1.A client is being discharged home after a routine hip replacement surgery.The nurse is instructing the client on how to prevent postoperative complications. What statements by the client would indicate the need for further teaching? Select all that apply. “Limiting fiber is necessary to avoid diarrhea.” “I should empty my bladder when I feel the urge.” “Avoiding pain medication will prevent constipation.” “I should drink plenty of liquids like iced tea or coffee.” “I should continue with my physical therapy and walking.” 2.The nurse is caring for a Vietnamese client diagnosed with tuberculosis. The client speaks limited English. What should the nurse do to ensure the client and family receives the most accurate information? Select all that apply. Provide culturally sensitive education. Encourage family members to obtain a tuberculosis skin test. Provide written instructions in English for the client to reference. Encourage the client and family to wash all dishes by hand to prevent the spread of infection. Urge all family and close contact community members to seek and complete treatment to enhance compliance. 3.A client with anxiety has just been seen by the health care provider and has been prescribed alprazolam. The client asks the nurse how long it will take for the medication to build up a steady state in her body. If the half life of this medication is approximately 11 hours, approximately how long will it take for this medication to build up and reach a steady state? _____ hours 4.The nurse is observing the cardiac monitor of a client and notes this cardiac rhythm (refer to figure). What is the initial nursing action? Check for a pulse Notify the health care provider Obtain a 12 lead electrocardiogram (ECG) Begin cardiopulmonary resuscitation (CPR) Record the answer using one decimal place. _____________ tablet(s) 8. Age Race Income Chronic illness Low birth weight Environmental exposure to toxins 6. the nurse decides to assign those children who have social or emotional delays amongst different nurses.5 mEq/L (3. The client is prescribed furosemide 40mg by the intravenous route once daily. How many tablet(s) would the nurse prepare every 8 hours to administer the correct dose? Fill in the blank. for the nurse should ask the mother about which risk factors associated with a developmental delay? Select all that apply.The nurse is caring for a client admitted to the hospital for shortness of breath and edema in both lower extremities.5 mmol/L) orally at bedtime Expiratory rales Atorvastatin prescription Peripheral vascular disease Potassium level of 3. Which children should be assigned to different nurses? Select all that apply. When planning the assignment.The nurse in a pediatric unit is planning the staff assignments for children with developmental delays.A mother brings her 9-month-old child to see the pediatrician and has concerns that the child may have a developmental delay because the child cannot roll over yet.5.The client has been prescribed amoxiciilin 250 mg three times daily for sinusitis.5 Atorvastatin 10mg Disease (PVD) mEq/L (3. What information in the chart would warrant the nurse to verify continuing the prescription with the health care provider (HCP)? Refer to chart. History and Laboratory Findings Medications Physical Expiratory rales on Blood pressure Lisinopril 20mg auscultation 145/94 mmHg orally daily Peripheral Vascular Serum Potassium 3.5 mmol/L) . A child with autism An infant with fetal alcohol syndrome A child with attention deficit disorder A child with generalized anxiety disorder A child with expressive language disorder 7. The medication is supplied in a 500 mg tablet. ” “Sometimes my grandson becomes angry with me when I can’t give him money. The nurse should include which helpful actions in the plan of care? Select all that apply. 10. “I can take my probiotic at any time of day or night. What statement by the client would warrant the need for further teaching? Select all that apply. The nurse suspects that the client has been abused.The nurse is caring for a client in the hospital and is reconciling the client’s home medications. Which statement by one of the students indicates that the teaching has been effective? Select all that apply. I don’t remember anything that would have caused the injuries.” “Probiotics can be found in yogurt and some juices. Allow the client to move around the halls as desired to decrease the confusion and acting-out. “A sign of neglect are bruises on the child’s body.” “This supplement will help me avoid getting diarrhea from antibiotics.” “Because I’m lactose intolerant.” “Neglect is parental failure to meet a child’s basic needs.” 