RN Comprehensive Online Practice 2026 A

When caring for a child, a nurse plans to use nonpharmacological interventions to enhance the effectiveness of pain medication. Which of the following strategies incorporates visualization techniques to help decrease the child's discomfort?

Taking a warm bath and playing with a bath toy

Coloring with crayons in a coloring book

Deep breathing and "going limp as a rag doll"

Blowing bubbles with liquid soap to "blow the hurt away"

Blowing bubbles with liquid soap to "blow the hurt away"

A nurse is providing education to a client who expresses a desire to lose weight. Which of the following recommendations should the nurse make?

"Follow the MyPlate plan."

A nurse is assigning task roles for a group of clients in a community mental health clinic. Which of the following tasks should the nurse assign to the member of the group functioning as the orienter?

Noting the progress of the group toward assigned goals

Sharing experiences as an authority figure

Offering new and fresh ideas about an issue

Measuring the group's work against the assigned objectives

Noting the progress of the group toward assigned goals

A nurse is caring for a client who has a leg cast and is returning a demonstration on the proper use of crutches while climbing stairs. Identify the sequence the client should follow. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)

Stand in the tripod position.

Move the affected leg and the crutches up to the stair.

Place the unaffected leg on the stair.

Place body weight on the crutches.

Stand in the tripod position.

Place body weight on the crutches

Place the unaffected leg on the stair.

Move the affected leg and the crutches up to the stair.

A nurse is assessing for correct placement of a client's NG feeding tube prior to administering a bolus feeding. Which of the following actions should the nurse take?

Insert air in the tube and listen for gurgling sounds in the epigastric area.

Review the medical record for previous x-ray verification of placement.

Auscultate the lungs for adventitious breath sounds.

Aspirate contents from the tube and verify the pH level.

Aspirate contents from the tube and verify the pH level.

A nurse is admitting a client to the mental health unit following a suicide attempt. The client states, "My family does not care whether I live or die." Which of the following responses should the nurse make?

"I'm sure your family does not want you to die."

"You should talk to your family about your feelings."

"How does this make you feel?"

"Why would you believe such things?"

"How does this make you feel?"

A nurse is caring for a client who is immediately postoperative following a total vaginal hysterectomy. Which of the following actions should the nurse take first?

Measure the client's vital signs.

Encourage the client to use an incentive spirometer.

Reposition the client.

Administer pain medication.

Measure the client's vital signs.

A nurse is caring for a 4-year-old preschooler in an emergency department (ED).

After completing the assessment and reviewing the preschooler's medical record, which of the following actions should the nurse plan to take?

Administer an antipyretic.

Place the preschooler on the affected side.

Prepare the preschooler for a CT scan of the abdomen.

Administer supplemental oxygen.

Obtain a sweat chloride test.

administer supplemental oxygen, place the preschooler on the affected side, and administer an antipyretic.

A nurse is caring for a client who has fluid volume overload. Which of the following tasks should the nurse delegate to an assistive personnel (AP)?

Measure the client's daily weight.

Palpate the degree of edema.

Assess the client's vital signs.

Regulate IV pump fluid rate.

Measure the client's daily weight.

A nurse is caring for a group of clients. Which of the following clients should the nurse attend to first?

A client who has kidney failure and returned from dialysis 4 hr ago

A client who has a terminal illness and is requesting a visit from the chaplain

A client who is anxious and attempting to pull out an IV line

A client who is reporting nausea after receiving pain medication

A client who is anxious and attempting to pull out an IV line

A nurse is providing discharge teaching about the use of car seats to the guardian of a newborn. Which of the following statements by one of the guardians indicates an understanding of the teaching?

"I should ensure that the harness is snug around my baby's body."

"I should position my baby's car seat so that it's facing the front of the vehicle."

"I should position the retainer clip over my baby's stomach."

"I should dress my baby in bulky clothing to provide cushioning beneath the retainer clip."

"I should ensure that the harness is snug around my baby's body."

A nurse is reviewing the laboratory results of a toddler who has hemophilia A. Which of the following aPTT (30 to 40 seconds) values should the nurse expect?

