Comp 2023 - Lithium

. A nurse is caring for a client…..5 exhibits (NGN)

Complete the following sentence by using the list of options

The nurse understands that the patient has likely developed ___________ and will need to be monitored for ______________.

lithium toxicity

seizure activity.

A nurse is preparing to initiate intravenous fluids via infusion pump to the client. Which of the following actions should the nurse take?

A. Obtain a surge protector that can accommodate the pump and several other appliances

B. verify that the extension cord for the pump is ungrounded

C. report the pump has a frayed cord and proceed with the infusion

D. check the expiration date on safety inspection sticker of the pump

D. check the expiration date on safety inspection sticker of the pump

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?

A. non coring needle

B. an angio catheter

C. a butterfly needle

D. a 25 gauge needle

A. non coring needle

a nurse is conducting an initial assessment of a client and notices A discrepancy between the client's current IV infusion and the information received during the shift report. Which of the following actions should the nurse take?

a. Contact the charge nurse to see if the prescription was changed

b. complete an incident report and place it in the client's medical record

c. submit a written warning for the nurse involved in the incident

d. compare the current infusion with the prescription and the client's medication

d. compare the current infusion with the prescription and the client's medication

(NGN) a nurse is caring for an older adult client.

Highlight the following choices!

General: I found the title to the car today; signed over to me

Physical: Client makes poor eye contact, speaks in a monotone voice, and has lack of facial expression. Client reports not wanting to eat anymore. Client's child reports their parent has lost about 8lb in the past month.

Affect: Client says, "Why don't you just leave me? I am of no use."

(NGN) A nursing is caring for a client on psychiatric unit.

For each potential action, the client is to specify if the action is indicated or contraindicated for the client.

Allow the client to watch TV at a high volume - Contraindicated

Place the client in a room near the activity room - Contraindicated

Ask the client about the content of their hallucinations - Indicated

Instruct the client on expected hygiene practices - Indicated

Assess the client for suicidal ideation - Indicated

A nurse is caring for a client who is near the end of life and is on a complete bed rest. The client states that he needs to have a bowel movement. The nurse offers a bed pan. The client states "I've always used the bathroom". Which of the following responses should the nurse make?

a. Tell me what concerns you have about using a bedpan

b. make sure to use a nearby furniture to support yourself when walking to the bathroom

c. I will have the physical therapist ambulate you to the bathroom

d. you have to use the bedpan for your own safety

a. Tell me what concerns you have about using a bedpan

(NGN) A nurse is caring for a client who is labor.

Select the 5 actions the nurse should take:

a. Increase the flow rate of the maintenance IV fluid

b. have the charge nurse notify the provider

c. place the client in a Trendelenburg position

d. exert upward pressure on the presenting part

e. attempt to push the umbilical cord back into the cervix

f. administer oxygen at 10L/min via nonrebreather face mask

a. Increase the flow rate of the maintenance IV fluid

b. have the charge nurse notify the provider

c. place the client in a Trendelenburg position

d. exert upward pressure on the presenting part

f. administer oxygen at 10L/min via nonrebreather face mask

A nurse is providing an in-service about client evacuation during a fire. Which of the following client should the nurse instruct the staff to evacuate first?

a. A client who is ambulatory and receiving oxygen

b. a client who has a fracture in is imbalance suspension traction

c. a client who is bedridden and wears a hearing aid

d. a client who uses a wheelchair and is confused

a. A client who is ambulatory and receiving oxygen

(NGN) A nurse is caring for a client who is 4 days postpartum following a cesarean birth.

For each potential assessment finding, click to specify if the assessment finding is consistent with mastitis or endometritis. Each finding may support more than 1 disease process.

