A home health nurse is caring for a fluent who has COPD. The client tells the nurse that
he becomes short of breath while eating despite the use of home oxygen. Which if the
following instructions should the nurse include? - ansDrink beverages at the end of
meals
A home health nurse is reinforcing teaching with a clear f about preventing
complications of peripheral vascular disease. Which of the following state meets
indicates that the client is adhering today the nurses instructions? - ansI don't cross my
legs anymore
A it's is reviewing the medical record of a client who has a cord pancreatitis. Which of
the following findings should the myself anticipate? - ansElevated serum amylase level
A jade is reinforcing teaching with a client who postoperative following a cemented total
hip arthroplasty. Which of the following instructions should the nurse include in the
teaching? - ansMaintain hip flexion to 90° or less when sitting
A nurse enters the room of a client whose transfusion of packed RBCs was initiated 15
min ago by the RN. The client reports dyspnea and urticaria. Which of the following
actions should the nurse perform first? - ansStop the infusion
A nurse in a clinic is assisting with the development of a pamphlet about STIs. Which if
the following f information should the nurse recommend to include in the pamphlet? -
ansWomen have a higher risk of contracting STI than men
A nurse in a health clinic is reinforcing teaching with a client who has tuberculosis about
transmission of the disease. Which of the following client statements indicates an
understanding of the teaching? - ansI inhaled the infected droplets that were in the air
A nurse in a long term care facility is collecting data from a client who reports fullness in
the rectum and abdominal cramping. Which of the following findings should indicate to
the nurse that the client might have a fecal impaction? - ansSmall liquid stools
A nurse in an oncology is reinforcing teaching about Mohs surgery with a client who has
skin cancer. Which of the following information should the nurse include in the
teaching? - ansMohs surgery is a horizontal shaving of thin layers of the tumor
A nurse in an orthopedic clinic is reinforcing teaching with a client who has
osteoarthritis. Which of the following instructions should the nurse include to promote
comfort? - ansSleep on a firm mattress.
A nurse in clinic is collecting data from a client who has hyperth yroidism and has been
taking methimazole for 4 weeks. Which of the following statements by the client
indicators a therapeutic response of the medication? - ansI have gained 3 ponds since
my last appointment
,A nurse is acting for a client who is bucks traction. Which of the following interventions
should the nurse perform to reduce skin breakdown? - ansKeep the skin dry and free of
perspiration
A nurse is admitting a client who is suspect of having active tuberculosis. Which of the
following actions should the nurse take first? - ansInstitute airborne precautions
A nurse is assisting a client who reports difficulty falling asleep. Which of the following
activities should the nurse recommend to promote sleep? - ansListen to soft music
before sleeping
A nurse is assisting in the care of a client who has AIDS related pneumonia. The client
is receiving antibiotics therapy and albuterol nebulizer treatments daily. Which of the
following findings should indicate to the nurse that the clients therapeutic regimen is
effective? - ansDecrease in exertional dyspnea
A nurse is assisting in the care of a client who has manifestations of sepsis. Which of
the following provider prescriptions should the nurse implement first? - ansInitiate
oxygen at 4 L/min via nasal cannula.
A nurse is assisting in the plan of care for a client who had a recent left hemispheric
stroke, which of the following actions should the nurse include in the plan? - ansUse
simple verbal cues when directing tasks
A nurse is assisting in the plan of care regarding bowel restraining for a client who has a
cervical spinal cord injury. Which of the following interventions should the nurse plan to
implement first? - ansDetermine the clients daily elimination habits
A nurse is assisting the charge nurse with developing an in service about caring for
clients who have internal sealed radiation implants. Which of the following information
should the nurse include? - ansDispose of radiation implants in a lead container.
A nurse is assisting with an educational program for clients who have been newly
diagnosed with diabetes mellitus. Which of the following instructions should the nurse
include in the oral gram regarding insulin? - ansOpened can be stored in a cool
countertop away from light
A nurse is assisting with the care of a care who is reconciled 0.9 % sodium chloride by
continuous IV infusion. The client report pain and swelling at the IV site. In which order
should the nurse perform that following steps? - ansCheck the IV site, stop the infusion,
withdraw the IV catheter, elevate the affected arm, notify the charge nurse
A nurse is assisting with the care of a client who had a stroke and is unable to speak.