11 seconds

30 seconds

22 seconds

45 seconds

45 seconds

A nurse manager is planning to make changes to the current scheduling system on the unit. To facilitate the staff's acceptance of this change, which of the following actions should the nurse manager take first?

Provide information about scheduling issues to the staff.

Develop goals to implement the new scheduling system.

Ask staff members to participate in a trial of the new scheduling system.

Encourage staff to offer alternate scheduling solutions.

Provide information about scheduling issues to the staff.

A nurse is caring for a client admitted with profuse vomiting and abdominal pain.

The client is at risk for developing "blank" due to "blank"

Peritonitis due to bowel obstruction.

The client is one day postoperative following a thyroidectomy.

Select the 2 findings the nurse should report to the provider.

Heart Rate

Dressing

A nurse is preparing an educational session about infection control measures. Which of the following statements should the nurse plan to make?

"You should wear a N95 mask for clients who require droplet precautions."

"You should wear sterile gloves when touching clients' contaminated items."

"You should wear eye goggles if splash is likely from a client's body fluids."

"You should don a gown before entering the room of a client who is on droplet precautions."

"You should wear eye goggles if splash is likely from a client's body fluids."

A nurse is discussing dietary sources of iron with a client who has anemia. Which of the following foods should the nurse identify as containing the most iron?

One slice of whole wheat bread

A nurse is providing teaching to a client who has HIV and a new prescription for combination antiretroviral therapy (cART). Which of the following client statements should the nurse recognize as an indication of understanding the teaching?

"I should not skip a dose of my medication, even if it makes me nauseous."

"I will not need to wear condoms during sex when I am on this treatment."

"I understand the goal of this treatment is to lower my CD4-T-cell count and increase my viral load."

"I should expect to develop a skin rash during the first few weeks of treatment."

"I should not skip a dose of my medication, even if it makes me nauseous."

A nurse is caring for a client who is receiving mechanical ventilation, and the low-pressure alarm sounds from the ventilator machine. Which of the following actions should the nurse take?

Administer the prescribed sedative to the client.

Empty the water from the ventilator tubing.

Suction the client's oral airway.

Check the tubing for disconnection.

Check the tubing for disconnection.

A nurse is preparing to administer heparin 5,000 units subcutaneously. Available is heparin injection 10,000 units/mL. How many mL should the nurse administer per dose? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)

0.5mL

A nurse in an outpatient diabetes clinic is planning care for a group of clients who have diverse cultural backgrounds. Which of the following actions should the nurse plan to take?

Prioritize appointments for clients who appear most motivated.

Ask each client about cultural or social factors that may affect care.

Provide the standard printed unit information sheet for each client.

Make referrals for each client before completing additional screenings.

Ask each client about cultural or social factors that may affect care.

A nurse is assessing a client who is taking propranolol. Which of the following findings should indicate to the nurse that this client is experiencing an adverse reaction to propranolol?

Weight loss

Wheezing

Blood pressure 146/92 mm Hg

Heart rate 110/min

Wheezing

A nurse is caring for a client who is in labor at 39 weeks of gestation. During the second stage of labor, the nurse observes early decelerations on the monitor tracing. Which of the following actions should the nurse take?

Prepare the client for continuous internal monitoring.

Assist the client to a knee-chest position.

Continue observing the fetal heart rate.

Prepare for an emergency cesarean birth.

Continue observing the fetal heart rate.

A nurse is educating a client who was recently diagnosed with chronic obstructive pulmonary disease (COPD). Which of the following instructions should the nurse include?

"Use a humidifier to keep the air moist."

"Avoid physical activity to conserve energy."

"Limit fluid intake to 1,000 milliliters per day."

"Consume a high-calorie, low-protein diet."

"Use a humidifier to keep the air moist."

A nurse is preparing to administer penicillin V PO 25 mg/kg/day to a child who weighs 44 lb. The dosage available is 250 mg/5 mL. How many mL will the nurse administer daily? (Round your answer to the nearest tenth. Do not use a trailing zero.)

10mL

A nurse is caring for a newborn immediately after delivery. Which of the following interventions should the nurse implement to prevent heat loss by conduction?

Maintain an ambient room temperature of 24° C (75.2° F).

Place the newborn's bassinet away from outside windows.

Use a protective cover on the scale when weighing the infant.