Foul-smelling lochia: endometritis

Painful, tender breast: mastitis

Temperature: endometritis and mastitis

Chills: endometritis and mastitis

A nurse is assessing a client who has a possible right pneumothorax. Which of the following findings should the nurse expect the?

a. Reduced right sided breath sounds

b. intercostal retractions

c. High pitched stridor

d. paradoxical chest movement

a. Reduced right sided breath sounds

(NGN) Which of the following interventions should the nurse include in the plan of care?

a. increase oxygen flow rate to 4L/min

b. assess the clients breath sounds

c. perform chest percussions and vibration

A nurse is caring for a client who is postoperative following a liver biopsy. Which of the following positions should the nurse place the client immediately following the procedure?

a. Prone

b. Trendelenburg

c. high fowlers

d. right lateral

d. right lateral

A nurse is caring for a client who states he recently purchase lavender oil to use when he gets the flu. The nurse should recognize which of the following findings as a potential contraindication for using lavender?

a. The client has a history of alcohol use disorder

b. the client has a history of asthma

c. the client takes vitamin C daily

d. the client takes furosemide twice daily

b. the client has a history of asthma

a nurse is providing discharge teaching to a client following a total gastrectomy. The nurse should instruct the client about which of the following medications?

a. Ranitidine

b. vitamin B12

c. vitamin K

d. metoclopramide

b. vitamin B12

a nurse is teaching a newly licensed nurse about caring for clients in the emergency department period which of the following should the nurse include when the teaching about interacting with the client who is aggravated, pacing, and speaking loudly?

A. Use a face shield with a mask when providing care for the client

B. tell the client you seem to be very upset

C. engage the panic alarm

D. initiate seclusion protocol

B. tell the client you seem to be very upset

A nurse is teaching a client about family planning using the basal body temperaturemethod. Which of the following instructions should the nurse include in the teaching?

a. Take your temperature immediately after waking and before getting out of bed

b. take your temperature within 30 minutes after your first morning void

c. take your temperature one hour after getting out of bed

d. take your temperature every night before going to bed

a. Take your temperature immediately after waking and before getting out of bed

A nurse is reading a tuberculin skin test for a client who received a purified protein derivative test 72 hours ago. Which of the following findings indicates a positive test?

a. An induration measuring 10mm

b. an induration measuring 5mm

c. A reddened area measuring 10mm

d. A reddened area measuring 5mm

a. An induration measuring 10mm

a nurse is providing teaching about home safety to the adult child of an older adultclient who is postoperative following knee replacement surgery. Which of the following instructions should the nurse include?

a. Encouraged the client to avoid wearing shoes at home

b. place a throw rug over electrical cords

c. mark the edges of the doorway to the house with tape

d. ensure that area rugs have rubber backs

c. mark the edges of the doorway to the house with tape

c. mark the edges of the doorway to the house with tape

A nurse is caring for a client who has heart failure. Which of the following manifestation should the nurse expect?

a. Crackles in the lungs

b. decreased thirst

c. tachycardia

d. poor skin turgor

a. Crackles in the lungs

A nurse is assessing a client who received hydromorphone 4 milligrams IV 15 minutes ago. The client has a respiratory rate of 10/min. The nurse should prepare to administer which of the following medications?

a. Acetylcysteine

b. Protamine

c. naloxone

d. flumazenil

c. naloxone

A nurse is planning care for a school age child who is 4 hours postoperative following appendicitis period which of the following should the nurse include in the plan of care?

A. Give cromolyn nebulizer solution every eight hours

B. administer analgesics on a scheduled basis for the first 24 hours

C. apply a warm compress to the operative site once daily

D. offer small amounts of clear liquids 6 hours following surgery

B. administer analgesics on a scheduled basis for the first 24 hours

A nurse came for a client whose child died from cancer. The client states it's hard to goon without him which of the following questions should the nurse ask the client first?

a. What has helped you through difficult times in the past

b. has anyone in your family committed suicide

c. is there anyone you would like involved in your care

d. are you thinking about ending your life

d. are you thinking about ending your life

A nurse is teaching a client about advanced directives. Which of the following statements by the client indicates an understanding of the teaching?

a. A living will is a document that includes my wishes about healthcare decisions

b. my provider will make my healthcare decisions if I complete advanced directives

c. advanced directives outline who inherits my material possessions in the event of my death

d. my partner needs to be present as a witness when I sign a living will

a. A living will is a document that includes my wishes about healthcare decisions

