I have a dream 12/5

A nurse is teaching an assistive personnel about a upper body mechanics to prevent injury. Which of the following actions by the AP demonstrate an understanding of the teaching?

The AP keeps the object he is lifting close to his body

a nurse is assessing a client who is immobile and notices a red area over the client's coccyx. Which of the following actions should the nurse take?

Assess the red area for blanching

a nurse is preparing to insert an iv catheter for a client following a right mastectomy. Which of the following veins should the nurse select when initiating an IV therapy?

The cephalic vein in the left distal forearm

a nurse is providing teaching to a client about colorectal cancer prevention guidelines. Which of the following recommendations should the nurse include?

Reduce intake of red meats

a nurse is planning care to prevent skin breakdown for a client who is immobile and is urinary incontinent. Which of the following actions should the nurse include in the plan of care?

Request a prescription for an indwelling urinary catheter

a nurse is preparing to apply a condom catheter for a client who is uncircumcised which of the following actions should the nurse plan to take?

Place adhesive tape directly on the penis

a nurse is teaching a client who had an enucleation about care of an artificial eye. Which of the following information should the include in the teaching? (select all that apply)

-Apply pressure just below artificial eye to break the suction

-Retract the upper and lower lids to reinsert the artificial eye

a nurse is reviewing client confidentiality with a newly licensed nurse. The nurse should identify which of the following examples as a violation of HIPPA?

Discussing the clients transfer to a long-term care facility with a nurse from another unit

a nurse is caring for a client who is 2 days postoperative following bowel resection and reports sudden severe abdominal pain. Which of the following actions should the nurse take first?

Expose the clients abdomen to look for changes in appearance

11. a nurse is providing care for a client who is to undergo a total laryngectomy. Which of the following interventions is the nurses priority?

For the client explain the techniques of esophageal speech

12. a home care nurse is teaching a client about home safety. Which of the following statements by the client indicates an understanding of the teaching? (select all that apply)

-I will use the bars when getting in and out of the bathtub

-I need to check my medications for expiration dates

-I need to have a fire escape plan with my family

13. a nurse is assessing a client's cranial nerve VII. Which of the following responses should the nurse expect?

The client has a symmetrical smile

14. a nurse in an emergency department is assessing a client who reports a right lower quadrant pain, nausea and vomiting for the past 48 hours? Which of the following actions should the nurse take first?

Auscultate bowel sounds

15. a nurse is caring for a client who recently received a diagnosis of terminal cancer. Which of the following statements by the clients partner indicates maladaptive coping?

I am going to ask my daughter to come and stay for a week

16. a nurse is planning care for a client who has a stage 1 pressure ulcer on the right heel. The nurse should anticipate application of which of the following dressings?

Transparent

17. a nurse is caring for a client who has brain cancer and is transferring to hospice care. The client's son tells the nurse "I don't know what to tell my dad if he asks how he is going to die". Which of the following is an appropriate response from the nurse?

I think you should discuss this with the hospice nurse

18. a nurse is teaching an older adult client who has type 2 diabetes mellitus about how to care for corns and calluses toes. Which of the following statements by the client indicates understanding of the teaching?

I can apply lotion to soften calluses as long as I don’t put lotion in between my toes.

19. a nurse is caring for a client who has wrists restraints after an episode of violent behavior. Which of the following actions should the nurse take?

Tie the restraints to the side rale

20. a nurse is admitting a client who has a clostridium difficile infection. Which of the following actions should the nurse take? Select all that apply

-Wear a gown and gloves when providing client care

-Wash hands with soap and water after contact with the client

21. a nurse is planning care for a client who has latex allergy and is scheduled for surgery. Which of the following actions is appropriate to include in the clients plan of care?

Remove the stop stocks from iv tubing

22. a nurse is providing discharge teaching to a client who does not speak the same language as the nurse. Which of the following actions should the nurse take?

Direct verbal discharge instructions to the interpreter

23. a nurse is teaching a client how to self-administer daily low dose heparin injections. Which of the following factors is most likely to increase the clients motivation to learn?