Dry the newborn immediately after birth.

Use a protective cover on the scale when weighing the infant.

A newly licensed nurse reports to their preceptor concerns about their ability to complete assignments. Which of the following time-management strategies is appropriate for the preceptor to suggest? (Select all that apply.)

Group activities together that should be performed on the same client.

Document nursing interventions at the end of the shift.

Develop a schedule that prioritizes client care.

Ensure that all equipment has been gathered for a procedure before entering a client's room.

Delegate selected tasks to an assistive personnel.

Group activities together that should be performed on the same client.

Ensure that all equipment has been gathered for a procedure before entering a client's room.

Delegate selected tasks to an assistive personnel.

Develop a schedule that prioritizes client care.

A nurse in a pediatric clinic is assessing the reflexes of a 1 week old newborn. Which of the following images demonstrates the correct procedure to elicit the plantar grasp reflex?

The nurse should elicit the plantar grasp reflex by touching the soles of the infant's feet near the base of the digits, causing flexion of the toes.

A nurse is planning care for a client who is receiving heparin to treat a deep vein thrombosis of the left lower leg. Which of the following interventions should the nurse include in the plan of care?

Elevate the affected leg.

Place cool compresses on the edematous area.

Maintain the client on bed rest.

Restrict the client to 1 L of fluid per day.

Elevate the affected leg.

A nurse in a clinic receives a call from a guardian whose child has varicella. The guardian asks when the child can return to school. Which of the following responses should the nurse make?

"When the lesions no longer itch."

"When the lesions disappear."

"When crusts have formed on every lesion."

"Three days after the lesions appeared."

"When crusts have formed on every lesion."

A home health nurse is caring for a group of older adult clients. The nurse should initiate a referral to the Program of All-Inclusive Care for the Elderly (PACE) for which of the following clients?

A client whose caregiver requests adult day care services

A client who requires transfer to a skilled care facility

A client who qualifies for telehealth for pacemaker diagnostics

A client whose family requests hospital-based hospice care

A client whose caregiver requests adult day care services

A nurse is caring for a client who is 12 hr postoperative, is receiving PCA for pain control, and requires a blood pressure check in 10 min. Which of the following staff members should the nurse assign to collect this information?

An assistive personnel (AP) who just began performing a bed bath

An RN who is monitoring a client who started receiving a blood transfusion 5 min ago

An assistive personnel (AP) who is assisting a client to return to bed

A licensed practical nurse (LPN) who is reinforcing discharge instructions with a client

An assistive personnel (AP) who is assisting a client to return to bed

A nurse manager is preparing a newly licensed nurse's performance appraisal. Which of the following methods should the nurse manager use to evaluate the nurse's time management skills?

Review client satisfaction reports about the nurse's performance.

Ask another staff nurse to evaluate the nurse's time management skills.

Compare the nurse's time management skills to the skills of coworkers.

Maintain regular notes about the nurse's time management skills.

Maintain regular notes about the nurse's time management skills.

A nurse is caring for four clients. Which of the following clients should the nurse assign to an assistive personnel (AP) to assist with meals?

A client who had diabetic ketoacidosis and is difficult to rouse

A client who has asthma and an increased respiratory rate

A client who had a stroke and is to start oral intake

A client who has Alzheimer's disease and is demonstrating aphasia

A client who has Alzheimer's disease and is demonstrating aphasia

A nurse is planning care for a client who has dementia. Which of the following interventions should the nurse include?

Ensure doors are labeled with written signs.

Provide dim lighting at night.

Maintain a stimulating environment.

Evaluate the client for a tendency to wander.

Evaluate the client for a tendency to wander.

A nurse is providing teaching to a client about how to ambulate with a standard nonwheeled walker. Which of the following statements by the client indicates understanding?

"I should keep my elbows straight when using the walker."

"I should pick the walker up and move it forward."

"I should lean over when using the walker."

"I should start with both feet behind the walker."

"I should pick the walker up and move it forward."

A nurse is caring for a client who has thrombocytopenia and is scheduled to receive IM injections of vitamin B12 and a pneumococcal vaccine. Which of the following actions should the nurse plan to take?

Obtain an 18-gauge needle to administer the medications.

