An S3 heart sound is auscultated in a client
Document in the client’s record
A client who is newly diagnosed with type 2 diabetes mellitus (DM) receives a prescription
for metformin 500 mg PO twice daily.
Recognize signs and symptoms of hypo
Take metformin with
Report persistent poly
The nurse is planning care for a client who admits having suicidal thoughts.
Begins to show signs of improvement in affect
Assessment by the home health nurse of an older client who lives alone indicates that the
client has chronic constipation. The client has deficiencies in fluid and fiber intake, eats
microwaved foods at home, and frequents fast-food restaurants. Daily medications include
furosemide for hypertension and heart failure and laxatives. To manage the client’s
constipation, which suggestions should the nurse provide?
Increase fluid intake by keeping water glass next to recliner
Include oatmeal with stewed prunes
Recommend seeking help with regular shopping and meal preparation
A postpartum client asks the nurse about different contraceptives that are available for use
after delivery. How should the nurse respond?
I Can Discuss Various Methods So You Can Decide What Is Best For You
A male client with antisocial personality disorder is admitted to an in-patient mental health
unit for multiple substance dependency. When providing a history, the client justifies his use
of illicit drugs to the nurse. Based on this pattern of behavior, this client’s history is most
likely to include which finding?
Multiple convictions for misdemeanors and class b felonies
A client with newly diagnosed type 2 diabetes mellitus, awakens in the morning with a
temperature of 101.6^ F (38.7^C). The client calls the clinic nurse and reports taking the
morning dose of metformin after obtaining a morning fasting blood glucose of 325 mg/dL
(18 mmol/L). Which instruction should the nurse provide to the client?
Monitor blood glucose levels more frequently
,The nursing staff in the emergency department are creating a continuous quality
improvement project on social media that addresses prevention and early detection of
cerebral vascular accidents (CVA). Which action should the nurse implement to protect
client privacy?
Ensure adherence with all state and federal privacy laws
Following a motor vehicle collision, an adult client with a ruptured spleen and a blood
pressure of 70/44 mmHg, had an emergency splenectomy. Twelve hours after the surgery,
the client’s urine output is 25 mL/hour for the last two hours. What pathophysiological
reason supports the nurse’s decision to report the finding to the healthcare provider?
Low urine output puts the client at risk for fluid overload
A female client is extremely anxious after being informed that her mammogram was
abnormal and needs to be repeated. The client is tearful and tells the nurse that her mother
died of breast cancer. What action should the nurse take?
Encourage the client to continue expressing her fears and concerns
An adolescent with anorexia nervosa is within 10 pounds of their normal weight and is being
discharged from the mental health unit with a prescription for fluoxetine. Which instruction
is most important for the nurse to provide the parents?
Listen for the adolescent’s expressions of wanting to harm themselves
To reduce the risk of being named in a malpractice lawsuit, which actions is most important
for the nurse to take? Adhere consistently to standards of care
While cleaning a client’s postoperative wound that is healing by granulation, the nurse
observes a 3 cm area of eschar. What information should the nurse tell the client about the
wound? Removal of the leathery tissue promotes wound healing
A client has a suspected brain tumor is scheduled for a computed tomography (CT) scan.
When preparing the client for the CT scan, which intervention should the nurse implement?
Obtain the client’s food allergy history
A client at 38-week’s gestation comes to the labor and delivery observation unit complaining
of “leaking water.” Based on this client’s complaint, what action should the nurse take?
Admit the client to labor and delivery if mucus is found in the vaginal vault
Which technique should the nurse include when applying an elastic bandage to a client’s
extremity? Apply the bandage over the injured area to mark the point of injury
, The nurse is assessing a client with an AV fistula who has been receiving hemodialysis for 2
years. The nurse auscultates a bruit over the site of the client’s fistula. What action should the
nurse take in response to this finding?
Document the finding in the electronic medical record
A female client with a long history of alcoholism is admitted with a blood alcohol level
(BAL) of 2.5 mg/dL (0.54 mmol/L) and a serum magnesium level of 1.1 mEq/L (0.55
mmol/L).she has hyperactive deep tendon reflexes, is confused, and the electrocardiogram
indicates a ventricular dysrhythmia. Which prescription should the nurse implement first?
Chlordiazepixide 100mg im prn? Magnesium sulfate 250mg iv per secondary infusion
The nurse identifies a respiratory rate of 6 breath/minute in a client who received fentanyl
during a procedure in the day surgical unit. Arterial blood gases (ABG) are obtained. Which
value should the nurse identify that results from the client’s hypoventilation? 80 mmHg
A client is admitted to the mental health unit with depressed mood and relationship distress
with spouse. Findings from which diagnostic test provide the most information for
developing this client’s plan of car? Urine drug screen
The nurse is triaging clients in an urgent care clinic. The client with which symptoms should
be referred to the health care provider immediately? Headache, photophobia, and nuchal
rigidity
Several days after returning from a mission trip to South Africa, a client presents with fever,
chills, and mild confusion. The family reports that the client had cold-like symptoms with
productive cough upon returning home. Which action is most important for the nurse to
implement? Initiate Air Borne Isolation Precautions
A continuous infusion of nitroglycerin is prescribed for an adult male admitted with an acute
myocardial infarction. The client is experiencing active chest pain that he describes as 8 out
of10. Which intervention is most important for the nurse to implement?
