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A nurse is caring for a client who had abdominal surgery 24 hr ago. Which of the following actions
is the nurse's priority? ✔✔Assist with deep breathing and coughing
A nurse is talking with a client who has stage IV breast cancer. The nurse should recognize which
of the following statements by the client as a constructive use of a defense mechanism? ✔✔"I told
my doctor that I would like to start a support group for other women who are sick in my
community"
A nurse is caring for a client who has immunosuppression and a continuous IV infusion. Which of
the following actions should the nurse take? ✔✔Monitor the client's mouth every 8 hr
A nurse is caring for a 2 month old infant who has Hirschsprung disease (HD). Which of the
following areas should the nurse assess for manifestations of HD? ✔✔C
The nurse should assess the infant's abdomen for distention and visible peristalsis, which are
manifestations of HD
A nurse at a mental health clinic is caring for four clients. The nurse should recognize the following
clients is using dissociation as a defense mechanism? ✔✔A client who was abused as a child
describes the abuse as if it happened to someone else
,A nurse is providing teaching to a client who has a new diagnosis of type 1 diabetes mellitus. The
nurse should instruct the client to monitor for which of the following findings as a manifestation
of hypoglycemia? ✔✔irritability
A nurse in an outpatient mental health clinic is caring for four clients. The nurse should recognize
that which of the following clients is effectively using sublimation as a defense mechanism? ✔✔A
client who channels their energy into a new hobby following the loss of their job
A hospice nurse is consulting with a client and her family about receiving home services. Which
of the following statements should the nurse identify as an indication that the family understands
home hospice care? ✔✔"We can expect the hospice nurse to provide support for us after our
mother's death"
A nurse is caring for a client who has active tuberculosis. Which of the following actions should
the nurse take? ✔✔Assign the client to a private room with negative air pressure
A nurse is providing teaching to a client who is at 24 weeks of gestation and is schedule for a 3
hour oral glucose tolerance test. Which of the following instructions should the nurse include in
the teaching? ✔✔"You will need to fast the night before the test"
A nurse on a pediatric unit has received change of shift report for four children. Which of the
following children should the nurse assess first? ✔✔A 10 year old child who is awaiting surgery
for an appendectomy and experienced sudden relief from pain
,A nurse in a community center is providing an education session to a group of clients about ovarian
cancer. Which of the following manifestations of ovarian cancer should the nurse include in the
teaching? ✔✔Abdominal bloating
A nurse is caring for a client who is postoperative after receiving moderate (conscious) sedation.
The client suddenly becomes restless and reports feeling lightheaded. Which of the following
actions should the nurse take? ✔✔Check the client's oxygen saturation level
A nurse is working in an emergency department is triaging four clients. Which of the following
clients should the nurse recommend for treatment first? ✔✔A middle adult client who has unstable
vital signs
A nurse is providing teaching for a client who has a fracture of the right fibula with a short leg cast
in place and a new prescription for crutches. The client is non-weight bearing for 6 weeks. Which
of the following instructions should the nurse include in the teaching? ✔✔Use a three-point gait
A nurse is preparing to initiate IV access for an older adult client. Which of the following sites
should the nurse select when initiating the IV for this client? ✔✔Radial vein of the inner arm
A nurse is planning to delegate client care tasks to an AP. Which of the following tasks should the
nurse plan to delegate to the AP? ✔✔Perform gastrostomy feedings through a client's established
gastrostomy tube
, A nurse is caring for a newborn immediately after delivery. Which of the following interventions
should the nurse implement to prevent heat loss by conduction? ✔✔Use a protective cover on the
scale when weighing the infant
A nurse is caring for a client who is receiving a continuous heparin infusion. Which of the
following laboratory tests should the nurse review prior to adjusting the client's heparin? ✔✔aPTT
A nurse administers an incorrect dose of medication to a client. The nurse recognized the error
immediately and completes and incident report. Which of the following facts related to the incident
should the nurse document in the client's medical record? ✔✔Time the medication was given
A nurse is providing education to the parent of a school age child who has asthma. Which of the
following statements by the parent indicates an understanding of the teaching? ✔✔"I will make
sure my child receives a yearly influenza immunization"
A nurse is caring for a client who has type 1 diabetes mellitus and reports severe ankle pain after
falling off a step stool at home. Which of the following prescriptions should the nurse clarify with
the provider? ✔✔Apply a cold pack to the client's ankle for 30 min every hour
A nurse is assessing a client who has a major depressive disorder and is taking amitriptyline. Which
of the following findings should the nurse identify as an adverse effect of the medication?
✔✔Blurred vision