Massage the injection site after administering the medications.

Administer the medications subcutaneously.

Clarify the medications with the provider.

Clarify the medications with the provider.

A nurse in an outpatient mental health clinic is working with a client who has posttraumatic stress disorder (PTSD) and asks the nurse to recommend a nonpharmacological therapy to use to provide relief of the manifestations. Which of the following complementary therapies should the nurse teach the client to use to help alleviate the distress?

Acupuncture

Guided imagery

Therapeutic touch

Spinal manipulation

Guided imagery

A nurse in a prenatal clinic is teaching a client about foods to avoid during pregnancy to decrease the risk of listeriosis. Which of the following images identifies a food the nurse should include in the teaching?

Pineapple

Eggs

Salami and Luncheon meats

Salmon

salami and other luncheon meats can harbor the bacteria Listeria

A nurse is caring for a newly admitted client. The client tells the nurse, "I'm afraid to go to sleep because I'm worried I will not wake up." Which of the following responses should the nurse make?

"Don't worry. Everything will be okay."

"Let's discuss this in the morning after you have had a chance to settle in."

"Would you like your provider to prescribe medication to help you sleep?"

"Would you like to talk about your concerns?"

"Would you like to talk about your concerns?"

A hospice nurse is consulting with a client and their family about receiving home services. Which of the following statements should the nurse identify as an indication that the family understands home hospice care?

"Now that my mother is receiving hospice services, we will not be able to get respite care."

"A hospice nurse will come to the house each time our mother needs pain medication."

"We can expect the hospice nurse to provide support for us after our mother's death."

"Hospice care focuses on arranging treatment that will prolong our mother's life."

We can expect the hospice nurse to provide support for us after our mother's death."

A nurse is caring for four clients. Which of the following tasks should the nurse delegate to an assistive personnel (AP)?

Assess I&O for a client who is receiving dialysis.

Evaluate dietary intake for a client who has anorexia.

Measure the vital signs of a client who just returned from the PACU.

Arrange the lunch tray for a client who has a hip fracture.

Arrange the lunch tray for a client who has a hip fracture.

A nurse is caring for a client who has a pulmonary embolism. The client is receiving heparin via continuous IV infusion at 1,200 units/hr and warfarin 5 mg PO daily. The morning laboratory values for the client are aPTT 98 seconds (30 to 40 seconds) and INR 1.8 (0.8 to 1.1). Which of the following actions should the nurse take?

Prepare to administer vitamin K1.

Withhold the heparin infusion.

Prepare to administer alteplase.

Withhold the next dose of warfarin.

Withhold the heparin infusion.

A nurse is facilitating a group family session for a client who has a substance use disorder. One of the family members is remaining silent. Which of the following statements should the nurse make?

"You are being very quiet. The rest of your family would like your input to know what you are feeling."

"You need to tell us your feelings so everyone is on board with this situation."

"You have been affected by this situation, too. How does it make you feel?"

"You haven't added anything to the conversation recently. Is there anything you would like to say?"

"You have been affected by this situation, too. How does it make you feel?"

A nurse on an inpatient unit is caring for a client who has schizophrenia and recently started taking risperidone. Which of the following actions should the nurse take?

Place the client on a fluid restriction.

Monitor the client's thyroid function.

Discontinue the medication if hallucinations occur.

Implement fall precautions for the client.

Implement fall precautions for the client.

A charge nurse is observing a newly licensed nurse administer enteral feedings via nasogastric (NG) tube. Which of the following actions by the newly licensed nurse indicates an understanding of the procedure?

Keeps the head of the bed elevated to a 45° angle after feeding is completed

Instills 100 mL of air into the NG tube after checking for residual

Flushes the NG tube with 0.9% sodium chloride irrigation every 2 hr

Uses cranberry juice to unclog the NG tube

Keeps the head of the bed elevated to a 45° angle after feeding is completed

A nurse is caring for a client who has schizophrenia and is exhibiting the finding of associative looseness. Which of the following actions should the nurse take?

Protect the client's feelings by pretending to understand the disorganized speech.

Reinforce to the client that it is inappropriate to use rhyming words in conversation.

Offer the client an opportunity to collect their thoughts and begin the conversation again.