A nurse is providing teaching to a client who is at 14 weeks of gestation about findings to report to the provider. Which of the following findings should the nurse include in the teaching?

a. Swelling on the face

b. bleeding gums

c. urinary frequency

d. faintness upon rising

a. Swelling on the face

A nurse is providing this church instructions to a client who has a new prescription for haloperidol. Which of the following adverse effects should the nurse instruct the client to report to the provider?

a. Weight gain

b. dry mouth

c. sedation

d. shuffling gait

d. shuffling gait

a nurse charged nurse is monitoring A newly licensed nurse who is caring for a client who is receiving total parenteral nutrition TPN which of the following statements by the newly licensed nurse indicates an understanding of the procedure?

a. I will hang a new bag of TPN and IV tubing every 24 hours

b. I will obtain the client's weight every other day

c. I will monitor the client's blood glucose level every eight hours

d. I will increase the rate of the TPN infusion to ensure the correct amount is given

c. I will monitor the client's blood glucose level every eight hours

A nurse is caring for a client who is in active labor and notes the FHR baseline has been 100/min for the past 15 minutes. The nurse should identify which of the following conditions is a possible cause of fetal bradycardia?

a. Chorioamnionitis

b. maternal fever

c. fetal anemia

d. maternal hypoglycemia

d. maternal hypoglycemia

A nurse is assessing a client who has histrionic personality disorder. Which of the following manifestation should the nurse expect?

a. Suspicious of others

b. self-centered behavior

c. violates others rights

d. callousness

b. self-centered behavior

A nurse in an emergency department is caring for a three-year-old child who has suspected epiglottitis. Which of the following actions should the nurse take?

a. Prepare to assist with intubation

b. obtain a throat culture

c. suction to child's oropharynx

d. prepare a cool mist tent

a. Prepare to assist with intubation

(NGN) A nurses came for a client who is pregnant. The nurse is reviewing the client's medical record. Select four findings that indicate a potential prenatal complication.

fetal activity

blood pressure

report of headache

gravida/parity

(NGN) The nurse is reviewing the assessment findings. For each assessment finding, click to specify if the finding is consistent with preeclampsia or HELLP syndrome. Each finding may support more than one disease process.

Hemoglobin: HELLP syndrome.

Alanine aminotransferase (ALT): HELLP syndrome.

Blood pressure: preeclampsia

Platelet count: HELLP syndrome.

(NGN) The nurse is continuing to care for the client. Drag words from the choices below to fill in each blank in the following sentence.

The client is a greatest risk for developing __________ and ___________

cervical insufficiency and seizures

(NGN) The nurse is continuing to care for the client and initiating the client's plan of care. Which of the following interventions should the nurse implement?

Provide a low-stimulation environment

given anti-hypertensive medication

administer betamethasone

Obtain a 24-hour urine specimen

perform a vaginal examination every 12 hours

(NGN) Complete the following sentence by using the list of options. The provider has admitted the client to the inpatient obstetrics and written prescriptions based on the client's condition.

The action the nurse should take first in __________ followed by ____________

evaluating the fetal heart rate tracing

inserting an indwelling urinary catheter

(NGN) A nurse is evaluating the client's response to therapy. Which of the following recent findings indicates the client's condition has improved or not changed?

For each assessment finding, click to specify if the finding indicates that the client's condition has improved or has not changed.

Heart rate: not changed

Deep tendon patellar reflex: improved

Edema: not changed

Blood pressure: improved

A nurse is teaching a client who is trying to conceive. Which of the following should the nurse instruct the client to increase in her diet to prevent a neural tube defect?

a. Calcium

b. zinc

c. Iron

d. Folate

d. Folate

A nurse is assessing a client who is postoperative and has a history of pulmonary embolism. Which of the following findings is a priority for the nurse to report to the provider?

a. Tachycardia

b. dry cough

c. Dyspnea

d. Hypotension

c. Dyspnea

A nurse is performing a neurological examination on a client as a part of a complete physical assessment. The nurse should identify the cranial nerve XI is intact when the client performs which of the following actions?