11. The client is taking Lactobacillus. Encourage friends and family to visit frequently. The nurse suspects the client is suffering from relocation stress. Which statement by the client indicates the need for further questioning by a social worker? Select all that apply.” “Well. and that there may be a history of abuse. Ensure the client is an active part of decision making regarding their care. Establish a trusting relationship with the client as soon as possible.” “Neglect occurs when a parent does not seek medical attention for a sick child.The nurse educator is presenting a lecture on child neglect. Change rooms frequently to prevent the client from becoming bored.” .” “I tripped over a rug and now I have a black eye.9. The client is confused and is acting out.” 12. a probiotic over-the counter medication.” “Neglected children show aggression after age 10. a probiotic would not benefit me.” “I should take this supplement to prevent gas and bloating.The nurse is obtaining the medical history from an older client with a black eye and bruising to the head.” “Neglected children often have learning problems and low self-esteem. The nurse is discussing the supplement with the client.A nurse employed at a nursing home is caring for a client who has recently been transferred from the hospital to the nursing home.” “I got into a car accident yesterday and the airbag deployed. “Perhaps I somehow did this to myself. Which nursing actions are most appropriate for increasing the client's caloric intake? Select all that apply. calming music during mealtimes.The nurse is meeting with an older client who was brought into the health care facility for evaluation. "Physical inactivity is one of the causes of obesity". "I will likely develop obstructive sleep apnea". when they fear the answers".The nurse is educating a client on obesity. "It is unlikely that I will develop peripheral artery disease". "Children are often reluctant to ask questions. 16. Determine the fit of the client's dentures. 15. 14.The nurse is caring for a malnourished client with dementia and a history of rheumatoid arthritis. "Complete honesty may cause problems for some family and staff members". .The nurse is attending a teaching sessionatt on communicating with the ill child. Assess the client's eyesight. Which statement by the nurse indicates that the teaching has been effective? Select all that apply. Encourage the client to eat quickly. "My heart and lungs are mildly affected by obesity". Obtain a list of the client's medications. "I will strive to maintain honesty and trust with each child". According to the family member. "To prevent misunderstandings. "Providing as much information as possible will help ease the child's fears". Serve the food at the appropriate temperature. Assess the client for mental status changes.13. to prevent fatigue. Play soft. Question the client about urinary habits. "Type II diabetes is a complication of obesity". Provide pain medications as needed. I should ask the child to explain what is known". and is creating a plan of care for the client’s nutrition. the client has lost a large amount of weight recently and does not eat much. Which actions would be the most important for the nurse to take? Select all that apply. Which statements by the client indicate a need for further teaching? Select all that apply. Provide the client with six small meals per day. 17." "My baby will not stop crying and I can't take it anymore. Which actions by the client would indicate a need for follow-up by the nurse? Select all that apply. Crying after talking with spouse on the phone.A client is being assessed for post-partum depression.The nurse is evaluating a client who is four weeks post-partum. Assist the child’s parents in obtaining the medication at an affordable cost.The nurse is preparing to discharge a child who was treated in the emergency department. Exercise on a regular schedule Eat a healthy. Provide the child's parents with a simple dosing schedule. Ensure that the child's family is able to read the written discharge instructions." "My husband never helps me with the baby. Which statement by the client would indicate a need for intervention? Select all that apply. Making statements about being fat and unattractive now.The client is being discharged home after the delivery of a healthy infant. Which should the nurse consider when planning medication discharge instructions for the client's parents? Select all that apply. The nurse is educating the client on how to prevent postpartum depression. 18. well-balanced diet Try to sleep when the baby sleeps Don’t overcommit yourself to activities that will be tiring Stay home with the baby as much as possible." "My milk has come in and my baby is nursing every 2 hours. Not responding to the infant’s cries. "I feel like giving up. Refer the family to the pharmacist with questions about medication side effects." 19. . Create a medication schedule that fits the parent’s lifestyle. Stating that family was not supportive of the pregnancy." "I wish I could get more than four hours of sleep at a time. Stating that that the infant latched on properly during a feeding. to promote bonding 20. Which activities are the most appropriate for the nurse to suggest? Select all that apply. “You may lose your hair.The nurse is preparing to administer blood to a client. Check the health care provider’s prescriptions with another nurse. Which pieces of information should the nurse verify has been included in the prescription? Select all that apply. 