Foundations
A nurse is caring for a client who is 2 days postop and has not achieved satisfactory pain relief. According to the nursing process, which of the following actions should the nurse take first?
Check the client to determine the reason for inadequate pain relief
Determine whether the change in plan reduces the clients pain
Change the plan of care to provide a different method of pain relief
Educate the client about the plan of care for managing the pain
Check the client to determine the reason for inadequate pain relief
The nurse knows that the best method for promoting and maintaining the newborns temperature is:
Early Skin to Skin
A nurse is assessing a 4-year old child for indications of autism spectrum disorder. For which of the following manifestations should the nurse assess?
Impulsive behavior
Repetitive counting
Destructiveness
Somatic problems
Repetitive counting
A nurse is preparing to provide teaching with a client who is taking Risperidone. Which of the following statements should the nurse make?
Add extra snacks to your diet to prevent weight loss.
Notify the provider if you have trouble sleeping.
You may begin to have mild seizures while taking this medication
This medication is likely to increase your libido.
Notify the provider if you have trouble sleeping.
During tracheostomy suctioning, the nurse notes the patient becomes cyanotic and tachycardic. What is the most appropriate immediate action?
Continue suctioning to clear the airway
Stop suctioning and hyperoxygenate the patient
Increase suction pressure to remove secretions faster
Call the provider before taking further action
Stop suctioning and hyperoxygenate the patient
A nurse is performing an admission assessment for an older adult client. After gathering the assessment data and performing the review of systems, which of the following actions is a priority for the nurse?
Orient the client to their room
Conduct a client care conference
Review medical prescriptions
Develop a plan of care
Orient the client to their room
The nurse is assessing a newborn for signs of adequate breastfeeding. All of the following are signs that feeding is adequate besides which one?
Breastfeeding atleast 8-12 times a day
Newborn is gaining weight
Newborn has 6-8 wet diapers a day
Newborn is content between feedings
Breastfeeding atleast 8-12 times a day
A nurse is caring for a client who smokes and has lung cancer. The client reports “I’m coughing because I have that cold that everyone has been getting”. The nurse should identify that the client is using which of the following defense mechanisms?
Reaction formation
Denial
Displacement
Sublimination
Denial
A nurse is reviewing the medication administration record for a client who is receiving transdermal fentanyl for severe pain. The nurse should identify that which of the following medications can cause an adverse effect when administered concurrently with fentanyl.
Ampicillin
Diazepam
Furosemide
Prednisone
Diazepam
A nurse is caring for a client who has an urinary tract infection (UTI). Which of the following is the priority intervention by the nurse?
Offer a warm sitz bath.
Recommend drinking cranberry juice.
Encourage increased fluids.
Administer an antibiotic.
Administer an antibiotic
A nurse is preparing discharge instructions for the client who has had a knee arthroplasty and is going home. Which of the following information about the client should the nurse include in the discharge instructions? SATA
1. Advance directive status
2. Follow-up care
3. Instructions for diet and medications
4. Most recent vital signs data
5. Contact information for the home health care agency.
2, 3, 5
A nurse is caring for a pediatric client who has a superficial partial-thickness burn/ Which of the following actions should the nurse take?
Administer IV fluid of 0.9% sodium chloride
Apply ice to the burn
Clean the affected area using a soft-bristle brush
Administer acetaminophen
Administer acetaminophen
A nurse is speaking with a client who has schizophrenia when the client suddenly seems to stop focusing on the nurses’ questions and begins looking at the ceiling and talking to themselves. Which of the following actions should the nurse take?
Stop the interview at this point, and resume later when the client is better able to concentrate
Ask the client, “are you seeing something on the ceiling?”
Tell the client “you seem to be looking at something on the ceiling. I see something there too”.
Continue the client interview without commenting on the client’s behavior
Ask the client, “are you seeing something on the ceiling?”
A nurse is providing discharge teaching to a client who has received a liver transplant and has a new prescription for cyclosporine. Which of the following instructions should the nurse include in the teaching plan?
