caring for a client who has a new prescription for furosemide and asks the nurse about the purpose of the medication. The nurse states, "This medication is a diuretic that removes excess fluid from your body." Which of the following ethical concepts is the nurse exhibiting? - Veracity A nurse is reinforcing teaching with a client who plants to bottle feed her newborn. Which of the following statements indicates an understanding of the instructions? - "I will feed my baby six to eight times a day." A nurse is caring for a client who is asking about the techniques of effleurage and its use in labor and delivery. Which of the following responses should the nurse make regarding this techique? - "It is a light stroking of the skin during a uterine contraction? A nurse is contributing to the plan of a care for a 12 month old infant following cleft palate repair. Which of the following actions should the nurse include? - Maintain elbow restraints on the infant A nurse is preparing to assist with the insertion of a nasogastric tube for a client who has a small bowel obstruction. which of the following supplies should the nurse gather? - pH test strips A nurse is reinforcing teaching with a school-age child who has hemophilia about participating in school sports. Which of the following sports should the nurse recommend for the child? - -swimming -golf -gymnastics A nurse is reinforcing teaching about foot care with a client who has diabetes mellitus. Which of the following statements by the client indicates an understanding of the teaching? - "I will be sure to wear cotton socks." A nurse is collecting data from a guardian of a toddler during a well child visit. The guardian expresses concern to the nurse because his child has a poor appetite, but drinks a quart of milk each day. The nurse should identify that this practice places the toddler at risk for which of the following conditions ? - Iron-deficiency anemia A nurse is reinforcing teaching with a client who was diagnosed with diabetes mellitus and requires insulin injections. Which of the following client statements indicates an understanding of the teaching? - "I will store my current bottle of insulin in the refrigerator." A nurse is caring for a client who has urolithiasis. Which of the following actions should the nurse take? - Strain the clients urine A nurse is reinforcing teaching with a client who is scheduled for a mammogram. Which of the following instructions should the nurse include in the teaching? - Refrain from using deodorant on the morning of the test A nurse is caring for a school age child whose family adheres to a vegan diet in the home. The nurse should recognize he child is at risk for a deficiency of which of the following? - Vitamin D A nurse is reinforcing teaching with a client who is about to undergo a thoracentesis. Which of the following statements by the client indicates an understanding of the information? - "I will have general anesthesia during the procedure."