22.The nurse is evaluating a medication prescription written by the health care provider. When creating the client’s plan of care. The specific dosage The client’s home address The generic medication name The length of time for the administration The route and frequency of administration 23. which opiate-induced side effects should the nurse monitor? Select all that apply. Obtain and assess vital signs.” “Diarrhea is a common side effect. Identify the client by room number and bed. Evaluate the client’s venous access.” . Assess laboratory values. Which instructions should the nurse give to the client? Select all that apply.21. Sedation High blood glucose Increased appetite Nausea and vomiting Elevated cardiac enzymes 24. Which actions by the nurse are the most appropriate before administration of the blood? Select all that apply.The nurse is providing discharge instructions to a client with rheumatoid arthritis who is taking leflunomide.The nurse is caring for a postoperative client with a patient controlled analgesia (PCA) pump.” “It has been shown that leflunomide can cause birth defects.” “It is ok to drink alcohol.” “Leflunomide is a potent medication that is generally tolerated. Which statement by the new nurse indicates an understanding of a PICC? Select all that apply.25. which interventions should the nurse include in the plan? Select all that apply.” “PICCs can accommodate infusions of all types of therapy. Potassium chloride can cause nausea and vomiting. unpleasant taste. “The tip of the PICC line sits in the superior vena cava. .The nurse is preparing to administer oral potassium chloride to a client. When creating a plan of care for the client. Potassium may be taken in a liquid or solid form.The nurse is caring for a client who has been admitted to the intensive care unit with acute pulmonary edema. Potassium has a strong.” “Insertion of the PICC line occurs in the operating room. the nurse administers furosemide as prescribed. What should the nurse keep in mind about this medication? Select all that apply. Potassium may be given as an intramuscular (IM) injection. Potassium can only be mixed with water.The nurse is assigned to care for a client who needs an intravenous (IV) catheter inserted and will receive an IV infusion of a vesicant medication. Assess the skin integrity Monitor the site frequently Place the IV at an area of flexion Educate the client about the signs and symptoms of infiltration Understand the vesicant potential before administering the infusion 28.” 27.” “PICCs with a lumen size of 14 Fr or larger can be used for blood sampling.” “PICCs are the most appropriate for client’s who require short-term antibiotics. After assessing the client. Which actions by the nurse are the most important after administering the medication? Select all that apply. Assess lung sounds Measure urine output Obtain and monitor vital signs Document the client’s meal intake Assess the client for pitting edema 26.The nurse preceptor is orienting a new nurse on an acute medical-surgical unit and educating the nurse on peripherally inserted central catheters (PICCs). 29. What actions would be appropriate for the nurse to implement into the care plan? Select all that apply. What priority actions should the nurse include in the plan of care? Select all that apply. which can help add moisture to the skin .The nurse is caring for a client with a latex allergy. Assess for pedal pulses Monitor urinary output Administer analgesics as needed Keep the head of the bed elevated to at least 60 degrees Encourage use of an abdominal pillow when coughing or deep breathing 32. Upon entering the client’s room. the nurse should plan to take which action as the priority? Perform a skin assessment Perform a physical assessment Ask if the client needs pain medication Remove the banana from the client’s breakfast tray 30.The nurse has been assigned to care for an older client with a hip fracture who had surgical repair.The nurse is caring for a client recovering from an abdominal aortic aneurysm (AAA) endovascular stent graft. Clarify the medication prescription with the health care provider. the nurse learns that the health care provider has prescribed meperidine for pain management. The nurse notices that an older client’s skin is very dry. 31. Ensure adequate hydration Wait 15 minutes after bathing to apply lotion Instruct the client to avoid caffeine and alcohol Rub skin surfaces dry in order to remove dead skin Use lavender scented lotion. Which action should the nurse take first? Prepare the medication Verify the dosage of meperidine Assess the client’s pain score before administration. After receiving report. 