The nurse explaining the need for education to the client

24. a nurse is preparing to teach a female client about osteoporosis prevention. Which of the following recommendations should the nurse make for this client?

Walk for 30 mins 3 to 5 times a week

25. a nurse is caring for a client who is receiving continuous enteral feedings through gastrostomy tubes. Which of the following actions should the nurse take?

Flush the tubing with 10 ml of water every 2 hours

26. a nurse is caring for a client who has an incisional wound and a prescription for wound care. Which of the following images indicates the proper method of cleaning a wound site?

[cleaning the wound from top to bottom and from the center to the outside]

27. a nurse is caring for a client who reports a pain level of 5 on a scale of 0- 10. The client informs the nurse that pain medications is not an option for managing pain. Which of the following is an appropriate response by the nurse?

Why do you think pain medication is not going to help you

28. a nurse is teaching a client who requires maximum support about how to use a two wheeled walker. Which of the following actions by the client indicates an understanding of teaching?

The client moves the walker ahead 10 inches with each step

29. a nurse is caring for a client who refuses to follow the providers prescription for bed rest. The nurse over hears an assistive personnel tell the client that if she does not remain in bed he will place her in restraints. The nurse should identify that the AP is committing which of the following torts?

Assault

30. a nurse is preparing to insert an IV catheter for an older adult client who has fragile skin. Which of the following actions should the nurse take?

Engorge the vein by placing the arm in the dependent position

31. a nurse is planning care for a client who has a new prescription for parental nutrition in 20% dextrose and fat emulsion. Which of the following is the appropriate action to indicate in the plan of care?

Prepare the client for a central venous line

32. a nurse is caring for a client who is schedule for surgery while witnessing the client signature. While the client is saying I trust my doctor, but I don't understand what he meant when he said he'll reset my intestines. Which of the following actions should the nurse take?

Notify the provider

33. a nurse is caring for a client who is agitated and threatening to harm others. The nurse places the client in restraints but does not notify the provider or obtain a prescription for the restraints. The situation respects which of the following torts?

False imprisonment

34. a nurse is conducting a Webber test on a client. Which of the following is an appropriate action for the nurse to take?

Place an activated tuning fork in the middle of the clients forehead

35. a nurse Is caring for a client who is 6 hours postoperative abdominal surgery and who is having difficulty voiding. Which of the following actions should the nurse take?

Encourage fluid intake up to 1000 ml daily

36. a nurse is preparing to use the Z track method to administer iron dextran to a client who has an iron deficiency anemia. The client asks why this method of injection is necessary. Which of the following responses should the nurse make?

It minimizes tissue irritation

37. a nurse on a medical unit is caring for a group of client's for which of the following tasks should the nurse wear a face shield?

Suctioning a clients tracheostomy tube

38. an adult client tells a nurse about recent lack of sleep due to changing to a night shift job. Which of the following interventions should the nurse suggest?

Listen to soft music before lying down

39. a nurse is teaching a group of newly licensed nurses about the Braden scale. Which of the following responses by a newly licensed nurse indicates understanding in the teaching?

The scale measures six elements

40. a nurse is planning care for client who is scheduled for an intravenous pyelogram. Which of the following actions is appropriate for the nurse to include?

Ensure the client is free of medal objects

41. a nurse in a long term care facility is planning care for 4 client's. which of the following client's is at greatest risk of developing a pressure ulcer?

Client who is unresponsive to pain stimuli

42. a nurse is preparing to perform a sterile dressing change for a client. Which of the following actions should the nurse plan to take?

Setup the sterile field above the waist level

43. a nurse is caring for a client who has a new diagnosis for fibromyalgia. The client tells the nurse that she wants to use traditional Chinese medicine for treatment instead the medication prescribed by the provider. Which of the following is an appropriate response by the nurse?

You should ask your provider if she recommends traditional Chinese medicine

44. a nurse is teaching newly licensed nurse about the care of a client who has a MRSA infection. Which of the following statements by the newly licensed nurse indicates understanding of the teaching?