The nurse should identify that the clients injury occurs in which of the following lobe of
the brain? - ansFrontal lobe
,A nurse is assisting with the care of a client who has a cardiac catheterization via the
right femoral artery. Which of the following actions should the nurse take to prevent lost
procedure complications? - ansMonitor the insertion site for bleeding is correct, maintain
the pressure dressing, check the clients peripheral pulses
A nurse is assisting with the development of a plan of care to manage pain for a client
who has herpes zoster with lesions on the lower extremities. Which of the following
interventions should the nurse include in the plan of care? - ansKeep bed linens off of
the affected areas
A nurse is assisting with the discharge planning for a client who is postoperative
following a total hip arthroplasty. Which of the following instructions should the nurse
include in the discharge plan? - ansObtain a raised toilet seat
A nurse is care for for a client who has a compound fracture of the femur and was
placed in balanced suspension skeletal traction 4 days ago. Which of the following
actions should the nurse take? - ansPerform pin site care daily
A nurse is care for for a client who is 2 hr postoperative following an amputation of the
foot. Which if the following actions should the n urse take first? - ansCheck the incisional
dressing
A nurse is caring for a client and administers penicillin IM. The client begins exhibiting
hives and has severe difficulty breathing. After establishing a patent airway, which f the
following actions should the nurse take next? - ansAdminister epinephrine
A nurse is caring for a client following a gastrectomy. Which of the following actions
should the nurse take to decrease episodes of dumping syndrome? - ansPlace the
client in the supine position after meals.
A nurse is caring for a client following a thyroidectomy. Which of the following findings
should alert the nurse to the possibility of parathyroid gland injury? - ansmuscle
twitching
A nurse is caring for a client undergoing testing for multiple sclerosis. Which of the
following findings should the nurse expect? - ansmuscle spasticity
A nurse is caring for a client who begins to have a seizure while ambulation in the hall.
Identify the sequence of actions the nurse should follow. - ansLower the client to floor,
place a pad beneath the clients head, loosen the clothing around the clients neck, time
the length of the clients seizure, reorient and reassure the client
A nurse is caring for a client who had an acute ischemic stroke 1 day ago. Which of the
following actions should the nurse take to reduce the risk for aspiration? - ansAllow for
30 min of rest before meals
, A nurse is caring for a client who has a history of breast cancer. The client asks the
nurse about birth control. Which of the following methods of birth control is
contraindicated for this client? - ansCombination oral contraceptive
A nurse is caring for a client who has a methicillin resistant staphylococcus aureus
MRSA infection in a surgical wound. Which of the following information should the nurse
plan to share with visitors? - ansVisitors must don a gown and gloves prior to entering
the clients room
A nurse is caring for a client who has a prescription for digoxin 0.25 mg PO daily. While
taking the clients apical pulse, the nurse notes a rate of 58/ min. Which if the following
actions should the nurse take? - ansWithhold the dose
A nurse is caring for a client who has a prescription for phenazopyrodine. Which of the
following findings should the nurse identify as a therapeutic effect of the medication? -
ansDecreased pain during urination
A nurse is caring for a client who has acute pancreatitis. While providing care, the nurse
observes ecchymosis around the umbillicus. The nurse should identify that this is a
manifestation of which of the following? - ansIntra abdominal bleeding
A nurse is caring for a client who has an intestinal obstruction and reports a new onset
of nausea. The client has an NG tube set at low intermittent suction and receiving
continuous IV infusion of 0.9 % sodium chloride. Which of the following actions should
the nurse take first? - ansCheck for kinks in the NG tube
A nurse is caring for a client who has bacterial meningitis. Upon monitoring the client,
which of the following findings should the nurse expect? - ansRed macular rash
A nurse is caring for a client who has been taking enalapril. The nurse should monitor
the client for which of the following adverse effects? - anscough
A nurse is caring for a client who has Cushing's syndrome and expressed concern
regarding body image changes. Which if the following should the nurse recognize as a
physical change cause by this disease? - ansTruncal obesity
A nurse is caring for a client who has dementia due to Alzheimer's disease. Which if the
following actions should the nurse take to reduce the clients confusion? - ansEncourage
reminiscence of past experiences
A nurse is caring for a client who has difficult swallowing. Which of the following actions