Obtain current serum potassium level
The nurse assesses a client with new onset diarrhea. It is most important for the nurse to
question the client about recent use of which type of medication? Antibiotics
, A client with anxiety does not want to communicate with friends, worries excessively, and
reports not being able to deal with life. Which coping strategy should the nurse included in
the plan of care? Focus on small achievable tasks, not taxing problems
The nurse is educating a client with chronic kidney disease (CKD) about dietary changes.
Which finding indicates to the nurse that the client needs additional teaching?
Restrict iron rich foods and iron supplements
Two days after syncopal episode, an adult woman is admitted to the telemetry unit because of
a new onset atrial fibrillation. The client is restless and complaining of shortness of breath at
rest, but insists on getting out of bed to go to the bathroom. Her vital signs are: blood
pressure 90/40 mm Hg, heart rate 145 beats/minute, respiratory rate 22 breaths/minute. While
in the bathroom, the client begins to cough, producing frothy, pink-tinged sputum. What
action should the nurse take first? Assist the client back to bed and into a fowler’s position
Following an esophagogastroduodenoscopy (EGD), an adult client is drowsy and difficult to
arouse. The client’s respirations are slow and shallow. Which action should the nurse
implement?
Check oxygen saturation level; prepare medication reversal agent; apply oxygen via
nasal agent
An older resident of a long-term care facility has a 5-year history of hypertension. The client
has a headache and rates the pain 5 on a pain scale of 0 to 10. The client’s blood pressure is
currently 142/89 mmHg. Which interventions should the nurse implement?
Administer a daily dose of lisinopril as scheduled; provide a prn dose of acetaminophen for
headache
The nurse is caring for a client who is in renal failure. In reviewing the client’s laboratory
data, which result must be reported immediately to the healthcare provider?
Serum Potassium 7 Meq/L (7mmol/L)
A client who had a below-the-knee amputation is experiencing severe phantom limb pain
(PLP) and asks the nurse if mirror therapy will make the pain stop. Which response by the
nurse is likely to be most helpful?
Research Indicates That Mirror Therapy Is Effective in Reducing Phantom Limb Pain
Document in the client’s record
A client who is newly diagnosed with type 2 diabetes mellitus (DM) receives a prescription
for metformin 500 mg PO twice daily.
Recognize signs and symptoms of hypo
Take metformin with
Report persistent poly
The nurse is planning care for a client who admits having suicidal thoughts.
Begins to show signs of improvement in affect
Assessment by the home health nurse of an older client who lives alone indicates that the
client has chronic constipation. The client has deficiencies in fluid and fiber intake, eats
microwaved foods at home, and frequents fast-food restaurants. Daily medications include
furosemide for hypertension and heart failure and laxatives. To manage the client’s
constipation, which suggestions should the nurse provide?
Increase fluid intake by keeping water glass next to recliner
Include oatmeal with stewed prunes
Recommend seeking help with regular shopping and meal preparation
A postpartum client asks the nurse about different contraceptives that are available for use
after delivery. How should the nurse respond?
I Can Discuss Various Methods So You Can Decide What Is Best For You
A male client with antisocial personality disorder is admitted to an in-patient mental health
unit for multiple substance dependency. When providing a history, the client justifies his use
of illicit drugs to the nurse. Based on this pattern of behavior, this client’s history is most
likely to include which finding?
Multiple convictions for misdemeanors and class b felonies
A client with newly diagnosed type 2 diabetes mellitus, awakens in the morning with a
temperature of 101.6^ F (38.7^C). The client calls the clinic nurse and reports taking the
morning dose of metformin after obtaining a morning fasting blood glucose of 325 mg/dL
(18 mmol/L). Which instruction should the nurse provide to the client?
Monitor blood glucose levels more frequently
,The nursing staff in the emergency department are creating a continuous quality
improvement project on social media that addresses prevention and early detection of
cerebral vascular accidents (CVA). Which action should the nurse implement to protect
client privacy?
Ensure adherence with all state and federal privacy laws
Following a motor vehicle collision, an adult client with a ruptured spleen and a blood
pressure of 70/44 mmHg, had an emergency splenectomy. Twelve hours after the surgery,
the client’s urine output is 25 mL/hour for the last two hours. What pathophysiological
reason supports the nurse’s decision to report the finding to the healthcare provider?
Low urine output puts the client at risk for fluid overload
A female client is extremely anxious after being informed that her mammogram was
abnormal and needs to be repeated. The client is tearful and tells the nurse that her mother
died of breast cancer. What action should the nurse take?