You may drink grapefruit juice daily to help maintain consistent nutritional status
Report any decrease in your daily urine output or swelling in your extremities to your provider
Discontinue the medication immediately if you experience mild gingival hyperplasia
You can stop taking this medication once your laboratory values return to the expected reference range
Report any decrease in your daily urine output or swelling in your extremities to your provider
A nurse is instructing a client who has an injury on the LEFT lower extremity, about the use of a cane. Which of the following instructions should the nurse include? SATA
1. Hold the cane on the right side
2. Keep 2 points of support on the floor
3. Place the cane 38 cm (15 in) in front of the feet before advancing
4. After advancing the cane, move the weakier leg forward
5. Advance the stronger leg so that it aligns evenly with the cane
1, 2, 4
A charge nurse is assigning client care to an RN and a PN. Understanding that an RN can perform each of the following tasks, match the tasks the nurse should assign to the RN or the PN.
1. Creating a plan of care for a client who is recovering from a stroke
2. Assessing a pressure injury on a client on bed rest
3. Providing nasopharyngeal suctioning for a client who has pneumonia
4. Teaching a client who has asthma to use a metered dose inhaler
5. Administering enteral feeding to a client who has NG tube
6. Inserting a urinary catheter for a client who has urinary retention
RN 1, 2, 4
LPN 3, 5, 6
A nurse educator on a postpartum unit is reviewing risk factors for postpartum hemorrhage with a group of nurses. Which of the following factors should the nurse include in the teaching? SATA
1. Proglonged Labor
2. Obesity
3. Inversion of the uterus
4. Oligohydramnios
5. Retained placental fragments
1, 3, 5
A nurse working on an acute mental health unit caring for a client who has posttraumatic stress disorder (PTSD). Which of the following findings should the nurse expect? SATA
1. Difficulty concentrating on tasks
2. Obsessive need to talk about the traumatic event
3. Negative self-image
4. Recurring nightmares
5. Diminished reflexes
1, 3, 4
A nurse is reviewing the healthcare record of a client who is asking about conjugated equine estrogens (ex. Estradiol). The nurse should inform the client that this medication is contraindicated in which of the following conditions?
Atrophic vaginitis
Dysfunctional uterine bleeding
Osteoporosis
Thrombophlebitis
Thrombophlebitis
A nursing is caring for a client who has a closed-head injury with ICP readings ranging from 16 to 22 mm Hg. Which of the following actions should the nurse take to decrease the potential for raising the client’s ICP? SATA
Suction the endotracheal tube frequently.
Decrease the noise level in the client’s room.
Elevate the client’s head on two pillows.
Administer a stool softener.
Keep the client well hydrated.
2, 4
A
A nurse is delegating the ambulation of a client who had knee arthroplasty 2 days ago to an assistive personal. Which of the following information should the nurse share with the assistive personal. SATA
1. The client ambulates wearing slippers over antiembolic stockings
2. The client uses a front-wheeled walker when ambulating
3. The client had pain medication 30 mins ago
4.The client is allergic to codeine
5. The client at 50% of breakfast this morning
6. The client’s roommate ambulates independently
1, 2, 3
A nurse in pediatric clinic is providing discharge instructions to the family of a child with chickenpox (varicella). Which of the following should be included in the teaching? SATA
1. The child is contagious until all vesicles have crusted
2. Calamine lotion may be applied to decrease itching
3. Fingernails should be kept short while lesions are present
4. Bed linens should be changed every other day
5. Bathe the child in tepid water
1, 2, 3, 5
A nurse is assisting with a court-ordered evaluation of a client who has antisocial personality disorder. Which of the following findings should the nurse expect? SATA
1.Demonstrates extreme anxiety when placed in a social situation
2.Often engages in magical thinking
3.Attempts to convince other clients to relinquish their belongings
4.Becomes agitated if personal area is not neat and orderly
5.Blames others for personal past and current problems
3, 5
A nurse is preparing to administer cyclophosphamide IV to a client who has Hodgkins disease. What action should the nurse take? SATA
1. Monitor for blood in urine
2. Monitor for manifestations of bleeding
3. Administer antiemetics as needed
4. Monitor CBC, uric acid levels and liver enzymes
5. Increase fluid intake to 2-3L a day
1, 2, 3, 4, 5
A nurse is monitoring a client who began receiving a unit of packed RBCs 10 min ago. Which of the following findings should the nurse identify as an indication of a febrile transfusion reaction?
SATA
3, 5