a. Shrugs his shoulders

b. sticks his tongue out

c. frowns symmetrically

d. identifies as our taste

a. Shrugs his shoulders

a nurse is preparing to admit a six year old with varicella to the pediatric unit. Which ofthe following action should the nurse take?

a. Assign the child to a negative air pressure room

b. use droplet precautions when caring for the child

c. assess the child for koplic spots

d. administer aspirin to the child for fever

a. Assign the child to a negative air pressure room

A charge nurses teaching a newly licensed nurse about medication administration. Which of the following information should the charge nurse include?

a. Avoid preparing medications for more than two clients at one time

b. complete and incident report if a client vomits after taking a medication

c. inform the client about the action of each medication prior to administration

d. Read medication labels at least twice prior to administration

a. Avoid preparing medications for more than two clients at one time

a nurse is planning care for a group of clients and is working with one licensed practical nurse LPN and one assistant personnel AP. Which of the following actions should the nurse take first to manage her time effectively?

a. Delegate tasks to the APP

b. determine goals of the day

c. develop an hourly time frame for tasks

d. schedule daily activities

b. determine goals of the day

a nurse is inserting an indwelling urinary catheter for a male client. Which of the following actions should the nurse take?

a. Perform the cleansing procedure with a swab 2 times

b. pick up the catheter 13 cm (5 in) from its tip

c. cleanse the tip of the penis in a side-to-side motion

d. lift the penis so that it is perpendicular to the client's body

d. lift the penis so that it is perpendicular to the client's body

a nurse is caring for a client who has severe hypertension and is to receive nitroprusside via continuous IV infusion. Which of the following actions should the nurse plan to take?

a. Monitor blood pressure every two hours

b. attach an inline filter to the IV tubing

c. protect the IV bag from exposure to light

d. keep calcium gluconate at the client's bedside

c. protect the IV bag from exposure to light

A Hospice nurse is visiting with the son of a client who has terminal cancer. The Sun reports sleeping very little during the past week due to caring for his mother. Which of the following responses should the nurse make?

a. It is 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 information about respite care if you're interested

d. I am sure you're doing a great job taking care of your mother

c. I can give you information about respite care if you're interested

A nurse is speaking with a caregiver of a client who has Alzheimer's disease. The caregiver states providing constant care is very stressful, and it is affecting all areas of my life. Which of the following actions should the nurse take?

a. Suggest that the caregiver seek a prescription for an antipsychotic medication for the client

b. recommend allowing the client to have time alone in their room throughout the day

c. discuss methods of how to communicate with the client about resolving problem behaviors

d. assist the caregiver to arrange for a daycare program for the client

d. assist the caregiver to arrange for a daycare program for the client

A nurse and an assistant personnel AP are assigned a group of clients on the unit. Which of the following clients should the nurse instruct the AP to report to the nurse?

a. A client who requests assistance to use the bedside commode

b. A client who has a prescription for compression stockings and did not receive them

c. a client who requests to sit in the bedside chair while watching TV

d. a client who consumes all the food from their meal tray

b. A client who has a prescription for compression stockings and did not receive them

A nurse is planning care for a client who sustained a major burn over 20% of the body. Which of the following intervention should the nurse include to support the clients nutritional requirements?

a. Maintain calorie intake at 1500 per day

b. provide a low protein, high carbohydrate diet

c. make a calorie count for foods and beverages

d. schedule meals at six-hour intervals

c. keep a calorie count for foods and beverages

A nurse is caring for a client who is receiving radiation therapy and it's experiencing anorexia. Which of the following actions should the nurse take?

a. Encouraged the client to drink low-protein supplements

b. tell the client to drink two glasses of water with meals

c. serve the client's largest meal in the evening

d. provide the client with cold foods rather than hot foods

d. provide the client with cold foods rather than hot foods

A nurse is teaching dietary guidelines to a client who has celiac disease. Which of the following food choices is appropriate for this client?

a. Wheat crackers

b. canned barley soup

c. potato pancakes

d. white flour tortillas

c. potato pancakes

A nurse is collecting A sputum specimen for a client who has tuberculosis. Which of the following actions should the nurse take?

