A nurse is teaching a family and a client how to care for the client's tracheostomy at home. Which of the following instructions is appropriate for the client and family?
Use tracheostomy covers when outdoors.
A nurse is giving an end-of shift report about a client admitted earlier that day with pneumonia. Which of the following pieces of information is most essential to provide?
Breath sounds
A nurse is checking blood pressure at a community health screening. Which of the following clients is at high risk for primary hypertension?
A client who has an elevated LDL
A nurse is planning care for a client who has had stroke, resulting in aphasia and dysphagia. Which of the following task should the nurse assign to an AP? (Select all that apply)
- Assist the client with a partial bed bath.
- Measure the clients BP after nurse administers anti-hypertensive medication.
- Use a communication board to ask what the client wants for lunch.
A nurse is caring for a client who is combative in the emergency department. The provider orders wrist restraints after the client attempts to assault the admitting nurse. Which of the following actions is appropriate for the nurse to take?
Remove each restraint one at a time every 2 hr.
A nurse is preparing to administer morphine 4 mg IV bolus to a client. Available is 5 mg/ml. Which of the following is an appropriate nursing intervention?
Have a second nurse witness the disposal of remaining medication.
A nurse is caring for a client who asks about the purpose of advanced directives. Which of the following is an appropriate response by the nurse?
"It indicates the form of treatment a client is willing to accept in the event of a serious illness."
A nurse finds a client on the floor upon entering the client's room. The roommate reports that the client was trying to get of bed and fell over the bedrail onto the floor. Which of the following is correct documentation of this incident?
Client found lying on floor.
A client who is postoperative is verbalizing pain as a 2 on pain scale of 0 to 10. The nurse understands that the preoperative teaching regarding pain control has been effective when the client states which of the following?
"It may help to listen to music while I'm lying in bed."
A Client demonstrates anger when the nurse does not respond within 5 min of ringing for the nurse. Which of the following is an appropriate response by the nurse?
"It must be frustrating. I have a few minutes now."
A nurse is admitting a client who is experiencing exacerbation of heart failure. In planning the client's care, when should the nurse initiate discharge planning?
During the admission process
A nurse manager is overseeing the care of a unit. Which of the following should the nurse manager identify as a violation of HIPAA guidelines?
A nursing student consults a former classmate to assist with her documentation.
A nurse is teaching a client about self-administering NPH insulin. Which of the following actions by the client indicates a need for further teaching?
The client inserts the needle at a 30 degree angle.
A nurse is reviewing a client's fluid and electrolyte status. Which of the following findings should the nurse report to the provider?
Potassium 5.4 mEq/L
A nurse contacts the facility's interpreter to explain a therapeutic procedure to a client who does not speak English. Which of the following guidelines should the nurse follow when working with the interpreter?
Explain the purpose of the communication to the interpreter.
A nurse is preparing to perform nasopharyngeal suctioning for a client who is unable to cough up excessive secretions. Which of the following actions is appropriate?
Perform suctioning while removing the catheter.
A nurse is caring for a client and performing blood glucose monitoring. Which of the following is a appropriate nursing intervention?
Wipe away the first drop of blood from the client's finger.
A nurse is caring for a client who cannot bear weight on his fractured ankle. Which of the following client statements indicates a need for further teaching regarding three-point gait crutch walking?
"When I get out of a chair, I hold both crutches on the side next to my weak leg."
A nurse is reviewing the medication documentation of a newly hired nurse. Which of the following images shows correct documentation?
REASON:
This documentation is correct because the nurse is using only approved abbreviations according to the Institute of Safe Medicine Practices (ISMP) Error-Prone Abbreviation List.
A nurse is preparing to administer oral medications to a client who has dysphagia. Which of the following is an appropriate action by the nurse?
Offer each medication one at a time.
A nurse is caring for a client who is receiving medication intramuscularly. The nurse should recognize that this route?
Increases infection rates.
A nurse is working with an Orthodox Jew who has just given birth to a stillborn infant. Which of the following interventions is appropriate?
Ask the family if there are any special rituals they would like to follow at this time.
A nurse is caring for four clients. Which of the following actions should the nurse take to prevent the spread of infection?
Place a client who has tuberculosis in a room with negative-pressure airflow.
A nurse is caring for a client who had a fasting blood sugar drawn at 0600. The client tells the nurse, "All I have had since midnight is water and some juice. Which of the following nursing actions is appropriate?
Reschedule this lab for the next morning.
A client is scheduled for surgery. The intraoperative nurse finds a necklace on the client after anesthesia has been administered. Which of the following interventions should be initiated?
Notify security for placement of necklace.
Nurse is providing discharge instructions to a client who will be using a walker. Which of the following statements by the client indicates a need for further instruction by the nurse?
"I will replace the old throw rug in the kitchen with a new one."
A nurse has an order to remove sutures from a client. After retrieving the suture remover kit and applying sterile gloves, which of the following actions should the nurse take next?
Clean sutures along with the incision site.
A nurse is planning care to promote improved self-feeding for a client who has a visual impairment. Which of the following interventions should the nurse include in the plan of care?
Use a clock pattern to describe food on the plate to the client.
A nurse is reviewing laboratory data for a client who has contusions to the chest wall following a motor vehicle crash. Which of the following values should the nurse report?
SaO2 86%
A nurse is caring for a client with a diagnosis of terminal cancer. The nurse understands that the client is ready to hear information regarding palliative care when the client states which of the following?
"I want you to tell me about measures available to keep me comfortable."
A nurse is caring for a client who is postoperative and has signs of hemorrhagic shock. When the nurse notifies the surgeon, he directs her to continue taking vital signs every 15 min and call him back in 1 hr. From a legal perspective, which of the following action should the nurse take next?
Notify the nursing manager.
A nurse is checking a client's blood pressure to check for orthostatic hypotension. Which of the following actions should the nurse take?
Obtain blood pressure 2 min after assisting the client to a sitting position.
Which of the following is the responsibility of a nurse who is caring for a client receiving PCA?
Instruct family to refrain from pushing button for the client while she is asleep.
The nurse is observing a newly licensed nurse who is preparing a sterile field for a dressing change. Which of the following actions by the newly licensed nurse should cause the nurse to intervene?
Newly licensed nurse places the cap of the sterile saline bottle on the sterile field.
A nurse is preparing to administer 750 mL of 0.9% sodium chloride IV to infuse over 7 hr. The nurse should set the infusion pump to deliver how many mL/hr? (Round to the nearest whole number.)
107 mL/hr
Formula: t otal volume/total hours = mL/hr
Solution:
Unit = mL/hr
Volume ( mL) = 750 mL
Time ( hr) = 7 hr
Convert = NO
* 750 mL/7 hr = 107.1 mL/hr = 107 mL/hr
A nurse is planning to teach a preschool child how to use a metered dose inhaler. Which of the following methods is appropriate for this child?
Use role play and imitation when explaining.
A nurse is preparing to care for a client who has methicillan-resistant Staphylococcus aureus (MRSA) in the lungs. In addition to a gown and gloves, the nurse will need which of the following equipment in order to provide care?
Face shield
A nurse is caring for a young child who is prescribed a blood transfusion. The parents have refused the treatment due to religious beliefs. Which of the following actions should the nurse take?
Examine personal values about the issue.
A nurse is caring for a client who is experiencing pain. Which of the following non-pharmacological comfort measures is the nurse using when instructing the patient to concentrate and focus on a pleasant thought to divert their focus of pain.
Guided imagery
A nurse is caring for a client who is postoperative following colostomy placement. Which of the following findings should the nurse report to the provider?
Stoma appears purple in color.