Clinical Scenarios for Nurses

A nurse is admitting a client who has schizophrenia. The client states, “I’m hearing voices.” Which of the following responses is the priority for the nurse to state? Answer: “What are the voices telling you?” A nurse is reviewing the laboratory levels of a client who is having elective surgery. Which of the following levels should the nurse report to the provider? Answer: Potassium 3.2 mEq/L 3.5 - 5.0 is normal A nurse is preparing to catheterize a toddler for a urine culture. Which of the following is an appropriate action for the nurse to take? Answer: Don sterile gloves prior to the procedure. A nurse is providing a preoperative teaching about patient-controlled analgesia (PCA) to a client. Which of the following statements should the nurse include in the teaching? Answer: “You should push the button before physical activity to allow maximum pain control.” A nurse is assessing a client who is prescribed valproic acid. Which of the following laboratory tests should the nurse monitor? Answer: Liver function test A nurse is interviewing the partner of a client who was admitted in the manic phase of bipolar disorder. The partner states, “I don’t know what to do. Everything has been happening so quickly.” Which of the following responses by the nurse is therapeutic? Answer: “Can you talk about what was happening with your partner at home?” A nurse is caring for a client who is in active labor and notes the FHR baselines has been 100/min for the past 15 min. The nurse should the identify which of the following conditions as a possible cause of fetal bradycardia? Maternal hypoglycemia A nurse is planning care for a client who is scheduled to have a paracentesis. Which of the following actions should the nurse include in the plan of care? Answer: Instruct the client to empty her bladder prior to the procedure A nurse on an antepartum unit is prioritizing care for multiple clients. Which of the following clients should the nurse see first? Answer: A client who has preeclampsia and reports a persistent headache A nurse is assessing a client who requests an oral contraceptive. Which of the following findings in the client’s medical history should the nurse identify as a contraindication for the use of a combination oral contraceptive? Answer: Migraines with aura A client’s partner tells a staff nurse that he overhears laboratory staff discussing the result of the client’s biopsy report while on the elevator. Which of the following actions should the nurse take? Answer: Report the information to the charge nurse A nurse is assessing a client's respirations which of the following actions should the nurse take? Answer: Count respirations for 1 minute if the rhythm is irregular A nurse is teaching a newly licensed nurse about therapeutic techniques to use when leading a group on a mental health unit. which of the following group facilitation techniques should the nurse include in the teaching? Answer: Use modeling to help the clients improve their interpersonal skills A nurse is observing a newly licensed nurse who is administering Total parenteral Nutrition tpn to a client. Which of the following actions by the newly licensed nurse indicates a need for the nurse to intervene? Answer: Uses the tpn IV tubing to administer the clients next dose of antibiotic A nurse is assessing a client Telemetry strip. Which of the following findings should the nurse report to the provider? answer: ST segment elevations_ Remember this could possibly lead to infarctions A nurse in a prenatal Clinic is teaching a client about nonpharmacological pain management during labor. Which of the following statements by the client indicates an understanding of the teaching? Answer: I can use my ultrasound picture as a focal point during contractions The nurse is caring for a client who has histrionic personality disorder. Which of the following findings should the nurse expect? Answer: Seductive Behavior A nurse is preparing to administer three medications to a client who is receiving continuous enteral tube feeding through an NG tube. Which of the following actions is appropriate for the nurse to take? Answer: Use a syringe to allow the medications to Flow by gravity A nurse is preparing to remove an IV catheter from the arm of a client who has phlebitis at the peripheral IV site. Which of the following actions should the nurse plan to take? Answer: Please a warm moist compress on the site A charge nurse is preparing to lead negotiations among nursing staff due to conflict about overtime requirements. Which of the following strategies should the charge nurse use to promote effective negotiation? Answer: Attempt to understand both sides of the issue Assess the situation first prior to trying to solve it. A nurse is providing teaching to family members of a client who has dementia. Which of the following instructions should the nurse include in the teaching? Answer: Establish a toileting schedule for the client A nurse is caring for four client who are scheduled for surgery the same day. Which of the following laboratory values indicates the need for intervention before surgery? Answer: Potassium 5.2 meq / L 3.5 - 5.0 = A charge nurse on a medical surgical unit is assisting with the emergency responses plan following an external disaster in the community. In anticipation of multiple client admissions, which of the following current client should the nurse recommend for early discharge? Answer: A client who is 1 day postoperative following a vertebroplasty A nurse is assessing a clients PAWP. The nurse should recognize that an elevated PAWP indicates which of the following complication? Answer: Left ventricular failure A nurse in a PACU is transferring care of a client to a nurse on the medical surgical unit. Which of the following statements should the nurse include in the hand off report? Answer: The estimated blood loss was 250 milliliters A nurse is administering an analgesic to a client who has a chest tube. The provider is preparing to discontinue the chest tube before the medication has taken effect. Which of the following actions should the nurse take first? Answer: Inform the provider of the time of the last does of pain medication A nurse is assessing a client who is at 36 weeks gestation. Which of the following findings should the nurse report to the provider? Answer: 3+ deep tendon reflexes -preeclampsia A nurse is developing an in service about personality disorders Which of the following information should the nurse include when discussing borderline personality disorder? Answer: The client exhibits impulsive behavior -spending money giving away money or possessions. A nurse is caring for a client who reports diarrhea for 3 days. The nurse should monitor the client for which of the following manifestations Answer: Orthostatic hypotension - A nurse is providing teaching about digoxin administration to the parents of a toddler who has heart failure. Which of the following statements should the nurse include in the teaching? Answer: “Have your child drink a small glass of water after swallowing the medication. A nurse is collecting a specimen for urinalysis and culture from a client who has an indwelling urinary catheter. Which of the following actions should the nurse take during collection? Answer: Clamp the catheter distal to the injection port A nurse is admitting a client who has acute heart failure. Which of the following prescriptions from the provider should the nurse anticipate? Answer: Administer enalapril 2.5 mg PO twice daily A nurse is caring for a client who asks for information regarding organ donation. Which of the following responses should the nurse make? Answer: “Your desire to be an organ donor must be documented in writing” A nurse is planning to administer ampicillin 100 mg/kg/day in divided doses every 12 hours to a newborn who weighs 4.34 kg(9.5 lbs). Available is ampicillin 125mg/ml. How many milliliters should the nurse administer per dose? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero) Answer is 1.7 mL per dose