Tell the client they are having difficulty understanding what the client is saying.

Tell the client they are having difficulty understanding what the client is saying.

A nurse is assessing a newborn who is 2 hr old. Which of the following findings should the nurse report to the provider?

Slightly blue hands and feet

Respiratory rate 40/min

Axillary temperature 36.2° C (97.2° F)

Apical pulse 136/min

Axillary temperature 36.2° C (97.2° F)

A nurse is caring for a client who has hyperthyroidism. Which of the following findings should the nurse expect?

Dry, coarse hair

Bradycardia

Periorbital edema

Tremors

Tremors

A nurse is caring for a client who is postpartum.

Click to highlight the findings that increase the client's risk for a postpartum complication. To deselect a finding, click on the finding again.

IV oxytocin started at 2 mU/min per provider's order to augment labor

weighing 4082 g (9 lb 0 oz).

The nurse determines that the client's assessment findings are consistent with

Postpartum hemorrhage

A nurse is caring for a client who is postpartum.

Based on the assessment findings, the nurse should address the client's uterus and the client's bladder

A nurse is caring for a client who is postpartum.

After reviewing the client's medical record, for each body system below, click to specify the potential nursing action that would be most appropriate for the care of the client. Choose the most likely response for the dropdowns in the table below by choosing from the lists of options.

Reproductive = massage fundus.

Cardiovascular = Administer IV fluids

Genitourinary = assisting the client to void

The nurse is caring for a client who is postpartum.

Which of the following actions should the nurse take?Select all that apply.

Increase oxytocin infusion as prescribed.

Assess for perineal laceration.

Continue frequent fundal massage.

Inserting an indwelling urinary catheter.

The nurse is caring for a client who is postpartum.

The nurse reassesses the client to determine the client's response to the interventions.

Which of the following findings indicate the client is improving?

Select the 3 assessment findings that indicate the client is improving.

Fundal location

Lochia

Blood Pressure

A nurse is caring for a client who is attempting to pull out their indwelling urinary catheter. The nurse should identify that which of the following types of restraints is least restrictive?

A jacket restraint

A wrist restraint

A mitt restraint

A belt restraint

A mitt restraint

A nurse is caring for a client who states "My cancer has returned because God has abandoned me." Which of the following responses should the nurse make?

"It seems like you are upset at God."

A nurse is assessing a client who has a chest tube attached to wall suction. The nurse observes that there is no bubbling of water in the water seal chamber. Which of the following actions should the nurse take?

Increase the amount of suction.

Add water to the water seal chamber.

Strip the tubing.

Check to see if the chest tube is kinked.

Check to see if the chest tube is kinked.

A nurse in an outpatient setting is caring for a client.

what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.

most likely experiencing pyelonephritis

Action to take:

prepare to administer antibiotics.

encourage increased fluid intake.

Parameter to Monitor:

BUN level

Fever

A night shift nurse is giving change-of-shift report to the day shift nurse on a client who is ready for discharge. Which of the following information is the priority for the nurse to communicate to the oncoming nurse?
The client will have a visit by a home health nurse tomorrow.

The client's partner will bring clothes for the client to change into prior to discharge.

The client needs assistance when transferring from the bed to a wheelchair.

The client often needs encouragement to engage in personal hygiene activities.

The client needs assistance when transferring from the bed to a wheelchair.

!!!Think Safety!!!

A nurse is caring for a client who has alcohol use disorder who states, "If my partner wasn't nagging me, I wouldn't drink as much." Which of the following defense mechanisms is the client demonstrating?

Undoing

Displacement

Rationalization

Repression

Rationalization

A nurse is caring for a client following a lobectomy who has two mediastinal chest tubes connected to a closed drainage system. Which of the following actions should the nurse take?

Empty drainage from the system every 4 hr.

Check for kinks in the tubing.

Place the drainage system near the head of the client's bed.

Clamp the chest tubes for at least 4 hr daily.

Check for kinks in the tubing.

A nurse is caring for a client in an inpatient mental health facility.

Select the 2 findings from the client's medical record that are manifestations of borderline personality disorder (BPD).

