RN Comp 2023 - (Lyme Disease )

A home health nurse is caring for a child who has lyme disease. Which of the following is an appropriate action for the nurse to take a. Ensure the state health department has been notified a. Ensure the state health department has been notified b. Administer antitoxin c. Educate the family to avoid sharing personal belongings d. Assess for skin necrosis A nurse is caring for a client who has been admitted to the hospital. (NGN) - Provide frequent rest periods - Restrict client sodium intake - Advise client to avoid using soap and alcohol based lotions - Instruct the client to avoid blowing their nose forcefully - Assess the client's IV of orientation A nurse is caring for a client who has a vented NG tube set to low intermittent suction and has vomited. Which of the following actions should the nurse perform first? b. Evaluate functioning of the suction device a. Administered an antiemetic medication b. Evaluate functioning of the suction device c. Provide oral hygiene care d. Replace the NG tube While performing a routine assessment, a nurse notices fraying on the electrical cord of a client's continuous passive motion device. Which of the following actions should the nurse take first c. Remove the device from the room a. Initiate a requisition for a replacement CPM device b. Report the defect to the equipment maintenance staff c. Remove the device from the room d. Ensure the device inspection sticker is current A nurse is setting up a sterile field to perform would irrigation for a client. Which of the following actions should the nurse take when pouring the sterile solution a. Remove the cap and place it sterile-side up on a clean surface c. Hold the bottle in the center of the sterile field when pouring the b. Pace sterile gauze over areas of spilled solution c. Hold the bottle in the center of the sterile field when pouring the solution d. Hold the irrigation solution bottle with the label facing away from the palm of the hand A nurse is creating a plan of care for a female client who has recurrent urinary tract infections. Which of the following interventions should the nurse include in the plan a. Wear loose-fitting underwear a. Wear loose-fitting underwear b. Take a bubble bath after intercourse c. Drink four 240 ml (8 oz) glasses of water each day d. Void every 5-6 hr during the day A nurse is caring for a newborn. Drag words from the choices below to fill in the blank in the following sentence. (NGN) Bronchopulmonary dysplasia and Transient tachypnea of the newborn. The client at risk for developing _____ and _____. a. Hypoglycemia b. Bronchopulmonary dysplasia 1 / 28 c. Transient tachypnea of the newborn d. Tachycardia A nurse is caring for an infant who has gastroenteritis. Which of the following assessment findings should the nurse report to the provider? b. Sunken fontanels and dry mucous membranes a. Pale and a 24-hr fluid deficit of 30 mL b. Sunken fontanels and dry mucous membranes c. Decrease appetite and irritability d. Temperature 38 C and pulse rate of 124/min A nurse is conducting health promotion education regarding contraindication to combination oral contraceptive use to a group of women. Which of the following conditions should the nurse includes in the teaching? a. Hypertension a. Hypertension b. Fibromyalgia c. Renal calculi d. Fibrocystic breast diseases A nurse is providing teaching to a client who has a depressive disorder and a new prescription for amitriptyline. Which of the following statements by the client indicates an understanding of the teaching? b. I know it will be a couple of weeks before the medication helps a. I can continue to take St. john wort while taking this medication me feel better b. I know it will be a couple of weeks before the medication helps me feel better c. I expect this medication to raise my blood pressure d. I should take this medication on an empty stomach A nurse is caring for a client who is immobile. Which of the following interventions is appropriate to prevent contracture a. Position a pillow under the client's knee b. Place a towel roll under the client's neck c. Align a trochanter wedge between the client's legs d. Apply an orthotic to the client's foot c. Align a trochanter wedge between the client's legs A nurse is assessing a client who is post-op following abdominal surgery and has an indwelling urinary catheter that is draining dark yellow urine at 25 ml/h. Which of the following should the nurse anticipate? b. Administer fluid bolus a. Initiate continuous bladder irrigation b. Administer fluid bolus c. Clamp the catheter tubing for 30 min d. Obtain a urine specimen for culture and sensitivity A nurse is reporting a client's laboratory tests to the provider to obtain a prescription for the client's daily warfarin. Which of the following should the nurse report to obtain the prescription for warfarin? c. INR a. Fibrinogen lv b. aPTT c. INR d. Platelet count A nurse is assessing a client ho is taking haloperidol and is experiencing pseudo parkinsonism. Which of the following is the signs of pseudo parkinsonism a. Serpentine limb movement b. Shuffling gait 2 / 28 b. Shuffling gait c. Nonreactive pupils d. Smacking lips A nurse care for client with expressive aphasia and right hemiparesis after a stroke. What is the best way to promotes communication among staff caring for the client? a. Posting swallow precautions at the head of client's bed d. Have interdisciplinary team meetings for the client on a regular b. Noting changes in the treatment plan in the client's medical basis record c. Recording the clients progress in the nurse's note d. Have interdisciplinary team meetings for the client on a regular basis A nurse is caring for a 2 yo toddler. Which food choice should the nurse recommended to promote independence in eating? a. Banana slices b. Grapes c. Hot dog d. Popcorn a. Banana slices A nurse on med-surge unit got notified that a mass casualty event has occurred. Which action should the nurse take? a. Act as a liaison between the facility and media b. Recommend to the provider specific acute care clients for discharge c. Determine the medical needs of incoming clients through the emergency department d. Call in additional med-surge unit nursing care staff c. Determine the medical needs of incoming clients through the emergency department A nurse has received report for 4 clients. Who should the nurse see first? a. A client who is scheduled for a procedure in 1 hr c. A client who has just given a glass of orange juice for a low blood b. A client who received a pain med 30 min ago fir post-op pain glucose lv c. A client who has just given a glass of orange juice for a low blood glucose lv d. A client who has 100 ml of fluid remain in his IV bag A nurse is performing postmortem care prior to the client's family visit. Which action should the nurse take? a. Cross patient's arms across their chest b. Hold client's eyes shut for a few seconds c. Place client in a high fowler's position d. Removed the client's dentures from their mouth b. Hold client's eyes shut for a few seconds A nurse admitting a schizophrenic client. Client state: "I'm hearing voices". Which responses is the priority for the nurse to state? a. What are the voices telling you? b. I realize the voices are real to you, but I don't hear anything c. Have you taken your med today? d. How long have you been hearing the voices? a. What are the voices telling you? A nurse is administered furosemide IV bolus to a client who has fluid volume excess. Which finding is an indication that the med has been effective? b. Weight loss a. Increase blood pressure b. Weight loss c. Decrease inflammation d. Decrease pain 3 / 28 A nurse is caring for a client who requires nasal tracheal suctioning. Identify the sequence the nurse should follow to perform suctioning. (Move the steps into the box on the right placing them in the order of performance. Use all the steps). - Apply suction while rotating the catheter - Don sterile gloves - Insert the catheter during the client inspiration - Rinse the catheter to remove secretions - Turn on the suction and set the pressure 1. Turn on the suction and set the pressure 2. Don sterile gloves 3. Insert the catheter during the client inspiration 4. Apply suction while rotating the catheter 5. Rinse the catheter to remove secretions A nurse is caring for a client who is in a coma and is scheduled for a surgical procedure. Which of the following action should the nurse take? a. Send the unsigned informed consent to the facility's risk manb. Determine if the client's health care surrogate is aware of the ager risks and benefits of the procedure b. Determine if the client's health care surrogate is aware of the risks and benefits of the procedure c. Ensure that the client's family supports the provider's decision for surgery d. Determine if the procedure is medically necessary for the client A nurse is preparing to give