I will tell the client's visitors to wear a mask when they are within 3 feet away of the client

45. a nurse is caring for a client who reports that she has insomnia. Which of the following interventions is appropriate for the nurse to recommend?

Exercise 1 hour before bedtime

46. a staff nurse is teaching a newly hired nurse about alternatives to the use of restraints on clients who are confused. Which of the following instructions should the staff nurse include?

Check on the client frequently while he is in the restroom

47. a nurse is providing teaching to a client about reducing first effects of immobility. Which of the following statements by the client indicates an understanding of the teaching?

I will perform my ankle and knee exercises every hour

48. to ensure a clients safety a manager is planning to observe a newly licensed nurse perform a straight catheterization on a client. Which of the following roles is the nurse manager functioning?

Client advocate

49. a nurse is planning to obtain a blood sample from a client for capillary blood glucose post test. Which of the following should the nurse take to obtain the sample?

The lateral aspect of the finger

50. a nurse enters a clients room an discovers a smoldering fire in the drapes. After moving clients to a safe location which of the following actions should the nurse take next?

Pull the fire alarm

51. a nurse is planning to discharge a client who has diabetes and a new prescription for insulin which of the following actions should the nurse plan to complete first?

Determine whether the client can afford the insulin administration supplies

52. a nurse is assessing a client who's therapy has included bedrest for several weeks. Which of the following findings the nurse would identify as priority?

Left lower extremity tenderness

53. a nurse is caring or a client who has a influenza and has isolation precautions in place. Which of the following actions should the nurse take to prevent the spread of infection?

Wear a mask when working within 3 ft of the client

54. a nurse is delegating client's care to an assistive personnel. Which of the following tasks should the nurse delegate to the AP?

ADLs (bathing, grooming, toileting, ambulate etc) specimen collection, I&O, vital sign (stable)

55. a nurse is teaching about home safety with a client . which of the following instructions should the nurse include?

Use electrical tape to secure extension cords next to base boards on the floor

56. a nurse is caring for a client who has restraints to each extremity. Which of the following assessment should the nurse perform first?

Skin integrity

57. a nurse is caring for a client who has a new prescription of inserting a NG tube. Which of the following is the most reliable method for evaluating tube placement?

Obtain an x-ray of the abdomen

58. a nurse in long term care facility is assessing a client which of the following findings should the nurse recognize as an indication of a fecal impaction?

Hypoactive bowel sounds

59. a nurse is caring for a client who has a tracheostomy which of the following actions should the nurse take?

Cleanse the skin around the stoma with normal saline

61. a nurse is caring for a client who has a drainage evacuator. Which of the following is a appropriate action by the nurse?

Ensure the drainage suction is set on high pressure

62. nurse is preparing to transfer a client is partially weight bearing from the bed to a chair. Which of the following actions should the nurse take?

Have the client bear weight on the stronger leg

63. nurse is preparing change of shift report after the night shift using ISBAR communication tool . which fof the following data should the nurse include when reporting background information?

Start first dose of penicillin

64. a nurse in an acute care facility is preparing to transfer a client to a long term care facility. Which of the following information should the nurse include in the hand off report?

Effectiveness of the last dose of pain medication

65. nurse is teaching a client how to perform breast self-examination. Which of the following instructions should the nurse include?

Squeeze the nipple to see if discharge

66. nurse is assessing a breath sounds of an adult client who has pneumonia. which of the following actions should the nurse take?

Follow systemic pattern side to side by moving down the clients chest

67. nurse is assessing a client's bowel sounds. Which of the following actions should the nurse take

Place diaphragm of stethoscope over each quadrant

69. nurse is caring for a client who is prescribed a special diet the client is concerned that he does not have the resources to purchase the food he needs to adhere to. The nurse should notify which of the following members of the health care team?

Social worker

70. nurse is providing teaching to a client who is self-administer an ophthalmic solution. Which of the following statements by the client indicates understanding of the teaching?

I will press the inner corner of my eye after insert drops