Skin assessment

Behavior toward roommate

A nurse is providing teaching to a client who is at 24 weeks of gestation and is scheduled for a 3-hr oral glucose tolerance test. Which of the following instructions should the nurse include in the teaching?

"A blood sample will be collected every 15 minutes during the test."

"You will need to fast the night before the test."

"Limit your fat intake for 72 hours before the test."

"We will collect a urine sample the day after testing."

"You will need to fast the night before the test."

A nurse is caring for a client who is scheduled to receive a dose of bumetanide. Which of the following client findings should cause the nurse to hold this medication until further review?

BUN 8 mg/dL (10 to 20 mg/dL)

Potassium 6 mEq/L (3.5 to 5 mEq/L)

Chloride 110 mEq/L (98 to 106 mEq/L)

Sodium 123 mEq/L (136 to 145 mEq/L)

Sodium 123 mEq/L (136 to 145 mEq/L)

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

Extreme mood swings

Sensitivity to rejection

Self-mutilating behavior

Lack of remorse

Lack of remorse

A nurse is providing discharge teaching to a client who is recovering from an acute episode of diverticulitis. Which of the following instructions should the nurse include?

Limit intake of oral fluids.

Perform 1 hr of strenuous exercise daily.

Use an enema daily.

Increase intake of high-fiber foods.

Increase intake of high-fiber foods.

A nurse is providing discharge teaching to a client who has colorectal cancer and a new colostomy. The client states, "I'm worried about being discharged because I live alone, and my insurance doesn't cover ostomy supplies." Which of the following actions should the nurse take?

(Select all that apply.)

Postpone the discharge until someone can stay with the client.

Provide the client with information about the American Red Cross.

Initiate a consult with a home health care provider.

Give the client information about local support groups.

Refer the client to a community-based social worker.

Initiate a consult with a home health care provider.

Give the client information about local support groups.

Refer the client to a community-based social worker.

A nurse is providing discharge teaching about disease management for a client who has a new diagnosis of type 1 diabetes mellitus. Which of the following activities is the nurse's priority?

Explain proper foot care techniques to the client.

Encourage the client to participate in daily exercise.

Ensure that the client understands the medication regimen.

Instruct the client about the importance of regular medical appointments.

Ensure that the client understands the medication regimen.

A nurse is caring for a school-age child who is experiencing status asthmaticus. For which of the following medications should the nurse anticipate a stat prescription?

Montelukast

Salmeterol

Cromolyn

Albuterol

Albuterol

A nurse on the pediatric unit is providing care for an infant who is 2 months old.

Which of the following findings should the nurse recognize require immediate follow-up? Select all that apply.

Abdominal findings

Weight

BUN value

Pain rating

The infant has returned from diagnostic studies.

specify if the assessment finding is consistent with intussusception, gastroesophageal reflux, or hypertrophic pyloric stenosis.

intussusception:

Vomiting, irritability, weight trends

Gastroesophageal reflux:

vomiting, irritability, weight trends

Hypertrophic pyloric stenosis:

vomiting, palpable small ovaloid lesion in epigastric area, weight trends, hunger after feedings

The infant has returned from diagnostic studies.

The nurse should identify the complication the infant is at risk for developing is "blank"

as evidenced by the infant's "blank"

Metabolic Alkalosis

Chloride lab result

The infant has returned to the pediatric unit following diagnostic studies.

For each potential provider order, click to specify if the potential order is anticipated or not anticipated for the infant.

Anticipated:

Administer IV fluids

Initiate strict intake and output

Witness parental signature on surgical consent form.

Initiate NPO.

Provide nonnutritive sucking.

Not Anticipated:

Administer oxygen via nasal cannula

Initiate contact precautions.

The nurse is caring for the infant upon return to the pediatric unit.

The nurse is providing postoperative care. Which of the following actions should the nurse take?

Select the 2 actions the nurse should take.

Change dressing every 2 hr until discharge.

Begin feedings with formula or human milk within 1 hr after surgery.

Administer analgesics around the clock.

Insert NG tube.

Inspect incision for erythema and drainage.

The infant has returned from the procedure.

A nurse is evaluating the infant findings 1 day following a pyloromyotomy. Which of the following findings indicate a potential postoperative complication that the nurse should address?