IV vancomycin. The client ask if the med can be give 2 hr earlier. Which statement should the nurse make? a. I can start 30 min earlier b. I can adjust the time and schedule for when it's convenient for you c. I can infuse the med at a faster rate d. I have up to 2 hr after the usual schedule time to give you this med a. I can start 30 min earlier A nurse care for a client who required seclusion to prevent harm to others on the unit. Which action should the nurse take? a. Document the client's behavior prior to being placed in seclusion a. Document the client's behavior prior to being placed in seclusion b. Assess the client's behavior once every hr c. Offer fluids every 2hr d. Discuss with the client his inappropriate behavior prior to seclusion A nurse care for an adolescent who has hyperthermia. Which action should the nurse take? a. Administered oral acetaminophen b. Cover the adolescent with a thermal blanket c. Submerge the adolescent's feet in ice water d. Initiate seizure precaution d. Initiate seizure precaution A nurse is caring for a client who asks for info about organ donation. Which responses should the nurse state? a. I cannot be a witness for your consent to donate c. Your desire to be an organ donor must be documented in writing b. You must be at least 21 yo to become an organ donor c. Your desire to be an organ donor must be documented in writing d. Your name can't be removed once you are listed on the organ donor list A parish nurse is leading a support group for clients whose family members have committed suicide. Which strategies should the 4 / 28 nurse use during the session? a. Encourage client to establish a timeline for their own grieving process b. Initiate a discussion with clients about ways to cope with changes in family dynamics c. Assist clients in identifying ways suicided could have been prevented d. Discourage clients from sharing negative aspects of their relationship with the deceased persons A nurse is developing a care plan for a client who is in buck's traction and is scheduled for surgery for a fractured femur of the right leg. Which of the following intervention should the nurse delegate to an assistive personnel? b. Initiate a discussion with clients about ways to cope with changes in family dynamics d. Remind the client to use the incentive spirometer a. Ask the client to describe her pain b. Check the client's pedal pulse on the right leg c. Observe the position of the suspended weight d. Remind the client to use the incentive spirometer A nurse is caring for a client who repeatedly refuse meals. The nurse overhears the UAP told the client: "If you don't eat, I'll put restraints on your wrists and feed you." The nurse intervene and explain the the UAP that the statement constitute which torts? b. Assault a. Battery b. Assault c. Negligence d. Malpractice - Last pregnancy resulted in a preterm spontaneous vaginal birth A nurse is caring for a client who has admitted to the antepartum at 30 weeks unit. Click to highlight the findings that require follow up. (NGN) - Client reports lover Back pain and pinkish vaginal discharge - Uterine contraction every 8 mins, palpate strong, duration 30 - 30 ys at 33 weeks gestation, Gravida 4 para 3 secs - Maternal blood type: Rh+ - Cervical exam indicates 2 cm, 50% effaced, 0 station - Last pregnancy resulted in a preterm spontaneous vaginal birth at 30 weeks - Client reports lover Back pain and pinkish vaginal discharge - Uterine contraction every 8 mins, palpate strong, duration 30 secs - FHR baseline 145, minimal variability - Cervical exam indicates 2 cm, 50% effaced, 0 station - Membranes intact A nurse is caring for a client who has admitted to the antepartum unit. Complete the sentence by using the list of choice. (NGN) Preterm labor and previous preterm birth The nurse should recognize the client is experiencing ______ due to ______ A nurse is caring for a client who has admitted to the antepartum unit. Select 2 complications client at risk for developing. (NGN) a. Disseminated intravascular coagulation b. Sepsis c. Preeclampsia d. Seizure e. Placenta previa f. Preterm prelabor rupture of membranes (PROM) b. Sepsis f. Preterm prelabor rupture of membranes (PROM) A nurse is caring for a client who has admitted to the antepartum unit. Choose anticipated or unanticipated for each potential prescription (NGN) 5 / 28 Anticpated: - Limited intake to 3000 ml/day - Administer oxytocin - Administer betamethasone - Place client in supine pos - Limited intake to 3000 ml/day - Administer oxytocin - Maintain bedrest with bathroom privileges - Administer betamethasone - Administer terbutaline Unanticipated: - Place client in supine pos - Maintain bedrest with bathroom privileges - Administer terbutaline ** The nurse continues to care for the client. Which actions should the nurse takes? (NGN) - Urine culture - Obtain provider prescription for antibiotics - Obtain prescription for phenazopyridine - Vaginal culture - Urine culture - Obtain provider prescription for antibiotics - Ibuprofen 600 mg Q6h for mild to moderate pain - Obtain prescription for phenazopyridine ** The nurse continues to care for the client. Highlight the finding indicate improvement in client's condition. (NGN) - Client rate back pain 0 - No report of vaginal discharge - No uterine contractions noted - No further report of burning with urination - WBC 12,000 (5000 - 10,000) - Platelet 188,000 (150,000 - 400,000) - Temp: 37.1 (98.7) - BP 120/78 - Client rate back pain 0 - No report of vaginal discharge - Membrane intact - No uterine contractions noted - FHR baseline 138, minimal variability - No further report of burning with urination - WBC 12,000 (5000 - 10,000) - Platelet 188,000 (150,000 - 400,000) - Temp: 37.1 (98.7) - BP 120/78 A nurse is teaching a client who has new diagnosis of DM about foot care. Which instruction should the nurse include? a. Soak feet twice daily b. Round the edge of toe nail when trim c. Use moisturizing lotion between toe d. Wear clean cotton socks ever day d. Wear clean cotton socks ever day A nurse is preparing to feed a newly admitted client who has dysphasia. Which action should the nurse take? a. Instruct client to lift her chin when swallow b. Talk with the client during her feeding c. Sit at or below the client's eye lv during feedings d. Discourage client form coughing during feedings c. Sit at or below the client's eye level during feedings A nurse is caring for a client who has acute glomerulonephritis. Which findings should the nurse expect? a. Polyuria b. Hypertension c. Weight loss d. Hematuria d. Hematuria A nurse is care for a client whose partner recently died. The nurse sits with client to provide comfort. Which following ethical principles is the nurse demonstrating? d. Beneficence a. Fidelity b. Veracity c. Autonomy d. Beneficence An ED nurse is care for a child who reports being sexually abused by a family member. Which action should the nurse take? 6 / 28 a. Use leading statements to obtain info from the child b. Ensure that multiple nurses are present for the physical examination c. Explain to the child what will happen when the abuse is reported c. Explain to the child what will happen when the abuse is reported d. Reassure the child that no one will be told about the abuse A newly licensed nurse working at an HIV clinic is reviewing the responsibilities of her position at the clinic. Which tasks should the nurse identify as tertiary prevention? a. Using an electronic messaging system to remind clients when a. Using an electronic messaging system to remind clients when to take med to take med b. Educate clients about contraindications to specific immunizations c. Help client understand health screenings covered by their insurance plans d. Provide info about the benefits if exercise A nurse is care for a client who has given informed consent for electroconvulsive therapy. Just before the treatment, the client tells the nurse she's considering not doing the treatment. Which statement should the nurse make? a. Most people who have this procedure feel better following the treatment b. Your dr wouldn't have ordered this treatment unless it was necessary c. It's ok to be nervous before the treatment d. You don't have to go through with the treatment d. You don't have to go through with the treatment A nurse is teaching a new parent about breastfeeding her 2 week old infant. Which statements by the parent indicates understanding of the teaching? a. After 5-10 min when the breast is empty, my baby should be d. The more my baby is at the breast sucking, the more milk I will removed from the breast produce. b. Manually expressing my milk will decrease my milk supply c. My baby should always start on the same breast when feeding d. The more my baby is at the breast sucking, the more milk I will produce. A nurse is preparing to reposition a client who has a stroke. Which action should the nurse take? a. Evaluate the client's