a. Wait one day to collect the specimen if the client cannot provide sputum

b. where's sterile gloves to collect the specimen from the client

c. ask the client to provide 15 to 20 ML of sputum into the container

d. obtain the specimen immediately upon the client waking up

d. obtain the specimen immediately upon the client waking up

a nurse is planning teaching for a client who has a nearly implanted implantable cardioverter/ defibrillator. Which of the following information should the nurse include?

a. Expect to have a rapid pulse rate for the first few weeks

b. Wear loose-fitting clothing

c. return in two weeks for a follow-up MRI

d. resume tub baths and swimming after 24 hours

b. Wear loose-fitting clothing

a nurses planning care for a client who has acute appendicitis. Which of the following actions should the nurse plan to take?

a. Place the client's head of bed flat

b. apply heat to the client's abdomen

c. keep the client on NPO status

d. Administer a laxative to the client

c. keep the client on NPO status

A community health nurse is working with a family that is struggling to adapt following the loss of a family member. Which of the following action should the nurse take first?

a. Refer the family to a grief support group

b. determine the roles of individual family members

c. encourage the family to assign specific task to individual family members

d. assist the family to establish a daily routine

b. determine the roles of individual family members

A nurse in a clinic is planning care for a child who has ADHD and is taking atomoxetine. Which of the following laboratory values should the nurse monitor?

a. Liver function test

b. kidney function test

c. hemoglobin and hematocrit

d. serum sodium and potassium

a. Liver function test

A nurse is teaching a prenatal class about infection prevention at a Community Center which of the following statements by a client indicates an understanding of the teaching?

a. I should take antibiotics when I have a virus

b. I can visit my nephew who has chicken pox five days after the sores have crusted

c. I can clean my cat's litter box during my pregnancy

d. I should wash my hands for 10 seconds with hot water after working in the garden

b. I can visit my nephew who has chicken pox five days after the sores have crusted

A home health nurse is planning care for a client who has Alzheimer's disease. Which of the following actions should the nurse include in the plan of care?

a. Replace the carpet with hardwood floors

b. encourage physical activity prior to bedtime

c. wear clothing with zippers instead of buttons

d. place the locks at the tops of exterior doors

d. place the locks at the tops of exterior doors

A nurses came for a client who is receiving brachytherapy for an endometrial cancer. Which of the following actions should the nurse take?

a. Discard the radioactive source in the client's trash can

b. place the client soiled bed linen in a biohazard bag outside the client's room

c. where in isolation gown when caring for the client

d. keep visitors at least six feet (1.8m) away from client

d. keep visitors at least six feet (1.8m) away from client

A nurse enters our clients room and sees a small fire in the client's bathroom. Identify the sequence of steps the nurse should take. (Move the steps into the box on the right. Placing them in the order of performance. Use all the steps) RACE

1. transport the client to another area of the nursing unit

2. use the units fire extinguisher to attempt to put out the fire

3. Activate the facilities fire alarm system

4. Close all nearby windows and doors

1. transport the client to another area of the nursing unit

2. Activate the facilities fire alarm system

3. Close all nearby windows and doors

4. use the units fire extinguisher to attempt to put out the fire

A nurse is discussing discharge plans with an older adult client who lives alone and has left-sided weakness following a stroke. Which of the following information is the priority for the nurse to discuss?

a. Reviewing information about support groups for individuals who have had a stroke

b. obtaining an alert system to get help in case of a fall

c. providing information about available transportation resources

d. choosing an agency to provide home physical therapy

b. obtaining an alert system to get help in case of a fall

(NGN) The nurse is assessing the client. Select the four findings that require immediate follow up.

hallucinations

sleep pattern

skin turgor

hygiene

(NGN): For each assessment finding, click to specify whether it is consistent with psychosis or mania. Each finding may support more than one diagnosis.

Hallucination: Mania & Psychosis

Lack of sleep: Mania

Excessive spending habits: Psychosis

Disorganized thought process: Mania

Pressured speech: Mania

(NGN) Drag 1 condition and 1 client finding to fill each black in the following sentence.