should the nurse implement to prevent aspiration? - ansGive the client liquids with
increased viscosity
he becomes short of breath while eating despite the use of home oxygen. Which if the
following instructions should the nurse include? - ansDrink beverages at the end of
meals
A home health nurse is reinforcing teaching with a clear f about preventing
complications of peripheral vascular disease. Which of the following state meets
indicates that the client is adhering today the nurses instructions? - ansI don't cross my
legs anymore
A it's is reviewing the medical record of a client who has a cord pancreatitis. Which of
the following findings should the myself anticipate? - ansElevated serum amylase level
A jade is reinforcing teaching with a client who postoperative following a cemented total
hip arthroplasty. Which of the following instructions should the nurse include in the
teaching? - ansMaintain hip flexion to 90° or less when sitting
A nurse enters the room of a client whose transfusion of packed RBCs was initiated 15
min ago by the RN. The client reports dyspnea and urticaria. Which of the following
actions should the nurse perform first? - ansStop the infusion
A nurse in a clinic is assisting with the development of a pamphlet about STIs. Which if
the following f information should the nurse recommend to include in the pamphlet? -
ansWomen have a higher risk of contracting STI than men
A nurse in a health clinic is reinforcing teaching with a client who has tuberculosis about
transmission of the disease. Which of the following client statements indicates an
understanding of the teaching? - ansI inhaled the infected droplets that were in the air
A nurse in a long term care facility is collecting data from a client who reports fullness in
the rectum and abdominal cramping. Which of the following findings should indicate to
the nurse that the client might have a fecal impaction? - ansSmall liquid stools
A nurse in an oncology is reinforcing teaching about Mohs surgery with a client who has
skin cancer. Which of the following information should the nurse include in the
teaching? - ansMohs surgery is a horizontal shaving of thin layers of the tumor
A nurse in an orthopedic clinic is reinforcing teaching with a client who has
osteoarthritis. Which of the following instructions should the nurse include to promote
comfort? - ansSleep on a firm mattress.
A nurse in clinic is collecting data from a client who has hyperth yroidism and has been
taking methimazole for 4 weeks. Which of the following statements by the client
indicators a therapeutic response of the medication? - ansI have gained 3 ponds since
my last appointment
,A nurse is acting for a client who is bucks traction. Which of the following interventions
should the nurse perform to reduce skin breakdown? - ansKeep the skin dry and free of
perspiration
A nurse is admitting a client who is suspect of having active tuberculosis. Which of the
following actions should the nurse take first? - ansInstitute airborne precautions
A nurse is assisting a client who reports difficulty falling asleep. Which of the following
activities should the nurse recommend to promote sleep? - ansListen to soft music
before sleeping
A nurse is assisting in the care of a client who has AIDS related pneumonia. The client
is receiving antibiotics therapy and albuterol nebulizer treatments daily. Which of the
following findings should indicate to the nurse that the clients therapeutic regimen is
effective? - ansDecrease in exertional dyspnea
A nurse is assisting in the care of a client who has manifestations of sepsis. Which of
the following provider prescriptions should the nurse implement first? - ansInitiate
oxygen at 4 L/min via nasal cannula.
A nurse is assisting in the plan of care for a client who had a recent left hemispheric
stroke, which of the following actions should the nurse include in the plan? - ansUse
simple verbal cues when directing tasks
A nurse is assisting in the plan of care regarding bowel restraining for a client who has a
cervical spinal cord injury. Which of the following interventions should the nurse plan to
implement first? - ansDetermine the clients daily elimination habits
A nurse is assisting the charge nurse with developing an in service about caring for
clients who have internal sealed radiation implants. Which of the following information
should the nurse include? - ansDispose of radiation implants in a lead container.
A nurse is assisting with an educational program for clients who have been newly
diagnosed with diabetes mellitus. Which of the following instructions should the nurse
include in the oral gram regarding insulin? - ansOpened can be stored in a cool
countertop away from light
A nurse is assisting with the care of a care who is reconciled 0.9 % sodium chloride by
continuous IV infusion. The client report pain and swelling at the IV site. In which order
should the nurse perform that following steps? - ansCheck the IV site, stop the infusion,
withdraw the IV catheter, elevate the affected arm, notify the charge nurse
A nurse is assisting with the care of a client who had a stroke and is unable to speak.