ability to help with repositioning b. Reposition client without the use of assistive device c. Raise the side rails on both sides of the client's bed during reposition d. Discuss the client's preferences for determining a reposition schedule a. Evaluate the client's ability to help with repositioning A nurse is providing discharge teaching to a client who is post-op following the repair of a detached retina. Which statements by the client indicate understanding of the teaching? c. I can lift objects that are less than 10 lbs a. I can go jogging after 2 weeks b. I should bend at the waist when putting on my shoes c. I can lift objects that are less than 10 lbs d. I can resume activities, such as sewing A nurse is giving discharge teaching about home care of a surgical incision to a client who speaks a different language. The nurse communicating using an interpreter. Which action should the nurse take? c. Speak directly to the client a. Speak slowly when talking to the interpreter 7 / 28 b. Pause in the middle of sentence c. Speak directly to the client d. Use gestures to convey meaning A nurse is teaching a client who has new prescription for enoxaparin. Which pain med should the nurse include that can be taken concurrently with enoxaparin? c. Acetaminophen a. Ibuprofen b. Naproxen sodium c. Acetaminophen d. Aspirin A nurse is receiving report for a group of clients. Which clients should the nurse assess first? a. A client who has epidural analgesia and weakness in the lower extremities b. A client who has a hip fracture and a new onset of tachypnea b. A client who has a hip fracture and a new onset of tachypnea c. A client who has sinus arrhythmia and is receiving cardiac monitoring d. A client who has DM and an HbA1c of 6.8% A nurse is assessing skin of a client who has dark skin. Which locations should the nurse observe to assess for cyanosis? a. Sacrum b. Palms of the hands c. Shoulders d. Area of trauma b. Palms of the hands A charge nurse is teaching new staff about factors that increase a client's risk to become violent. Which factors should the nurse include as the best predictor future violence? d. Previous violent behavior a. A history of being in prison b. Male gender c. Experiencing delusions d. Previous violent behavior A nurse is assessing a client who is in active labor. which findings should the nurse report to provider? a. Temp 37.4 (99.3) b. Early decelerations in FHR c. FHR baseline 170/min d. Contractions last 80 secs c. FHR baseline 170/min A quality control control nurse is reviewing med prescription for a group of clients. Which prescription is correct? a. Tetracycline 200 mg PO b. Epoetin alfa 150 units/kg three times weekly c. Digoxin 0.25 mg PO daily d. Cimetidine PO twice daily c. Digoxin 0.25 mg PO daily A nurse if care for a client in an ED. (Bowtie NGN) Action to take: - Teach client to use self talk - Ask: "What kind of drug have you been taking?" - Reduce external stimuli - Ask: "Have you been sick recently?" - Engage with client several times each day to establish trust - Complication experiencing: Brief psychotics disorder - Action to take: Reduce external stimuli, engage with client several Complication most likely experiencing - Brief psychotics disorder 8 / 28 - Delirium - Anxiety - Substance use disorder Parameters to monitor - Ability to care for self - Fearfulness - Suicide risk - Temperature -? times each day - Monitor: ability to care for self, suicide risk A nurse is providing in-service about client evacuation during a fire. Which of the following clients should be evacuate first? a. A client who is ambulating and receiving O2 b. A client who has a fracture and is balance suspension traction c. A client who is bedridden and wears hearing aid d. A client who uses a wheelchair and is confuse A nurse is planning care for an older adult client who has dementia. Which interventions should the nurse include? (SATA) a. Give one simple direction at a time b. Refute client's delusions using logic c. Allow client to choose among a variety of activities each day d. Reinforce orientation to time, place, person e. Establish eye contact when communicating with the client A nurse is providing discharge teaching to the partner of a client who has a tracheostomy. Which of the following information should the nurse include in the teaching? a. A client who is ambulating and receiving O2 a. Give one simple direction at a time d. Reinforce orientation to time, place, person e. Establish eye contact when communicating with the client a. How to operate portable suction machine a. How to operate portable suction machine b. How to secure trache tube with ties at the back of the neck c. How to change the nondisposable trache tube daily d. How to change trache dressing using clean technique A nurse care for a client who report xerostomia after radiation therapy to the mandible. Which actions should the nurse take? a. Suggest rinsing his mouth with an alcohol-based mouth wash b. Provide humidification of the room air c. Offer the client saltine cracker between meal d. Instruct client on the use of esophageal speech b. Provide humidification of the room air A public heath nurse work in a rural area is developing a program to improve health for local population. Which action should the nurse take? a. Launch a media campaign to increase awareness about industrial pollution d. Provide anticipatory guidance classes to parents through public b. Have a nurse from outside the community provide health lec- school tures at the county hospital c. Encourage rural residents to focus health spending on tertiary heath intervention d. Provide anticipatory guidance classes to parents through public school A nurse is assessing a child who has bacteria pneumonia. Which of the following manifestation should the nurse expect? a. Drooling b. Malaise c. Tinnitus d. Rhinorrhea b. Malaise 9 / 28 ** A nurse from an emergency department is caring for a client. Highlight findings that requires follow-up. (NGN) Client presents for evaluation of severe pain in upper abdomen that radiates into his back. States pain began approximately 12 hr ago and is worse when he is supine or after he eat. Rates pain a 7. Sclera noted to be yellow. HR regular, lungs clear. Abdomen firm, bowel sounds hypoactive. Client guards abdomen and grimaces during palpation. Report last bowel movement was yesterday. Denies recent illnesses. Takes no prescribed meds. Client alert and oriented x4 - Client presents for evaluation of severe pain in upper abdomen that radiates into his back - States pain began approximately 12 hr ago and is worse when he is supine or after he eat - Sclera noted to be yellow - Abdomen firm, bowel sounds hypoactive - Client guards abdomen and grimaces during palpation A nurse from an emergency department is caring for a client. Specify if the finding is consistent with pancreatitis or peritonitis. (NGN) Bloody stools Hyperbilirubinemia Abdominal pain Elevated WBC Pancreatitis: - Hyperbilirubinemia - Abdominal pain - Elevated WBC count Peritonitis: - Bloody stool - Abdominal pain - Elevated WBC count A nurse from an emergency department is caring for a client. Complete the following sentence (NGN) The nurse should first address the client's _____ - Lung sound - Pain lv - Bowel sound followed by client's _____ - Blood sugar - BP - Temp Lung sound and temp ** A nurse from an emergency department is caring for a client. Specific if the prescription is anticipated or contraindicated. (NGN) - Administer famotidine 20 mg via intermittent IV BID - Insert an indwelling catheter - Administer Lactated Ringer's 1 l via IV bolus - Insert a NG tube and maintain low intermittent suction - Administer famotidine 20 mg via intermittent IV BID: An - Insert an indwelling catheter: Co - Administer Lactated Ringer's 1 l via IV bolus: An - Insert a NG tube and maintain low intermittent suction: An A nurse from an emergency department is caring for a client. Select 3 statements the nurse should include in the teaching about self-care. (NGN) a. Notify your provider if you experience vomiting or diarrhea c. You should eat foods that are low in fat e. You should eat foods high in protein a. Notify your provider if you experience vomiting or diarrhea b. Limit alcohol intake to no more than 1 drink per day c. You should eat foods that are low in fat d. You can drink beverages that contain caffeine e. You should eat foods high in protein A nurse from an emergency department is caring for a client. Which statements by the client indicate understanding of discharge teaching? (SATA) a. I will eat small, frequent meal b. I should expect my bowel movements to be pale in color d. I will notify my provider if my urine is dark a. I will eat small, frequent meal b. I should expect my bowel movements to be pale in color c. I will limit my morning coffee to no more than 2 cups d. I will notify my provider if my urine is dark e. I will eat fish for diner at