Mania (target 1)

Euphoric Mood (target 2)

(NGN) A nurse on the inpatient mental health unit is planning care for the client. For each potential provider's prescription, click to specify if the prescription is anticipated or contraindicated for the client.

Encourage the client to avoid napping during the day: ANTICIPATED

Place the client in a room away from the nurses' station: CONTRAINDICATED

Weigh the client each day: CONTRAINDICATED

Provide the client with high-calorie fluids every hour: ANTICIPATED

(NGN) The nurse is providing teaching about lithium to the client and the client's adult child. Select the 3 statements the nurse should include.

Blurred vision is an expected adverse effect of this medication

it will take at least a week before this medication reaches a therapeutic level

this medication can cause nausea and drowsiness

(NGN) The nurse is assessing the client. Which of the following findings indicates an improvement in the client's condition? (SATA)

The client engages in quiet activities in their room

The client slept 5 hours the previous night

The client consumes 8 ounces of high-calorie fluids each hour

The client takes 2 short naps during the day

A nurse in a family health clinic is caring for a client who requires information regarding the correct use of condoms. Which of the following statements should the nurse make?

a. Use of a petroleum-based lubricant with a condom increases the condom's effectiveness

b. condoms are equally effective for birth control with or without the use of vaginal spermicides

c. when using implanted contraceptive methods; condoms should also be used to protect against STD's

d. ensure that the condom fits snugly over the tip of the penis

c. when using implanted contraceptive methods; condoms should also be used to protect against STD's

A nurse is assessing the fontanelles of an 8 month old infant which of the following findings should the nurse recognize as an expected finding?

a. Both fontanelles are the same size

b. both fontanelles show molding

c. the posterior fontanelle is open

d. the anterior fontanelle is open

d. the anterior fontanelle is open

A nurses containing the temperature of a newborn. Which of the following sites should the nurse use?

a. Rectal

b. Tympanic

c. Axillary

d. Oral

c. Axillary

(NGN) A nurse is reviewing the client's electronic medical record. Which of the following findings requires follow-up?

breath sounds

WBC count

temperature

A nurse is providing care for a client who has esophageal cancer and has received radiation therapy period which of the following findings should the nurse identify as the priority?

a. Dysphagia

b. excoriation of the skin in the neck and chest

c. xerostomia

d. client reports a pain level of six on a scale from zero to 10

a. Dysphagia

A nurse is assessing a client who has type one diabetes mellitus and was administered insulin lispro one hour ago. Which of the following manifestations indicates that the client might be experiencing hypoglycemia?

a. Hot dry skin

b. acetone breath

c. confusion

d. polydipsia

c. confusion

A nurse is preparing an in-service for a group of nurses about malpractice issues in nursing. Which of the following examples should the nurse include in the teaching as an example of malpractice?

a. Document communication with a provider in the progress notes of the client's medical record

b. placing a yellow bracelet on a client who is at risk for falls

c. leaving a nasal gastric tube clamped after administering oral medication

d. administering potassium via IV bolus

d. administering potassium via IV bolus

A nurse is admitting a client to a medical surgical unit. When performing medication reconciliation for the Client, which of the following actions should the nurse take?

a. Encourage the client to make his own list after he returns to his home

b. include any adverse effects of the medications the client might develop

c. exclude nutritional supplements from the list of medications the client reports

d. compare new prescriptions with the list of medication the client reports

d. compare new prescriptions with the list of medication the client reports

A nurse is caring for an adolescent client who has cystic fibrosis. Which of the following actions should the nurse instruct the client to take prior to initiating postural drainage?

a. Take pancrealipase

b. complete oral hygiene

c. eat a meal

d. using an albuterol inhaler

d. using an albuterol inhaler

A nurse is working with a client who has an anxiety disorder and is in orientation phase of the therapeutic relationship. Which of the following statements should the nurse make during this phase?

a. We should discuss resources to implement in your daily life

b. let me show you simple relaxation exercise to manage stress

c. we should establish our rules in the initial session

d. let's talk about how you can change your response to stress

c. we should establish our rules in the initial session

A nurse manager is planning a staff in service to address advocacy and client care period the nurse should promote which of the following practices during the in service? Select all that apply.