Temperature 38.4° C (101.2° F) axillary

SpO2 92% on room air

FLACC pain scale rate: 8

Dressing with moderate amount of bright sanguineous drainage.

Projectile vomiting noted after each feeding.

A nurse is caring for a client who has schizophrenia. The client states, "The FBI told me you are the enemy" while shaking a fist at the nurse. Which of the following statements should the nurse make first?

"I understand that you believe the FBI wants me to hurt you."

"I am your nurse and I don't want to hurt you."

"If you continue to use threatening behavior additional measures will be implemented."

"I am not your enemy."

"I am your nurse and I don't want to hurt you."

A nurse is caring for a client whose morning dose of furosemide was not administered. Which of the following actions should the nurse take first?

Complete an incident report.

Notify the charge nurse of the omission.

Check the client's condition.

Administer the medication.

Check the client's condition.

A nurse is providing teaching to a client who has hypertension. Which of the following oral over-the-counter medications should the nurse instruct the client to avoid?

Acetaminophen

Dextromethorphan

Phenylephrine

Diphenhydramine

Phenylephrine

A nurse is preparing to administer a combination of NPH insulin and regular insulin into the same syringe for a client who has diabetes mellitus. After injecting the air into the vial of NPH insulin, what action should the nurse take next?

Inject air into the vial of regular insulin.

Label the syringe with the total number of units of insulin.

Verify the withdrawn dose of NPH insulin with another nurse.

Withdraw the prescribed dose of NPH insulin from the vial.

Inject air into the vial of regular insulin.

A nurse is preparing a client who is in the third trimester of pregnancy for a nonstress test (NST) to assess fetal well-being. Which of the following actions should the nurse take to prevent complications during the test?

Position the client in a semi-Fowler's position with a wedge under one hip.

Ask the client to fast for 4 hr before the test.

Instruct the client to not empty their bladder until after the test.

Administer intravenous oxytocin before starting the test.

Position the client in a semi-Fowler's position with a wedge under one hip.

A nurse is caring for a postoperative client following a perineal prostatectomy.

For each potential postoperative complication below, click to specify the nursing intervention that the nurse should implement.

Pain and discomfort: Administer an antispasmodic medication PRN

Constipation: Encourage the client to drink prune juice.

DVT prevention: Instruct the client to perform calf pump and foot circle exercises.

A nurse is planning care for a client who has Clostridium difficile. Which of the following actions should the nurse plan to take?

Obtain a prescription for fluconazole.

Initiate contact precautions.

Initiate protective precautions.

Wear an N95 mask.

Initiate contact precautions.

A nurse is assessing a newborn following a vaginal delivery. Which of the following findings should the nurse report to the provider?

Nasal flaring

A nurse is teaching home wound care to the family of a child who has a large wound. Which of the following interventions should the nurse recommend?

Apply heat to the wound for 10 min, four times per day.

Apply 0.9% sodium chloride if the dressing sticks to the wound during removal.

Apply an over-the-counter cream if the wound becomes infected.

Clean the wound twice a day with povidone-iodine.

Apply 0.9% sodium chloride if the dressing sticks to the wound during removal.

A nurse is caring for a client in an outpatient setting.

Complete the following sentence by using the lists of options.

The client is most likely developing heart failure as evidenced by the client's BNP level,

A nurse is providing discharge teaching to a client who is postpartum about perineal care following an episiotomy. Which of the following instructions should the nurse give to the client?

Take warm sitz baths twice per day.

Increase the amount of time spent sitting upright.

Apply heat packs to the perineum.

Avoid using perineal creams or sprays.

Take warm sitz baths twice per day.

A nurse is reviewing laboratory results for a client who has a diagnosis of recurrent deep vein thrombosis (DVT) and is receiving warfarin. The client's International Normalized Ratio (INR) is 5.2 (2 to 3). Which of the following should the nurse anticipate will occur with the next scheduled administration of warfarin?

The warfarin dose will be increased.

The warfarin will be discontinued.

The warfarin dose will be held.

The warfarin dose will be unchanged.

The warfarin dose will be held.

(Above the therapeutic range)

A nurse is caring for an adolescent who reports nausea, shortness of breath, and an inability to concentrate during examinations at school. Which of the following instructions should the nurse give the adolescent?