least twice per week A nurse is planning care for a client who is scheduled for a thoracentesis. Which if the following actions should the nurse plan to take. 10 / 28 a. Position the client on the affected side for 4hr following procedure b. Instruct client to avoid coughing during the procedure c. Inform client that he will be NPO for 6hr prior to the procedure d. Place client in the prone position during procedure b. Instruct client to avoid coughing during the procedure A nurse is assessing a 2 year old toddler which of the following findings should the nurse expect? d. Nontender, protruding abdomen a. Head circumference exceeds chest circumference b. Palpable fontanels c. Natural loss of deciduous teeth d. Nontender, protruding abdomen A nurse manager is updating protocols for the use of belt restrain. Which guidelines should the nurse manager include? a. Remove client's restrain q4h b. Document client's condition every 15 min c. Request a PRN restraint prescription for clients who are aggressive d. Attach the restraint to the bed's side rails b. Document client's condition every 15 min A nurse in a PACU is transferring care of a client to a nurse on med-surg unit. Which statement should the nurse include in the report? a. The estimated blood loss was 250 ml a. The estimated blood loss was 250 ml b. Client is a member of the board of directors c. There was a total of 10 sponges used during the procedure d. Client was intubated without complications A nurse in ED care for a client who has a closed head injury. Which action should the nurse take first? a. Determine client's Glasgow coma scale b. Insert an indwelling catheter for client c. Administer mannitol IV bolus to client d. Prepare client for a brain MRI a. Determine client's Glasgow coma scale A nurse in ED care for a client following a motor-vehicle crash. Client's Glasgow scale rating is 15. Which finding should the nurse expect? a. Client oriented x3 a. Client oriented x3 b. Client open eyes to sound c. Client is unable to obey commands d. Client withdraws from pain A nurse is reviewing a client's cardiac rhythm strips and notes a constant P-R interval of 0.35 s. Which dysrhythmias is client displaying? a. 1st degree atrioventricular block a. 1st degree atrioventricular block b. Complete heart block c. Premature atrial complexses d. A-fib The nurse is caring for a client who at end-stage kidney disease. The client's adult child asks about becoming a living kidney donor for their parent. Which conditions in the child's medical history is contraindicated with the procedure? a. Amputation b. Osteoarthritis 11 / 28 c. Hypertension c. Hypertension d. Primary glaucoma Ulcerative Colitis: - Fever - Weight Loss - Diarrhea A nurse is caring for a client. Specify if the finding is consistent with ulcerative colitis, diverticular, or crohn's disease (NGN). Diverticulitis: - Fever - Anemia - Diarrhea Fever Steatorrhea Anemia Weight loss Diarrhea Crohn's Disease (ALL): - Steatorrhea - Weight loss - Anemia - Fever - Diarrhea A case manager is meeting with a client who asks about using alternative therapies to manage her rheumatoid arthritis. Which statements should the nurse make? a. We can review some info to help you select a safe alternative practitioner a. We can review some info to help you select a safe alternative b. If there are therapies available to you, your provider will tell you practitioner about them. c. Feel free to try whatever therapies that fit within your personal belief system d. I'm sure you can find alternative remedies through an online support group. A nurse is prepare to obtain a heath history from a client on bedrest. Which positions should the nurse take to place the client at ease? a. Sit in a chair next to the bed a. Sit in a chair next to the bed b. Stand at the side of the bed c. Sit on the bed next to the client d. Stand at the foot of the bed A nurse is care for a newborn whose mother was talking methadone during pregnancy. Which findings indicate the newborn is experiencing withdrawal? d. Hypertonicity a. Bulging fontanels b. Acrocyanosis c. Bradycardia d. Hypertonicity A nurse is care for a client who is receiving TPN. The bag has 20 mL remaining to infuse, but a new bag is not readily available. Which actions should the nurse take? a. Administer dextrose 10% in water a. Administer dextrose 10% in water b. Give 500 mL lactated Ringer's c. Slow TPN infusion rate d. Temporarily discontinue the infusion C: below left chest A nurse is auscultating for crackles on a pneumonia client. Which area of the anterior chest wall should the nurse auscultate? 12 / 28 A nurse is providing teaching about immunizations to a client who is pregnant. Which statements should the nurse include in the teaching? a. The immunization for varicella should be given at least 1 month prior to delivery b. You can receive rubella immunization during third trimester c. Hep B immunization should not be obtained until after you finish breast feeding d. You can received the immunization for influenza at any time during pregnancy d. You can received the immunization for influenza at any time during pregnancy A nurse is planning teaching for a client and their family about home oxygen therapy. Which info should the nurse plan to teach? a. Apply petroleum jelly to soothe the mucous membranes b. Use synthetic fabrics for the client's bedding c. Clean the equipment with an alcohol-based cleaning product d. Avoid using nail polish remover around the client d. Avoid using nail polish remover around the client A nurse is instructing a school-age child who has asthma about peak expiratory flow meter. Which instructions should the nurse include in the teaching? d. Blow into the meter as hard and quickly as possible a. Place tongue on the mouthpiece of the meter b. Maintain a semi-fowler's position during testing c. Record the average of the readings d. Blow into the meter as hard and quickly as possible A nurse is caring for a client who is 12 hr postpartum and has 3rd degree perineal laceration. Client report not having a bowel movement for 4 days. Which med should the nurse give? a. Bisacodyl 10 mg rectal suppository b. Magnesium hydroxide 30 mL PO c. Famotidine 20 mg PO d. Loperamide 4 mg PO b. Magnesium hydroxide 30 mL PO A nurse is provide discharge teaching to the parents of a toddler who has cystic fibrosis. Which instructions should the nurse include? a. Perform chest percussion and postural drainage at least twice a. Perform chest percussion and postural drainage at least twice daily daily b. Restrict intake of foods that contain gluten c. Administer pancreatic enzymes on an empty stomach d. Use a nebulizer to administer a bronchodilator following airway clearance therapy. A nurse is planning care for a client who has a prescription for bowel-training program after a spinal cord injury. Which actions should the nurse include on the care plan? c. Administer a suppository 30 min prior to scheduled defecation a. Increase the amount of refined grains in client's diet times b. Provide client with a cold drink prior to defecation c. Administer a suppository 30 min prior to scheduled defecation times d. Encourage a maximum fluid intake of 1500 mL/day ** A nurse is caring for a client who has an implanted venous access port. Which of the following should the nurse use to access the port? d. A non coring needle a. An angiocatheter b. A 25-gauge needle c. A butterfly needle d. A noncoring needle 13 / 28 A nurse is assessing a client immediately after a cardiac catheterization. The nurse should notify provider for which findings? a. Report of discomfort at the insertion rate b. HR 90/min c. Bounding pulse in the affect extremity d. Hematuria over the insertion site d. Hematoma over the insertion site A nurse is assessing a client who has preeclampsia and is receiving magnesium sulfate visa continuous IV. Which therapeutic effects should the nurse monitor? c. Urine output 20 mL/hr a. Deep tendon reflexes +2 b. Pulse 100/min c. Urine output 20 mL/hr d. 1+ proteinuria via urine dipstick A nurse is teaching a newly licensed nurse about care for clients in ED. Which actions should the nurse include when teaching about interacting with a client who is aggravated, pacing, and speaking loudly? b. Tell the client "you seem to be very upset" a. Use a face shield with a mask when providing care b. Tell the client, "you seem to be very upset" c. Engage the panic alarm d. Initiate seclusion protocol A nurse care for a client who is admitted to the med-surge unit. Select 5 findings that required immediate follow up. (NGN) a. Stool result b. H&H c. RR d. HR e. Current medication f. Temp g. WBC h. BP a. Stool result b. H&H d. HR e. Current medication h. BP A nurse care for a client who is admitted to the med-surge unit. Complete the sentence (NGN) The nurse anticipates client will likely requires _____ - an endoscopy - an antifungal prescription - O2 via nonbreather mask as evidenced by