The nurse should identify that the clients injury occurs in which of the following lobe of
the brain? - ansFrontal lobe
,A nurse is assisting with the care of a client who has a cardiac catheterization via the
right femoral artery. Which of the following actions should the nurse take to prevent lost
procedure complications? - ansMonitor the insertion site for bleeding is correct, maintain
the pressure dressing, check the clients peripheral pulses
A nurse is assisting with the development of a plan of care to manage pain for a client
who has herpes zoster with lesions on the lower extremities. Which of the following
interventions should the nurse include in the plan of care? - ansKeep bed linens off of
the affected areas
A nurse is assisting with the discharge planning for a client who is postoperative
following a total hip arthroplasty. Which of the following instructions should the nurse
include in the discharge plan? - ansObtain a raised toilet seat
A nurse is care for for a client who has a compound fracture of the femur and was
placed in balanced suspension skeletal traction 4 days ago. Which of the following
actions should the nurse take? - ansPerform pin site care daily
A nurse is care for for a client who is 2 hr postoperative following an amputation of the
foot. Which if the following actions should the n urse take first? - ansCheck the incisional
dressing
A nurse is caring for a client and administers penicillin IM. The client begins exhibiting
hives and has severe difficulty breathing. After establishing a patent airway, which f the
following actions should the nurse take next? - ansAdminister epinephrine
A nurse is caring for a client following a gastrectomy. Which of the following actions
should the nurse take to decrease episodes of dumping syndrome? - ansPlace the
client in the supine position after meals.
A nurse is caring for a client following a thyroidectomy. Which of the following findings
should alert the nurse to the possibility of parathyroid gland injury? - ansmuscle
twitching
A nurse is caring for a client undergoing testing for multiple sclerosis. Which of the
following findings should the nurse expect? - ansmuscle spasticity
A nurse is caring for a client who begins to have a seizure while ambulation in the hall.
Identify the sequence of actions the nurse should follow. - ansLower the client to floor,
place a pad beneath the clients head, loosen the clothing around the clients neck, time
the length of the clients seizure, reorient and reassure the client
A nurse is caring for a client who had an acute ischemic stroke 1 day ago. Which of the
following actions should the nurse take to reduce the risk for aspiration? - ansAllow for
30 min of rest before meals
, A nurse is caring for a client who has a history of breast cancer. The client asks the
nurse about birth control. Which of the following methods of birth control is
contraindicated for this client? - ansCombination oral contraceptive
A nurse is caring for a client who has a methicillin resistant staphylococcus aureus
MRSA infection in a surgical wound. Which of the following information should the nurse
plan to share with visitors? - ansVisitors must don a gown and gloves prior to entering
the clients room
A nurse is caring for a client who has a prescription for digoxin 0.25 mg PO daily. While
taking the clients apical pulse, the nurse notes a rate of 58/ min. Which if the following
actions should the nurse take? - ansWithhold the dose
A nurse is caring for a client who has a prescription for phenazopyrodine. Which of the
following findings should the nurse identify as a therapeutic effect of the medication? -
ansDecreased pain during urination
A nurse is caring for a client who has acute pancreatitis. While providing care, the nurse
observes ecchymosis around the umbillicus. The nurse should identify that this is a
manifestation of which of the following? - ansIntra abdominal bleeding
A nurse is caring for a client who has an intestinal obstruction and reports a new onset
of nausea. The client has an NG tube set at low intermittent suction and receiving
continuous IV infusion of 0.9 % sodium chloride. Which of the following actions should
the nurse take first? - ansCheck for kinks in the NG tube
A nurse is caring for a client who has bacterial meningitis. Upon monitoring the client,
which of the following findings should the nurse expect? - ansRed macular rash
A nurse is caring for a client who has been taking enalapril. The nurse should monitor
the client for which of the following adverse effects? - anscough
A nurse is caring for a client who has Cushing's syndrome and expressed concern
regarding body image changes. Which if the following should the nurse recognize as a
physical change cause by this disease? - ansTruncal obesity
A nurse is caring for a client who has dementia due to Alzheimer's disease. Which if the
following actions should the nurse take to reduce the clients confusion? - ansEncourage
reminiscence of past experiences
A nurse is caring for a client who has difficult swallowing. Which of the following actions
should the nurse implement to prevent aspiration? - ansGive the client liquids with
increased viscosity