"Make sure you get at least 6 hours of sleep the night before every examination."

"Limit watching television to no more than 3 hours per day."

"Exercise at least 30 minutes every day."

"When you feel that way, take three or four slow, deep breaths."

"When you feel that way, take three or four slow, deep breaths."

A nurse is caring for a client in an emergency department.

Specify if the finding requires follow-up and does not require follow-up the client.

Requires follow up: Blood pressure, Hemoglobin A1C, Heart rate, BMI

Does not require follow up: Sodium, BUN

A nurse is observing an assistive personnel (AP) transferring a client from bed to bedside chair. The nurse determines the AP is safely transferring the client when they observe which of the following actions?

The AP straightens their hips and knees while lowering the client into the chair.

The AP grasps the client's hands to pull them to a standing position.

The AP uses a rocking motion to assist the client to a standing position.

The AP stands with their feet closely together

The AP uses a rocking motion to assist the client to a standing position.

A nurse in a provider's office is caring for a client.

The nurse is assessing the client. Which of the following findings should the nurse identify as manifestations of a urinary tract infection?

Select all that apply.

Frequency

Dysuria

Urgency

A nurse in a provider's office is caring for a client.

Which of the following provider prescriptions should the nurse anticipate for this client?

Select the 4 prescriptions the nurse should anticipate.

Educate client on new prescription for phenazopyridine.

Educate client on new prescription for furosemide.

Collect urine specimen for urinalysis.

Collect urine specimen for urine culture.

Initiate home oxygen therapy regimen.

Educate client on new prescription for sulfamethoxazole/trimethoprim.

Educate client on new prescription for phenazopyridine.

Educate client on new prescription for sulfamethoxaxole/trimethoprim.

Collect urine specimen for urinalysis.

Collect urine specimen for urine culture.

A nurse in a provider's office is caring for a client.

The client is at highest risk for developing "blank" as evidence by the clients "blank".

pyelonephritis

urinalysis results

A nurse in a provider's office is caring for a client.

The nurse is planning to teach the client how to prevent further UTIs from occurring. Which of the following instructions should the nurse plan to include?

Drink approximately 4 L of fluids daily.

Void every 4 to 6 hr during the day.

Gently cleanse the perineum before intercourse.

Drink orange juice daily.

Gently cleanse the perineum before intercourse.

The client returns to the provider's office 3 days later.

Which of the following assessment findings should the nurse report to the provider as unexpected?

Assessment Finding

Expected

Unexpected

Oxygen saturation

Skin

Blood pressure

Voiding pattern

Urine color

Bowel elimination

Temperature

Expected:

urine color

voiding pattern

oxygen saturation

blood pressure

Unexpected:

temperature

skin

bowel elimination

A nurse manager is reviewing unit records and discovers that client falls occur most frequently during the hours of 0530 and 0730. Which of the following actions should the nurse take when conducting a root cause analysis?

Investigate environmental factors that might be contributing to client injury during these hours.

Review the performance evaluations of nurses who work during these hours.

Implement a plan to transition from team nursing to primary care nursing during these hours.

Discuss a plan with the providers to reduce the use of barbiturate sedatives prior to these hours.

Investigate environmental factors that might be contributing to client injury during these hours.

A nurse is performing an admission assessment of a preschooler who is in the acute phase of Kawasaki disease. Which of the following findings should the nurse expect?

Decreased heart rate

Peeling of the soles of the feet

Fever unresponsive to antipyretics

Pain in weight-bearing joints

Fever unresponsive to antipyretics

A nurse is teaching a client who is at 20 weeks of gestation about common discomforts associated with pregnancy. Which of the following statements by the client indicates an understanding of the teaching?

"I will sleep flat on my back if I develop back pain."

"I will wear a supportive bra overnight."

"I will apply hydrocortisone cream if I develop a rash on my face."

"I will decrease my intake of high-fiber foods."

"I will wear a supportive bra overnight."

A nurse is providing teaching to a client who has a new prescription for phenelzine. Which of the following foods should the client avoid while taking this medication?

Yogurt

Liver

Fresh tomatoes

Grapefruit juice

Liver