client's _____ - temp - stool result - RR an endoscopyAEB client's stool result A nurse care for a client who is admitted to the med-surge unit. Complete the sentence (NGN) The nurse should first anticipate to _____ (- place client in a supine pos with elevated feet - obtain IV access - recheck client's O2 - call the surgical) suite to notify that the client is arriving STAT then _____ (- prepare to give IV fluid - check an ABG - check an ECG - transport client for endoscopy) obtain IV access FIRST, THEN - prepare to give IV fluid 14 / 28 The nurse reviews the entries in the medical record. The nurse preparing client for a blood transfusion. Which action should the nurse take? (SATA) a. Have a 2nd nurse confirm the info on the blood lable b. Insert a large bore IV catheter c. Witness client sign an informed consent a. Have a 2nd nurse confirm the info on the blood lable b. Insert a large bore IV catheter c. Witness client sign an informed consent d. Flush the transfusion tubing with dextrose 5% in water e. Explain to the client that transfusion reactions are not serious The nurse reviews the entries in the medical record. The nurse is INDICATED: ready for blood transfusion. Specify if the action is indicated or not - Document the blood product transfusion in the client's medical indicated (NGN) record - Stay with the client for the first 15 min of transfusion - Document the blood product transfusion in the client's medical - Obtain the first unit of packed RBCs from the blood bank record. - Stay with the client for the first 15 min of transfusion NOT INDICATED: - Titrate the rate of infusion to maintain client's blood pressure at - Titrate the rate of infusion to maintain client's blood pressure at least 90/60 least 90/60 - Obtain the first unit of packed RBCs from the blood bank - Start an IV bolus of lactacted ringer's solution - Start an IV bolus of lactacted ringer's solution The nurse assessing client after the transfusion of 2 units of packed RBCs. Highlight the finding indicate improvement in client's condition. (NGN) - WBC 6000 - Hemo 12 - Hema 36% - BP 112/74 - HR 95 - RR 18 - Temp 37.5 (99.5) - O2 100 at 2 L nasal canula - General: no distress - HEENT: oropharynx clear, mucous membranes moist and pink - Resp: bilateral breath sound clear - GI: Epigastric tenderness to palpation, no rebound tenderness or guarding - Neuro: awake and alert - Hemoglobin 12 - Hematocrit 36% - BP 112/74 - HR 95 - General: no distress - HEENT: oropharynx clear, mucous membranes moist and pink A nurse cares for a client who has placenta previa. Which findings should the nurse expect? a. Spotting b. Nausea c. Polyhydramnios d. Uterine tenderness a. Spotting A nurse in a mental health clinic received a request from client to obtain a copy of the therapist's note. Which responses should the nurse make? a. Are you not happy with the treatment? b. We can provide a copy of your records, but the therapist's note b. We can provide a copy of your records, but the therapist's note are not included are not included c. Why are you interested in seeing your therapist's note d. I don't think you will benefit from reviving your therapist's notes right now A nurse is preparing to give med that is available in a glass ampule. Which action should the nurse plan to take? a. The nurse should use a filter needle to withdraw the med a. The nurse should use a filter needle to withdraw the med b. The nurse should break the neck of the ampule toward their body 15 / 28 c. The nurse should use the same needle to draw up and inject the client d. The nurse should dispose of the ampule in the trash can A nurse in a provider's office is caring for a client who asks about using acupuncture to manage his osteoarthritis pain. The nurse should identity which conditions is contraindicated for receiving the treatment? d. Herpes zoster a. Hypertension b. Obesity c. Hypothyroidism d. Herpes zoster A nurse is admitting a client who is hesitate to create advance directives due to concerns about affording legal representation. Which of the following statements should the nurse make? a. We can initiate medical care until you get legal assistance preparing your advance directives b. Advance directive can be signed without legal representative b. Advance directive can be signed without legal representative c. Advance directives can be a verbal agreement between you and your provider until legal review can be obtained d. A social worker will assist you to find affordable legal representation A nurse is preparing to insert an IV for a client. Which actions should the nurse plan to take? a. Choose a vein that is palpable and straight b. Elevate client's arm prior to insertion c. Apply a tourniquet below the venipuncture site d. Select a site on client's dominant arm a. Choose a vein that is palpable and straight A nurse in an emergency department is assessing an adolescent who has conduct disorder. Which of the following questions is the priority for the nurse to ask client? d. Do you have thoughts of harming yourself? a. How do you manage your behavior? b. Do you have a criminal record? c. How do you get along with your peers at school? d. Do you have thoughts of harming yourself? A nurse is caring for a school-age child who is post-op and received morphine via IV bolus for pain 10 min ago. Which findings is the nurse's priority? c. Bradypnea a. Constipation b. Sedation c. Bradypnea d. Euphoria A nurse planning to teach a client about prednisone. Which instructions should the nurse include? a. Monitor for weight loss b. Increase dietary calcium c. Take on an empty stomach d. Schedule dosage at bedtime b. Increase dietary calcium A nurse is caring for a client who is receiving penicillin G via intermittent IV piggyback. Which actions should the nurse take? a. Infuse the med over 10 min b. Instruct client to notify provider if diarrhea develops c. Refrigerate the med after reconstitution d. Check the client for a sulfate allergy b. Instruct client to notify provider if diarrhea develops 16 / 28 A nurse is planning care for a school age child who is 4hr post-op after appendicitis. Which action should the nurse include in the care plan? b. Administer analgesics on a scheduled basis for the first 24 hr a. Give cromolyn nebulizer q8h b. Administer analgesics on a scheduled basis for the first 24 hr c. Apply a warm compress to the operative site once daily d. Offer small amounts of clear liquids 6h after surgery A nurse in an acute care mental heath facility is participating in a medication education group. The leader of the group uses a laissez-faire leadership style. Which actions should the nurse expect from the leader during session? a. The leader allows the group to discuss whatever they would like a. The leader allows the group to discuss whatever they would like to regarding their meds to regarding their meds b. The leader encourages groups members to remain silent until questions are called for c. The leader has group members vote on what they would like to learn about during the session d. The leader lectures about med adverse effects to the group members A nurse is prepare to assess FHR for a client who is at 12 weeks. Which of the following actions should the nurse take? a. Place client in a side-lying pos prior to assessing the FHR c. Position the ultrasound stethoscope above the symphysis pubis b. Measure the fundal height to determine the placement of the to assess the FHR ultrasound stethoscope c. Position the ultrasound stethoscope above the symphysis pubis to assess the FHR d. Perform Leopold maneuvers prior to auscultating the FHR A nurse is teaching a client who has A-fib and is starting dabigatran. Which statements by the client indicates understanding of teaching? a. I should keep the med in the original container a. I should keep the med in the original container b. I should replace any unused med every 6 months c. I can store the med in the fridge d. I can crush the med and mix with applesauce A charge nurse is observing a conflict between two nurses who both insist that the charge nurse favors the other when making assignments. Which conflict-resolution strategies should the charge nurse use? a. Encourage collaboration between 2 nurses when making asa. Encourage collab between 2 nurses when making assignment signment b. Ask each nurse to take turns making assignments c. Tell the nurses that the assignments will be more equitable in the future d. Arrange for the nurses to have as few shifts together as possible A nurse is caring for a client who has end-stage liver diseases and is undergoing a paracentesis. Which of the following actions should the nurse take to evaluate effectiveness of the procedure? a. Examine for leakage at the site of the procedure b. Compare the client's current weight with preprocedural weight c. Confirm that client is able to urinate d. Check client's serum albumin lv b. Compare the client's current weight with pre procedural weight A nurse is reviewing the lab data of a client who received 2 units of packed RBCs. Which lab findings should the nurse expect after the transfusion? 