33. The nurse should administer how many milligrams per dose? Fill in the blank.The nurse is caring for a client in the emergency department who is being treated for major burns and smoke exposure. as Japanese Americans often remain stoic Provide personal space boundaries if client is in a semi-private room Allow for family to visit and participate in the decision-making process Encourage the client to verbally express their feelings and thoughts often 34.The nurse is caring for an older Japanese American man being treated in the oncology unit for prostate cancer.The nurse is caring for a 55-pound child on the pediatric medical surgical unit being treated for Lyme disease. What statements made by the client would indicate a need for further teaching? Select all that apply.” “I should report any skin itching or yellowing of the skin to my healthcare provider. The health care provider has prescribed ceftriaxone (Rocephin) intramuscular 50 mg/kg/day in two divided doses.7 mellitus mmHg mmol/L) Asthma Hoarse voice Blood pressure of 98/62 mmHg Blood glucose of 68 mg/dL (3. “This medication is safe to take with my warfarin.” “I should not take this medication more often than 3 times per day.The nurse is caring for a client with joint pain and is educating the client on pharmacological management of pain with acetaminophen. Address client by first name to promote a trusting relationship Routinely assess for pain. In order to provide culturally competent care. Medical Assessment Findings Laboratory Values History Asthma Hoarse voice Sodium 131 mEq/L (131 mmol/L) Diabetes Blood pressure 98/62 Blood glucose 68 mg/dL (3. What information in the medical chart would warrant the nurse to call the Rapid Response Team immediately? Refer to chart.” “To prevent a stomach ache.7 mmol/L) 35. I should take this medication with food. the nurse should include what actions in the care plan? Select all that apply.” “I should avoid eating grapefruit while taking this medication. ________ mg 36.” . Select all that apply. I should notify my healthcare provider. . The nurse is caring for a client in active labor. Which position should the nurse assist the client into? Refer to figures 1-4. What statements made by the client would indicate teaching was effective.37.” 38.” “If I notice any swelling or fluid retention. I should take two pills the next time.” “I may notice my cheeks become fat and rounded but this is okay.” “If I forget a dose.” “Weight gain is common and I should expect it.The nurse is providing discharge education to a client that was admitted for treatment with Addison’s crisis and is reviewing the medication hydrocortisone. “ I should take this medication twice a day. The nurse notices that the fetal heart rate pattern is demonstrating late decelerations. A client is being treated on the medical surgical unit for a deep vein thrombosis (DVT). Which actions by the nurse would be the most appropriate when providing for this client’s care and comfort? Select all that apply. The nurse should include which actions in the client’s care plan? Select all that apply. The prescription reads: morphine 4 mg intravenous (IV) push every three hours as needed.39.The nurse is planning care for a client who is confused. Ask if the client lives alone. Allow a pet visit Play soft. The client will be discharged home on oral anticoagulants. calming music Toilet the client every 2 to 3 hours Evaluate the client for signs of pain Apply restraints as needed if the client becomes agitated .The nurse is caring for an older client who is being treated for malnutrition.The post-operative client is experiencing moderate pain and requests pain medication from the nurse. History and Laboratory Findings Medications Physical Iron-deficient Sodium 142 mEq/L Lisinopril 10 mg anemia (142 mmol/L) orally daily 10 pack year Positive D-Dimer Vitamin D 400 IU history of smoking daily Sodium result D-Dimer result Vitamin D 400 IU daily 10 pack year history of smoking 40. ________ mL 41. The morphine is supplied in an ampule of 10 mg/mL. Educate the client on how to choose healthy foods. 42. Recommend that the client choose over-the-counter medications for ailments. What information in the client’s medical record would warrant the need for teaching? Refer to chart. Determine if the client qualifies for any food services. How many milliliters should the nurse administer? Fill in the blank and record your answer using the one decimal place. Evaluate the fit of the client’s dentures. ” “Corporal punishment should not be used to encourage good behaviors. Administer salt tablets to the client.” “Negative behaviors are recorded where the child can see them. Contact a surgeon immediately.” “I will plan a quick ascent when changing to a higher altitude.” 46. Give the client an oral rehydrating solution. The client reports a bite from a brown recluse spider. The nurse assesses the bite mark and notes that it is possibly infected.The nurse is caring for a client who has just come in to the emergency department to receive treatment. Which actions would be the appropriate in order to effectively treat the client? Select all that apply. Remove any restrictive clothing. Which statements indicate that the teaching has been effective? Select all that apply.The nurse is educating a child’s parents on using the behavior modification technique of discipline.43. Cleanse the area with a topical antiseptic.The nurse is educating a client on how to prevent altitude sickness.” “Rewards are given at the end of the training period only. Apply cool water soaks to the client. Apply a non-sterile dressing to the site. Apply ice to the site. Which actions should the nurse take? Select all that apply. Apply ice packs to the client’s neck and groin. “I will drink plenty of water.” .” “I will wear sunscreen and high quality goggles. Assess the date of the client’s last tetanus shot.” “I will refrain from consuming alcohol when I am at a high altitude. 