a. Encouraging clients to seek further information from the provider

b. honoring family requests to withhold medical information

c. addressing client needs when providing resources

d. making decisions about health care on clients behalf

e. promoting health care access

a. Encouraging clients to seek further information from the provider

c. addressing client needs when providing resources

e. promoting health care access

A nurse is implementing seizure precaution for a client who has had a clonic tonic seizure. Which of the following intervention should the nurse include in the plan of care?

a. Provided tracheostomy tray at the bedside

b. place the client in supine position

c. insert an IV saline lock

d. A plastic tongue depressor at the client's bedside

c. insert an IV saline lock

A nurse is caring for a male who has a spinal cord injury. Which of the following techniques should the nurse use when providing perineal care?

a. Wash the penis from the scrotum to the tip using a spiral motion

b. use water with no soap to prevent skin irritation

c. discard the washcloth after cleansing the urethral meatus

d. don't sterile gloves to prevent infection

c. discard the washcloth after cleansing the urethral meatus

A nurse is reviewing the medical history of a client who asks about the use of warfarin. The nurse should identify which of the following findings as a contraindication for the administration of this medication?

a. Recent myocardial infarction

b. recent eye surgery

c. breast cancer

d. thrombophlebitis

d. thrombophlebitis

A nurse is caring for a client is experiencing expressive aphasia and right hemiparesis following a stroke. Which of the following actions by the nurse best promotes communication among staff caring for the client?

A. Posting swallowing precautions at the head of the client's bed

B. nothing changes in the treatment plan and the client's medical record

C. recording the client's progress and the nurse's notes

D. having interdisciplinary team meetings for the client on a regular basis

D. having interdisciplinary team meetings for the client on a regular basis

A nurse is preparing a client to undergo a cardiac catheterization. Which of the following tasks should the nurse perform prior to the procedure?

a. Administer nitroglycerin 0.4mg SL 30 minutes before the procedure

b. draw blood specimens for culture and sensitivity

c. obtain a CBC with differential

d. transport the client to radiology for a CT scan

c. obtain a CBC with differential

A nurse is caring for a client who has a new diagnosis of chlamydia trachomatis Which of the following actions should the nurse take?

a. Report the infection to the state Department of Health

b. administers attracts the phone via intermittent IV bolus

c. schedule the client for retesting in one week

d. instruct the client to abstain from sexual intercourse for one month

a. Report the infection to the state Department of Health

A nurse in an acute mental health care facility is prioritizing care for multiple clients. Which of the following clients should the nurse see first?

a. A client who has narcissistic personality disorder and is mocking others during group therapy

b. a client who has obsessive-compulsive disorder and is upset about a change in daily routine

c. a client who has depressive disorder and requires assistance with ADL's

d. a client who is taking clozapine to treat schizophrenia and reports a sore throat

d. a client who is taking clozapine to treat schizophrenia and reports a sore throat

a nurse is reviewing change of shift report for a group of clients which of the following clients should the nurse plan to assess first?

A. Our 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

C. a client who has a sinus arrhythmia and is receiving cardiac monitoring

D. a client who has diabetes mellitus and an HbA1c of 6.8%

B. a client who has a hip fracture and a new onset of tachypnea

A nurse is assessing the coping strategies of a client who has recently retired. Which of the following statements by the client indicates that the client is using compensation as a defense mechanism?

a. I'm so glad I've retired because the work was making me sick and depressed

b. since I retired I have entered many gardening competitions

c. There were layoffs on my company so I journaled about what I accomplished during my career

d. I had to retire because my boss didn't like me

c. There were layoffs on my company so I journaled about what I accomplished during my career

(NGN) A nurse is planning care for a child during admission to the facility. Which of the following actions should the nurse take first?

a. Obtain a prescription for pain medication

b. collect blood cultures

c. transport the child to obtain a CT scan

d. initiate seizure precautions

d. initiate seizure precautions

A nurse is assessing a client who has a chest tube with a water seal drainage system. Upon assessment, the nurse notes tidaling in the water seal. Which of the following is an explanation for the tidaling?