17 / 28 b. Increased Hematocrit a. Increased platelets b. Increases Hct c. Decreased Hgb d. Decreased WBC A nurse is reviewing the medical records of four clients. The nurse should identify which of the following client's findings requires follow-up? a. A client who is taking bumetanide and has potassium levels of 3.6 b. A client who is scheduled for a colonoscopy and is taking sodium phosphate c. A client who us taking warfarin and has an INR of 1.8 d. A client who received a Mantoux test 48 hr ago and has an induration c. A client who us taking warfarin and has an INR of 1.8 A nurse is caring for a client who has a prescription for a peripheral IV catheter. After puncturing the skin with the vascular access device and noting a blood return in the flashback chamber, which actions should the nurse perform next? c. Advance the catheter into the vein a. Flush the catheter with saline b. Retract the stylet c. Advance the catheter into the vein d. Release the tourniquet A nurse is providing preoperative teaching to a client about promoting circulation during the post-op period. Which instructions should the nurse include? b. Participate in ROM exercises a. Remain on bed rest for 24 hr after the procedure b. Participate in ROM exercises c. Use an inventive spirometer q4h d. Place a pillow under your knee while in bed A nurse is teaching a client who has chronic pain about avoiding constipation from opioids. Which infos should the nurse include in the teaching? d. Increase exercise activity a. Take mineral oil at bedtime b. Decrease insoluble fiber intake c. Drink 1.5 L of fluid each day d. Increase exercise activity A nurse is teaching a client who has rheumatoid arthritis about illness management. Which instructions should the nurse include? a. Apply cold packs directly in the skin of the affected area b. Administer biological response modifiers to prevent infection c. Take a hot shower in the morning to decrease stiffness d. Cluster physical activities during the day c. Take a hot shower in the morning to decrease stiffness A nurse is preparing in-service for a group of nurses about malpractice in nursing. Which example should the nurse include as malpractice? a. Documenting communication with a provider in the progress notes of client's medical record b. Place a yellow bracelet on a client who is at risk for falls c. Leaving a NG tube clamped after administering oral medication d. Administering potassium via IV bolus A nurse is providing teaching about the use of crutches using a three-point gait to a client who has tibial fracture. Which actions by the client indicate understanding of teaching? 18 / 28 d. Administering K via IV bolus a. Stepping with his affected leg first when going up stairs b. Moving both crutches with the stronger leg forward first c. Supporting his body weight while leaning on the axillary crutch pads d. Positioning both hands on the grips with his elbows slightly flexed d. Positioning both hands on the grips with his elbows slightly flexed A nurse in an ED is caring for a client. Highlight findings that the nurse should report to the provider. (NGN) - Temp 26.7 (98) - HR 96 - BP 142/96 - RR 16 - O2 97 - Client is an 82 ys male who presents with his adult child for eval of right arm pain after a fall. Client noted to have several superficial abrasions on right forearm and elbow. Also has numerous bruises in various stages of healing on arms and upper chest. Client rates pain in right lower forearm an 8/10 an is not moving the arm. - BP 142/96 - Client noted to have several superficial abrasions on right forearm and elbow. Also has numerous bruises in various stages of healing on arms and upper chest. - Client rates pain in right lower forearm an 8/10 an is not moving the arm. A nurse in an ED is caring for a client. Specify if the findings is an indication of physical maltreatment, neglect, or financial maltreatment. Each finding may support more than one type of abuse (NGN). PHYSICAL MALTREATMENT: - Client has bruises in various stages of healing NEGLECT: - Client reports having little food in the house - Client wears dirty clothing - Client report having little food in the house - Client has bruises in various stages of healing - Client wears dirty clothing - Client has no access to bank account FINANCIAL MALTREATMENT: - Client has no access to bank account A nurse in an ED is caring for a client. Complete the sentence. (NGN) The nurse should first address the client _____ - safety - abrasion - hygiene Safety; pain followed by _____ - HR - Pain - BMI A nurse in an ED is caring for a client. Select 5 findings the nurse should report to the social worker. (NGN) - Client report lack of food in the house - Numerous bruises on various stages of healing - Client's avoidance of eye contact - Client's report lack of access to bank accounts - Client's report of weight los - Client report lack of food in the house - ECG result - Numerous bruises on various stages of healing - Client's avoidance of eye contact - Client's report lack of access to bank accounts - Client's report of weight loss A nurse in an ED is caring for a client. Highlight findings that require immediate follow-up (NGN) Resp - RR 11 - O2 94 room air - Lungs clear to auscultation Musculo - Report pain worsening in right forearm - States right hand is tingly - Able to move fingers - RR 11 - O2 94 room air - Report pain worsening in right forearm - States right hand is tingly 19 / 28 A nurse in an ED is caring for a client. A nurse in an outpatient ortho clinic is caring for client 6 weeks after surgical repair of a fracture radius. Which finding indicate improvement? (SATA) b. Client make eye contact and smile when speaking c. Client's adult child prepares 2 meals /day for client d. Client clothing is clean and appropriate for weather e. Client has gained 1.8 kg. BMI 18.9 f. Client receives three baths per week from a home care aide a. Client reports frequent toothaches and lack of dental care b. Client make eye contact and smile when speaking c. Client's adult child prepares 2 meals /day for client d. Client clothing is clean and appropriate for weather e. Client has gained 1.8 kg. BMI 18.9 f. Client receives three baths per week from a home care aide A nurse is teaching a prenatal class about infection prevention. Which statements by a client indicates understanding of teaching? a. I should take antibiotics when I have a virus b. I can visit my nephew who has chickenpox 5 days after the sores b. I can visit my nephew who has chickenpox 5 days after the sire have crusted have crusted c. I can clean my cat's little box during my pregnancy d. I should wash my hands for 10 secs with hot water after working in the garden A nurse cares for a client who has experienced a stroke and is moving in with their adult child. Which actions should the nurse encourage client and family to take as they adjust to their new roles a. Implement firm but flexible boundaries in their relationship b. Encourage authoritative communication from the adult child c. Decrease socialization with extended relatives until roles are identified d. Minimize open discussion regarding the changes to avoid embarrassment a. Implement firm but flexible boundaries in their relationship Nurse is assessing client who has an abdominal incision. Which findings should the nurse report to the provider? a. Pink-tinged coloration on the incisional line b. Mild swelling under the sutures near incisional line c. Crusting of exudate on the incisional line d. Partial separation of upper part of the incisional line d. Partial separation of upper part of the incisional line A nurse cares for a client who has generalized petechiae and ecchymoses. The nurse should expect a prescription for which lab tests? a. Platelet count a. Platelet count b. K lv c. Creatinine clearance d. Prealbumin A nurse provides teaching for a hypertensive client. Which food should the nurse suggest to include in client's diet? a. Cheese b. Red meat c. Canned black beans d. Fish d. Fish A nurse in ED receives the medical record if a client who is having an acute MI. Which findings places client at risk if he receives alteplase? b. Hip arthroplasty 1 week ago a. Family history of malignant hypertension b. Hip arthroplasty 1 week ago c. COPD d. Acute renal failure 6 months ago 20 / 28 A nurse cares for a school age child who is 2 hr post-op after a cardiac catheterization. The nurse observes blood on child's dressing. Which actions should the nurse take? a. Apply intermittent pressure 2.5 cm (1 in) below the percutaneous skin site b. Apply continuous pressure 2.5 cm (1 in) above the percutaneous skin site c. Apply continuous pressure 2.5 cm (1 in) below the percutaneous skin site d. Apply intermittent pressure 2.5 cm (1 in) above the percutaneous skin site