Encourage the client to continue expressing her fears and concerns
An adolescent with anorexia nervosa is within 10 pounds of their normal weight and is being
discharged from the mental health unit with a prescription for fluoxetine. Which instruction
is most important for the nurse to provide the parents?
Listen for the adolescent’s expressions of wanting to harm themselves
To reduce the risk of being named in a malpractice lawsuit, which actions is most important
for the nurse to take? Adhere consistently to standards of care
While cleaning a client’s postoperative wound that is healing by granulation, the nurse
observes a 3 cm area of eschar. What information should the nurse tell the client about the
wound? Removal of the leathery tissue promotes wound healing
A client has a suspected brain tumor is scheduled for a computed tomography (CT) scan.
When preparing the client for the CT scan, which intervention should the nurse implement?
Obtain the client’s food allergy history
A client at 38-week’s gestation comes to the labor and delivery observation unit complaining
of “leaking water.” Based on this client’s complaint, what action should the nurse take?
Admit the client to labor and delivery if mucus is found in the vaginal vault
Which technique should the nurse include when applying an elastic bandage to a client’s
extremity? Apply the bandage over the injured area to mark the point of injury
, The nurse is assessing a client with an AV fistula who has been receiving hemodialysis for 2
years. The nurse auscultates a bruit over the site of the client’s fistula. What action should the
nurse take in response to this finding?
Document the finding in the electronic medical record
A female client with a long history of alcoholism is admitted with a blood alcohol level
(BAL) of 2.5 mg/dL (0.54 mmol/L) and a serum magnesium level of 1.1 mEq/L (0.55
mmol/L).she has hyperactive deep tendon reflexes, is confused, and the electrocardiogram
indicates a ventricular dysrhythmia. Which prescription should the nurse implement first?
Chlordiazepixide 100mg im prn? Magnesium sulfate 250mg iv per secondary infusion
The nurse identifies a respiratory rate of 6 breath/minute in a client who received fentanyl
during a procedure in the day surgical unit. Arterial blood gases (ABG) are obtained. Which
value should the nurse identify that results from the client’s hypoventilation? 80 mmHg
A client is admitted to the mental health unit with depressed mood and relationship distress
with spouse. Findings from which diagnostic test provide the most information for
developing this client’s plan of car? Urine drug screen
The nurse is triaging clients in an urgent care clinic. The client with which symptoms should
be referred to the health care provider immediately? Headache, photophobia, and nuchal
rigidity
Several days after returning from a mission trip to South Africa, a client presents with fever,
chills, and mild confusion. The family reports that the client had cold-like symptoms with
productive cough upon returning home. Which action is most important for the nurse to
implement? Initiate Air Borne Isolation Precautions
A continuous infusion of nitroglycerin is prescribed for an adult male admitted with an acute
myocardial infarction. The client is experiencing active chest pain that he describes as 8 out
of10. Which intervention is most important for the nurse to implement?
Obtain current serum potassium level
The nurse assesses a client with new onset diarrhea. It is most important for the nurse to
question the client about recent use of which type of medication? Antibiotics
, A client with anxiety does not want to communicate with friends, worries excessively, and
reports not being able to deal with life. Which coping strategy should the nurse included in
the plan of care? Focus on small achievable tasks, not taxing problems
The nurse is educating a client with chronic kidney disease (CKD) about dietary changes.
Which finding indicates to the nurse that the client needs additional teaching?
Restrict iron rich foods and iron supplements
Two days after syncopal episode, an adult woman is admitted to the telemetry unit because of
a new onset atrial fibrillation. The client is restless and complaining of shortness of breath at
rest, but insists on getting out of bed to go to the bathroom. Her vital signs are: blood
pressure 90/40 mm Hg, heart rate 145 beats/minute, respiratory rate 22 breaths/minute. While
in the bathroom, the client begins to cough, producing frothy, pink-tinged sputum. What
action should the nurse take first? Assist the client back to bed and into a fowler’s position
Following an esophagogastroduodenoscopy (EGD), an adult client is drowsy and difficult to
arouse. The client’s respirations are slow and shallow. Which action should the nurse
implement?
Check oxygen saturation level; prepare medication reversal agent; apply oxygen via
nasal agent
An older resident of a long-term care facility has a 5-year history of hypertension. The client
has a headache and rates the pain 5 on a pain scale of 0 to 10. The client’s blood pressure is
currently 142/89 mmHg. Which interventions should the nurse implement?
Administer a daily dose of lisinopril as scheduled; provide a prn dose of acetaminophen for
headache
The nurse is caring for a client who is in renal failure. In reviewing the client’s laboratory
data, which result must be reported immediately to the healthcare provider?
Serum Potassium 7 Meq/L (7mmol/L)
A client who had a below-the-knee amputation is experiencing severe phantom limb pain
(PLP) and asks the nurse if mirror therapy will make the pain stop. Which response by the
nurse is likely to be most helpful?
Research Indicates That Mirror Therapy Is Effective in Reducing Phantom Limb Pain