a. There is a loop of tubing below the drainage system

b. the system is working properly

c. the tubing is partially obstructed by clots

d. the lung has re expanded

b. the system is working properly

A nurse is teaching a group of school aged children about healthy snack options. Which of the following snacks should the nurse include?

a. Cheesecake

b. air popped popcorn

c. milkshake made with whole milk

d. baked potato chips

b. air-popped popcorn

he nurses teaching a client who is pregnant and has genital herpes simplex virus HSV. Which of the following statements should the nurse include in the teaching?

a. You will need to have a cesarean birth if there are any visible lesions

b. you can apply a cortisone cream to the lesions twice each day

c. you should take 600 milligrams of ibuprofen every eight hours for discomfort during an outbreak

d. your baby's cord blood will be tested to determine if she has contracted HSV

a. You will need to have a cesarean birth if there are any visible lesions

(NGN) The nurse reviews the assessment findings.

Click to highlight the findings that require immediate follow-up. To deselect a finding.

Assessment

Right forearm and fingers are edematous

Fingers slightly cool to touch

Child can move fingers and reports a mild "tingling" sensation

Multiple areas of bruising are noted on lower extremities in various stages of healing

(NGN) The nurse should determine that the assessment findings are consistent with which of the following conditions.

Edema: SPRAIN, FRACTURE, DISLOCATION

Ecchymosis: FRACTURE

Pain Level: SPRAIN, FRACTURE, DISLOCATION

Sensation: SPRAIN, DISLOCATION

(NGN) Complete the following sentence by using the lists of options.

The child is at highest risk for developing ______________ as evidenced by the child's ____________________

compartment syndrome

paesathesia

(NGN) Drag words from the choices below to fill in each blank in the following sentence

The nurse should anticipate a prescription for ____________ and ____________

surgical consultation (target 1)

pain medication (target 2)

(NGN) Select the 3 priority actions that the nurse should take

Review cast care instructions with the child's parents

administer ibuprofen 200 milligrams PO

elevate the affected forearm with pillow

A nurse is caring for a client who has a stool culture that is positive for Clostridium difficile. Which of the following infection control precaution should the nurse take?

a. Place a mask on the client prior to transport

b. wear a face shield prior to entering the client's room

c. use an alcohol based rub following client care

d. remove the protected gown while in the client's room

d. remove the protected gown while in the client's room

A nurse is providing preoperative teaching to a client about the administration of morphine via PCA pump. Which of the following statements by the client indicates an understanding of the teaching?

a. Using this machine increases my risk of overdose

b. I can get pain medication anytime as long as I press the button

c. my partner can press my pain medication button for me if I am sleeping

d. I will receive a limited amount of pain medication when I press the button

d. I will receive a limited amount of pain medication when I press the button

A nurse is caring for a client who is alert and oriented and is receiving continuous ECG monitoring. The cardiac rhythm strip shows a wavy baseline, not distinguishable P waves, and an increased heart rate. The nurse should identify the cardiac rhythm as which of the following?

a. Second-degree heart block

b. sinus tachycardia

c. Ventricular asystole

d. atrial fibrillation

d. atrial fibrillation

(NGN) After reviewing the discharge instructions with the family, which of the following statements by a parent indicates an understanding of the teaching?

"We should notify the provider if the cast becomes loose over time" REFLECT UNDERSTANDING

"It is important that our child our avoids placing anything inside the cast" REFLECT UNDERSTANDING

"We should prop the casted arm on pillows for the next 24 hours" NEEDS IMPROVEMENT

"We should expect the swelling and tingling to worsen before it gets better." NEEDS IMPROVEMENT

"We need to be very careful about how we handle the cast for the first 2 days while it dries" REFLECT UNDERSTANDING

(NGN) Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing 2 actions the nurse should take to address that conditions, and 2 parameters the nurse should monitor to assess the client's progress

ACTION TO TAKE: instruct client to apply heat and

cold(1) instruct the client to apply topical analgesics (2)

CONDITION: Osteoarthritis

PARAMETERS TO MONITOR: Lymphadenopathy and ESR