b. Apply continuous pressure 2.5 cm (1 in) above the percutaneous skin site A nurse is planning care for a client who has a prescription for continuous enteral feedings through an NG tube. Which actions should the nurse plan to take? a. Flush the NG tube with 30 mL 0.9% sodium chloride before and a. Flush the NG tube with 30 mL 0.9% sodium chloride before and after medication after medication b. Maintain the head of the bed at 20' angle c. Advance the rate of feeding q2h d. Measure gastric residual volumes q4h A charge nurse is concerned about a recent increase in facility-acquired catheter infections. Which actions should the nurse take first? a. Meet with providers to discuss measures to decrease the infections b. Identify possible precipitating factors related to infections c. Schedule nursing staff training for infection control procedures d. Revise the current policy for catheter care b. Identify possible precipitating factors related to infections A nurse in an outpatient clinic is caring for a client. (Bowtie NGN) Action to take - Instruct client to avoid live vaccines - Instruct client to use mild soap for cleansing skin - Instruct client to avoid foods high in purines - Instruct client to apply topical analgesics - Instruct client to apply heat and cold Condition - SLE - OA - Gout - RA - Condition: OA - Action: apply topical analgesics, apply heat and cold - Monitor: ESR, lymphadenophathy Parameter to monitor - Uric acid lv - ESR - Joint deformity - Lymphadenopathy - ANA A charge nurse is delegating care for a group of clients. Which tasks should the charge nurse assign to a LPN? a. Complete discharge teaching for a client who has a new diagnosis of DM c. Perform a sterile dressing for a client who has an abdominal b. Complete Glasgow scale for a client who has an evolving stroke wound c. Perform a sterile dressing for a client who has an abdominal wound d. Perform an admission assessment for a client who is scheduled for surgery 21 / 28 A nurse cares for a 2 months old infant who has heart failure. Which action should the nurse take? a. Limit oral feeding to 30 min in length b. Check infant's O2 q6h c. Place infant in the prone pos for naps d. Weight infant every day a. Limit oral feeding to 30 min in length A nurse is admitting a client to a med-surge unit. When performing medication reconciliation for client, which actions should the nurse take? a. Encourage client to make his own list after he returns to his d. Compare new prescriptions with the list of med the client report home b. Include any adverse effects of the med client might develop c. Exclude nutritional supplements from the list of med the client reports d. Compare new prescriptions with the list of med the client report A staff nurse observes a newly licensed nurse suction a client's trache. Which action by the new nurse requires intervention? a. Waits for 2 min between suctions b. Encourages client to cough during suctioning c. Applies suction for 15 sec d. Inserts the catheter without applying suction a. Waits for 2 min between suctions A nurse is preparing to admit a 6 year old with varicella to the peds unit. Which action should the nurse take? a. Assign the child to a negative pressure room b. Use droplet precautions when care for the child c. Assess the child for Koplik spots d. Administer aspirin to the child for fever a. Assign the child to a negative pressure room ** A charge nurse on a med-surg unit is assisting with the emergency response plan after an external disaster in the community. In anticipation of multiple client admissions, which current clients should the nurse recommend early discharge. d. Client who is 1 day post-op after a vertebroplasty a. Client who is receiving heparin for deep vein thrombosis b. Client who has COPD and a RR 44/min c. Client who has cancer and sealed implant for radiation therapy d. Client who is 1 day post-op after a vertebroplasty A nurse provides teaching to a client who is at 14 weeks of gestation about findings to report to provider. Which findings should the nurse include in the teaching? a. Swelling of the face a. Swelling of the face b. Bleeding gums c. Urinary frequency d. Faintness upon rising A nurse cares fir a client who is in active labor and notes the FHR baseline has been 100/min for the past 15 min. The nurse identify which conditions as a passible cause of fetal bradycardia? d. Maternal hypoglycemia a. Chorioamnionitis b. Maternal fever c. Fetal anemia d. Maternal hypoglycemia A nurse assists with food selection for a client who follows kosher dietary traditions. Which food choices should the nurse include in the client's food tray? 22 / 28 a. Bacons and cheese quiche with milk b. Scrambled eggs and toast with milk c. Shrimp salad and tomato soup with milk d. Ham sandwich with milk b. Scrambled eggs and toast with milk A nurse provide discharge teaching to a client who is post-op for carpal tunnel syndrome. Which statements by the client indicate understanding of teaching? b. I will need to keep my hand elevated above my heart for several a. I should not use my affected hand for 4-6 weeks days b. I will need to keep my hand elevated above my heart for several days c. I should expect numbness and tingling in my hand d. I can apply heat for the first 24 hr to minimized pain in my hand A nurse is planning care for a toddler who has epiglottitis. Which interventions should the nurse include? a. Assess the child for frequent swallowing b. Carefully suction the child's oropharynx to remove secretions c. Administer pancreatic enzymes with meals d. Continuously monitor the child's respiratory status a. Assess the child for frequent swallowing A nurse assesses a client who is experiencing hypovolemia. Which manifestation should the nurse expect? a. Shortness if breath b. Dizziness c. Epistaxis d. Headache b. Dizziness A nurse care for a client who has an indwelling catheter. The nurse notes that sediments is present un the urine. Which actions should the nurse take to obtain a sterile urine specimen? b. Obtain the specimen from the retention port a. Disconnect the catheter from collection tubing b. Obtain the specimen from the retention port c. Use the balloon port to obtain sterile specimen d. Unclamp the collection port below the bag A nurse is positioning a client for a C-section. To prevent a compromise in placental blood flow during the intraoperative period, which actions should the nurse take? b. Place a wedge under one of the client's hips a. Position the client in reverse Trendelenburg b. Place a wedge under one of the client's hips c. Assist client into the lithotomy position d. Insert a pillow under client's knees A nurse cares for an infant who has coarctation of the aorta. Which findings should the nurse expect? a. Weak femoral pulses b. Frequent nosebleed c. Upper extremity hypotension d. Increased intracranial pressure a. Weak femoral pulses A nurse cares for a client who is 33 weeks after an amniocentesis. The nurse should monitor client for which complications? a. Contractions b. Hypertension c. Epigastric pain d. Vomiting a. Contractions A nurse is teaching the parents of newborn about genetic screening. Which statements should the nurse include in the teaching? 23 / 28 a. A nurse will draw blood from baby's inner elbow b. Your baby will be given 2 oz of water to drink prior to the test c. This test should be performed after your baby is 24 hr old d. This test will be repeated when your baby is 2 months old c. This test should be performed after your baby is 24 hr old A nurse is developing a care plan for a newborn whose mother tested positive for heroin during pregnancy. The newborn is experiencing neonatal abstinence syndrome. Which action should the nurse include in the care plan? b. Minimize noises in the newborn's environment a. Maintain eye contact with the newborn during feeding b. Minimize noises in the newborn's environment c. Swaddle the newborn with his legs extended d. Administer naloxone to the newborn A nurse is caring for a child who has cystic fibrosis and requires postural drainage. Which action should the nurse take? a. Administer a bronchodilator after the procedure b. Perform the procedure prior to meals c. Perform the procedure twice each day d. Hold hand flat to perform percussion on the child b. Perform the procedure prior to meals A school nurse teaches parents about absence seizures. Which info should the nurse include? a. This type of seizure last from 30 to 60 sec b. This type of seizure can be mistaken for daydreaming c. This type of seizure has gradual onset d. The child usually has an aura prior to onset b. This type of seizure can be mistaken for daydreaming A charge nurse is teaching a newly licensed nurse about the facility computerized documentation system. Which info should the nurse include? a. Information technology will install a firewall to secure client info a. Information technology will install a firewall to secure