45.” “I will pay attention to the manifestations of altitude-related illnesses. Which statement should the nurse make to the parents? “All behaviors should be acknowledged. 44.The nurse is working in the emergency department when a client with heat exhaustion is brought in. The nurse is caring for a client with bipolar disorder.The nurse is caring for a client who has been diagnosed with bladder cancer. The client will state the importance of taking medications as prescribed.A client has come to the emergency department complaining of burning with urination. The client will ask the nurse to refill the prescriptions each month.” “A history of anxiety can be a source of stress in the older person.” “Financial hardships can be a cause of stress. The client will perform activities of daily living (ADLs) independently. What should the nurse consider a priority when providing care in order to maintain the client’s psychosocial integrity? Use medical terminology when speaking to the client. Explain to the client that all questions will be answered at the time of discharge.47. “Relocating to a nursing home causes stress. Which action should the nurse take as a priority when planning psychosocial care for this client? Assess all urine for the presence of blood Question the client about insurance coverage Assess the client’s ability to cope with the diagnosis Ask the client if there is a history of cancer in the family 48.” “A lifestyle change such as retiring can cause stress. The client will be able to manage the symptoms of bipolar disorder. Administer medications as soon as they are prescribed by the health care provider. .The nurse is educating an older client on sources of stress. which should the nurse include? Select all that apply.” “The birth of a new grandchild is often a source of stress for the older person. 49. The client will understand what bipolar disorder is. When creating a care plan for this individual.” 50. Provide the client with as much privacy as possible during the examination. Which statements by the client indicate that the teaching has been effective? Select all that apply. Which actions should the nurse take to reduce the risk of skin break down? Select all that apply.The nurse is creating a plan of care for a client that will undergo a total joint replacement. Assess the skin daily Implement a turning schedule Decrease the risk for skin shearing Keep the client’s skin clean and dry Document skin breakdown prevention measures in the plan of care 54.The nurse is providing care to a client. the nurse determines that the client’s self- ability to change position is compromised. Clean the client’s room daily Wash hands when they are soiled Wear gloves when giving a bath to the client Keep fingernails short and without nail polish Place a mask on the client’s face when transporting to other departments . Teach interventions to reduce client anxiety Educate the client on what to expect after surgery Complete a physical assessment before the surgery Include the client’s family in discussions about the surgery Allow time for the surgeon to address questions after the surgery 52. What should the nurse include in the client’s plan of care? Select all that apply. After assessing the client. Which actions should the nurse include in the plan of care to prevent the spread of infection? Select all that apply. Insert a large-bore intravenous (IV) line Anticipate administering blood products Keep intravenous fluids to be administered cold Anticipate administering Ringer’s lactate solution Perform assessments and monitor the client closely 53. Which actions should the nurse take because of the risk of hypovolemic shock? Select all that apply.51.The nurse is caring for a client with a blood pressure of 80/54 mmHg.The nurse is creating a plan of care for a client with a respiratory infection. The nurse is caring for a client with cancer who has a sealed implant of a radioactive source. Yoga Meditation Biofeedback Acupuncture Herbal therapy 58. Which statements by the UAP indicate that teaching has been effective? Select all that apply.” “The client may not have a high fever if infection occurs.55. Keep the client’s door closed Limit each visitor to 1 hour per day Wear a lead apron while providing care Assign the client to a semi-private room Remove dressings and linens from the room as they are soiled 56.The nurse provides information to a unlicensed assistive personnel (UAP) about caring for a client with neutropenia.” “Healthy People 2020 aims to improve the health of the geriatric population.” “Healthy People 2020 aims to eliminate preventable disease. Which actions should the nurse take to promote safety for staff and visitors? Select all that apply.” “Any sores or skin irritations should be reported right away. and preventable death. injury.” “The client needs mouth care at least every 12 hours. disability.” 