client info b. You will be asked to change your password once per year c. Documentation of sensitive material is performed by the charge nurse d. You will be given access to the medical records of ever client in the facility A nurse administers 160 mg of valsartan PO to a client who was scheduled to receive 80 mg. Which actions is the priority for the nurse to take? a. Evaluate client for orthostatic hypotension a. Eval client for orthostatic hypotension b. Monitor client's urine output c. Obtain client's lab results d. Check client for nasal congestion A nurse at a community health clinic is planning care for an adolescent who recently learned that she's pregnant and is concerned about her ability to afford and care for her baby. Which action should the nurse take? d. Assist the adolescent in applying for Medicaid a. Refer the adolescent to a local mental health clinic b. Advise the adolescent to place the newborn for adoption c. Contact the adolescent's parent for assistance d. Assist the adolescent in applying for Medicaid A nurse is caring for a client. A nurse reviews clint's electronics medical record. Which findings require follow up? (SATA NGN) a. WBC count b. Temp a. WBC count b. Temp 24 / 28 c. K lv d. Breath sounds e. BP d. Breath sounds e. BP A nurse is admitting an adolescent who has rubella. Which actions should the nurse take? a. Monitor for development of Koplik spot b. Isolate client from staff who are pregnant c. Administer aspirin to the client d. Initiate airborne precautions b. Isolate client from staff who are pregnant A nurse is caring for a client who has a prescription for lactated ringers IV 4,080 mL/24 hr. The nurse said the IV infusion pump to deliver how many mL/hr to administer half the total volume in the first 8 hours? (round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.) ** A nurse is caring for a post-op client after a perineal prostatectomy. Specify if the potential prescriptions is anticipated or contraindicated. (NGN) 255 mL/hr ANTICIPATED: - Irrigate indwelling catheter with 50 mL NS - Apply warm compresses to the incision site - Irrigate indwelling catheter with 50 mL NS - Administer enema to relieve constipation - Maintain bed rest for 2 days post-op - Place a blanket roll under client's knee while in bed - Apply warm compresses to the incision site CONTRAINDICATED: - Administer enema to relieve constipation - Maintain bed rest for 2 days post-op - Place a blanket roll under client's knee while in bed A nurse cares for a client in an acute care setting. Complete the sentence. (NGN) The client is at risk for _____ - fluid volume overload - anemia - hypostatic pneumonia As evidenced by _____ - calorie deficiency - orthostatic hypotension - immobility hypostatic pneumonia ; immobility A nurse cares for a child who is post-op after a tonsillectomy. Which findings indicate the child may experiencing hemorrhage? a. Increase drowsiness b. Elevated pain lv c. Diminished breath sounds d. Frequent swallowing d. Frequent swallowing A nurse cares for a female client who requests a contraceptive diaphragm. Which actions should the nurse take first? a. Teach client how to insert the diaphragm b. Document client's lv of understanding about potential adverse effects c. Supervise return demonstration of diaphragm use d. Determine client's knowledge about diaphragm use A nurse cares for a 75 year old client who admitted to the med-surg unit. (Bowtie NGN) Too blurry to see d. Determine client's knowledge about diaphragm use - Condition: DVT - Action to take: Doppler, access Homans sign - Monitor: PT/INR, signs of bleedings A nurse cares fir a post partum client in an outpatient setting. Complete the sentence (NGN) mastitis AEB crackled nipples The client is at highest risk for developing _____ - endometritis - mastitis 25 / 28 - perineal hematoma as evidenced by client's _____ - large for gestational age newborn - group B strep - crackled nips A nurse cares for a client who experiencing a panic attack. Which actions should the nurse take? a. Encourage client to watch TV b. Administer a dose of atomoxetine to decrease anxiety c. Teach client how to meditate d. Sit with client to provide a sense of security d. Sit with client to provide a sense of security A nurse caring for a client. Complete the sentence. (NGN) After notifying the provider, the nurse should _____ - prepare client for cardiac catheterization - request a prescription for an increase in med - administer O2 2L/min via nasal cannula and then _____ - request a prescription for a beta-blocker - check STAT cardiac troponin - administer sublingual nitroglycerin administer O2 2L/min via nasal cannula THEN administer sublingual nitroglycerin A nurse is caring for a client at a clinic. Complete the sentence. (NGN) The client is at risk for developing _____ - mania - serotonin syndrome - psychosis due to _____ - feeling of hopelessness - adverse effects of paroxetine - anxiety serotonin syndrome DUE TO adverse effects of paroxetine A nurse is caring for a client in the med-surg unit. Which actions should the nurse take to decrease the risks for UTI for this client (SATA NGN) a. Change indwelling catheter every 3 days b. Empty the drainage bag when it's half full c. Place the drainage bag on the bed when transporting the client d. Use soap and water to provide perineal care e. Review the need for the indwelling urinary catheter daily f. Encourage client to drink 3000 mL of fluid a day d. Use soap and water to provide perineal care e. Review the need for the indwelling urinary catheter daily f. Encourage client to drink 3000 mL of fluid a day A hospice nurse visits with the son of a client who has terminal cancer. The son reports sleeping very little during the past week due to caring for his mother. Which responses should the nurse take? c. I can give you info about respite care if you are interested a. It's always difficult caring for someone who is terminally ill b. You should consider taking a sleeping pill before bed each night c. I can give you info about respite care if you are interested d. I'm sure you're doing a great job taking care of your mother ** A nurse is caring for a client who has a spinal cord injury. Specify if the action is anticipated or contraindicated. (NGN) - Perform suctioning - Assess for urinary retention - Assess BP every 15 min - Withhold pain med for headache until other manifestation resolve 26 / 28 ANTICIPATED: - Assess for urinary retention - Assess BP every 15 min - Administer nifedipine CONTRAINDICATED: - Perform suctioning - Place client in a supine position - Administer nifedipine - Withhold pain med for headache until other manifestation resolve - Place client in a supine position A nurse obtains a client's manual BP and is having difficulty auscultating sounds. Which actions should the nurse take? a. Use the palpatory method to determine blood pressure b. Place the arm above lv of client's heart c. Apply largest cuff available d. Deflate the cuff quickly a. Use the palpatory method to determine blood pressure ** A nurse is caring for a client who is post-op after a right hip arthroplasty. Specify if the findings is consistent with malignant hyperthermia, latex allergy, or hypovolemic shock. Each findings may support more than 1 disease process. (NGN) - Hypercapnia - Muscle rigidity - Tachycardia - Urticaria - Wheezes Malignant Hyperthermia: - Hypercapnia - Muscle rigidity - Tachycardia - Wheezes Latex Allergy: - Tachycardia - Urticaria - Wheezes Hypovolemic Shock: - Hypercapnia - Muscle rigidity - Tachycardia A nurse is caring for an older adult client. Highlight findings that require immediate follow-up (NGN) - TITLE OF CAR SIGNED OVER - POOR EYE CONTACT - GETS UP AT NIGHT TO GO POTTY - NOT WANTING TO EAT - LOST 8 LBS - STATEMENT "WHY DON'T YOU JUST LEAVE ME? I A NO USE." A nurse cares for a client who has cancer and is terminally ill. Client reports feeling depressed. Which statements should the nurse make? a. Do you need a prescription for an antianxiety med? b. Do you need info on hospice care? c. Would you like to talk to a counselor about advance directives? d. Would you like to speak to a spiritual advisor? A nurse is caring for a client in a clinic. Select 4 findings require immediate follow-up. (SATA NGN) a. Smoking marijuana to clear their mind b. Attends school regularly c. HR 99/min d. Client experiences nightmares e. BP 122/80 f. Caregiver report client acting differently than usual g. Witnessing their family's death h. Startle easily during thunderstorm d. Would you like to speak to a spiritual advisor? a. Smoking marijuana to clear their mind d. Client experiences nightmares f. Caregiver report client acting differently than usual g. Witnessing their family's death - Condition: Anorexia nervosa - Actions: structured meal, focus in feeling - Monitor: behavior 15 mins after meals, ECG 27 / 28 A nurse is caring for a recently admitted 18 year old client. (Bowtie NGN) 28 / 28