57. “Healthy People 2020 aims to promote healthy behaviors.” “I need to take precautions to protect myself from the client’s illness.The nurse is caring for a client who expresses an interest in alternative therapies to reduce the risk of illness and disease. Which statements by the RN indicate that teaching has been effective? Select all that apply.” “Healthy People 2020 aims to make health care more affordable.” .” “Healthy People 2020 aims to create social and physical environments that promote good health for all.The nurse is educating a new registered nurse (RN) about the Healthy People 2020 goals. “I should practice good hand washing. What noninvasive activities should the nurse recommend to the client? Select all that apply. Which agent is most likely to cause an allergic reaction in this client? Latex Medical tape Providone-Iodine Intravenous (IV) fluids 61. Explain the procedure to the client Instruct the client not to move during the procedure Teach the client to take slow.The nurse is completing a health history on a client who is 12 weeks pregnant.” “Be sure and report any bluish color to the skin. the client reports an allergy to shellfish.” “Discomfort on the unaffected side should be evaluated immediately.” .” “A pneumothorax can cause a feeling of air hunger.The nurse is providing discharge teaching to the client who had a thoracentesis about the manifestations of a pneumothorax. Which statements should the nurse make to the client to help the client recognize signs/symptoms of a pneumothorax? Select all that apply.” “Presents of a slanted trachea in the neck region need to be reported. “Frequent coughing should be reported.59. deep breaths during the procedure Tell the client to expect a stinging sensation from the anesthetic Inform the client that it is common to feel pressure from the needle insertion 62. Which findings should alert the nurse to the risk of potential parenting problems? Select all that apply. The client reports feeling depressed The client has new health insurance The client states that she likes hospitals The client states that the father is not supportive The client is homeless and often stays in local shelters 60.Which actions should the nurse take to adequately prepare a client for a thoracentesis? Select all that apply.When conducting the preoperative interview with the client. Crackles in the lungs Diminished lung sounds Decrease in blood pressure Increase in red blood cell count High oxygen saturation readings 64. Which actions should the nurse take to ensure that the intervention is effective? Select all that apply. strong bubbling.The nurse is caring for a client with heat stroke. Keep the drainage system lower than the level of the client’s chest. Cyanosis of the skin in the affected extremity Skin temperature cool to touch in the affected extremity Client complaints of problems moving the affected extremity Complaints of sudden and severe pain in the affected extremity Bounding pulse in the affected extremity below the level of the occlusion . Which assessments findings should alert the nurse to the onset of an acute arterial occlusion? Select all that apply.63. who is being cooled with a cooling blanket. Which symptoms should alert the nurse to the possibility of absorption atelectasis? Select all that apply.Which interventions should be included in the care of a client with a chest tube? Select all that apply. Administer antipyretics Rapidly lower the core temperature Monitor temperature continuously until it is stable Monitor for patency of the airway and prepare for intubation if necessary Prepare to insert an intravenous line for administration of fluids as needed 65. Assess the water seal chamber for a continuous. Alert the health care provider (HCP) if drainage in the tube stops in the first 24 hours. Assess the insertion site for signs of infection. Change the chest tube each shift.The nurse is caring for a client on a ventilator. 66.The nurse is providing care to a client with chronic peripheral arterial disease (PAD). ” 70.Which manifestations are specifically noted in a client with right-sided heart failure. following an admission to the hospital for heart failure.” “I will wear my oxygen at night as prescribed.” “I will report new signs and symptoms to my home care nurse when she visits. Which interventions should the nurse include in the client’s discharge teaching plan? Select all that apply.67.The client with heart failure is preparing to be discharged from the hospital. Ascites Hepatomegaly Breathlessness Dependent edema Neck vein distention 68. Which interventions should the nurse be prepared to discuss with the client? Select all that apply. Surgical management Required dietary changes Medication management Placing limits on physical activity Monitoring for an irregular heart rhythm .” “I have my medications and dosages written down for easy review and administration. “I will weight myself daily. Teach the client coping strategies Develop a regular exercise program Educate the client about dietary restrictions Give the client a minimal role in the self-management program Provide the client with a list of current medications and dosing times 69. Which statements by the client indicate that teaching has been effective? Select all that apply.? Select all that apply.The nurse is educating a client on how to self-manage care at home.” “I will follow up with my health care provider (HCP) as scheduled.The client has been diagnosed with valvular disease.