PN Comprehensive Online Practice 2023 B

A nurse is assisting with the care of a client who was admitted to the emergency department (ED).

Schizophrenia

- Pressured speech

- Social impairment

- Grandiose delusions

Bipolar 1 Disorder

- Pressured speech

- Social impairment

- Grandiose delusions

A nurse is caring for a client who is 12 hr postoperative following a total hip arthroplasty. Which of the following actions should the nurse take?

Place an abduction wedge between the client's legs when in bed.

A nurse is evaluating the safe use of electrical equipment by a newly hired assistive personnel (AP). Which of the following actions by the AP demonstrates an understanding of the proper use of electrical equipment?

Grasps the plug of a device in the client's room to pull it straight out from the wall

A nurse is assisting with the care of an adolescent in the emergency department (ED).

- skin findings

- temperature

- WBC count

- casual blood glucose

- potassium

- pain

A nurse is assisting with the care of a client admitted with profuse vomiting and abdominal pain.

- peritonitis

- bowel obstruction

A nurse on the medical-surgical unit is assisting with the care of a client who was admitted from the emergency department (ED).

- confusion

- sodium level

A nurse is assisting with care of a client who is on 24-hr observation.

- hemorrhage

- thrombocytopenia

A nurse is caring for a client who is postoperative following a perineal prostatectomy. For each potential postoperative complication below, click to specify the nursing intervention that the nurse should implement.

- offer the client a sitz bath to relieve pain and promote healing

- encourage the client to drink prune juice to relieve constipation

- instruct the client to perform calf pump and foot circle exercises to promote venous return and reduce the risk of a deep vein thrombosis.

A nurse is collecting data on a newborn who is 3 days old.

- temperature of 36.4° C (97.5° F)

- Weight 2,545 g (5 lb 9 oz) 12% weight loss

- Breastfeeding every 3 to 5 hr for 5 to 10 min.

- Birth parent reports nipple discomfort throughout the feeding

- Mild tremors noted when awake

A nurse on a mental health unit is caring for a client. For each nursing action, click to specify if the nursing action is anticipated or contraindicated for the client.

ANTICIPATED:

- Offer high calorie snacks frequently.

- Initiate suicide precautions.

- Encourage the client to attend group therapy.

CONTRAINDICATED:

- Allow the client to sleep with their hands beneath the blanket.

A nurse is assisting in the care of a client who is postoperative following administration of general anesthesia.

ACTIONS:

- administer dantrolene

- administer oxygen

CONDITION:

-malignant hyperthermia

PARAMETERS:

- monitor for hypercapnia

- monitor for muscle tension

A nurse is assisting with the care of a client who has a new diagnosis of anorexia nervosa. Complete the following sentence by using the lists of options.

- electrolyte imbalance

- fear of weight gain

A nurse is assisting with the care of a client who has bulimia nervosa. Drag words from the choices below to fill in each blank in the following sentence.

- cardiovascular abnormalities

- electrolyte imbalance

A nurse is assisting with the development of an in-service for newly licensed nurses about seclusion. In which of the following situations should the nurse identify the need to request a prescription for seclusion?

A client attempts to hit another client during group therapy.

A nurse is caring for a client who has an indwelling urinary catheter. Which of the following actions should the nurse take?

Wipe the drainage port with an antiseptic wipe after emptying urine from the bag.

A nurse is reinforcing teaching with a client who has acute diverticulitis. Which of the following statements by the client indicates an understanding of the instructions?

"I will receive the nutrients I need through my IV fluid."

A nurse is reinforcing teaching with a client about the client's recent diagnosis of multiple sclerosis. The client states, "I am very upset and I want to be alone for a little while." Which of the following responses should the nurse make?

"I see that you are feeling overwhelmed. I will come back when you are ready."

A nurse in an outpatient surgery center is reinforcing discharge teaching with a client following a lithotripsy for uric acid stones. Which of the following instructions should the nurse plan to include in the teaching?

Strain the urine to collect stone fragments.

A nurse is reinforcing teaching with a client who is at 20 weeks of gestation and will undergo routine abdominal ultrasonography the following day. Which of the following statements should the nurse include in the teaching?

"You will need to have a full bladder for the procedure."

A nurse assisting with a childbirth class is discussing nonpharmacological strategies used during labor. Which of the following statements by a client indicates an understanding of cutaneous stimulation?

"I should use counterpressure for back pain during labor."

A nurse is caring for a client who is 2 days postoperative following abdominal surgery and has a new prescription for a regular diet. For which of the following findings should the nurse notify the provider?

The client has absent bowel sounds.

A nurse is reviewing the medical record of a client who is receiving warfarin and has atrial fibrillation. Which of the following laboratory values should the nurse report to the provider?

INR 5

A nurse is assisting with the care of a client who is receiving peritoneal dialysis. Which of the following actions should the nurse plan to take?

Monitor the client's intake and output.

A nurse is collecting data from a client who has a newly applied cast to the right lower extremity. Which of the following findings should the nurse expect?

Capillary refill of 5 seconds to the client's toes

A nurse manager is preparing to complete a performance analysis for a group of assistive personnel (AP). The manager asks a staff nurse for feedback on each AP's abilities. Which of the following actions should the staff nurse take?

Discuss how each AP's actions measure against the job description.

A nurse in a long-term care facility is contributing to the plan of care for a client who has a new ostomy. Which of the following interventions should the nurse include?

Change the appliance two times each week.

A nurse is preparing to administer purified protein derivative (PPD) to a client who has suspected tuberculosis. Which of the following actions should the nurse plan to take?

Ensure the injection produces a wheal on the skin.

A nurse is caring for a client who is scheduled for surgery in the morning. The nurse learns that the client has decided not to have surgery even though they have already signed the informed consent form. Which of the following actions should the nurse take?

Report the situation to the provider who obtained the informed consent.

A nurse is reinforcing teaching about food selection with a client who has a moderate burn injury. Which of the following foods should the nurse recommend as being high in vitamin C?

Tomatoes

A nurse is reinforcing teaching with a client who is uncircumcised about obtaining a clean-catch midstream urine specimen. Identify the sequence of actions the nurse should instruct the client to take after washing their hands. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)

- Expose the glans of the penis is the first step

- Cleanse the penis using an antiseptic swab is the second step

- Begin urination is the third step

- Pass the cup into the urine stream is the fourth step.

- Move the cup out of the urine stream is the fifth step.

- Replace the foreskin is the sixth step.

A nurse is preparing to administer a dose of digoxin to a client who is receiving continuous tube feedings. Which of the following actions should the nurse take?

Flush the feeding tube with water before and after administering the medication.

A nurse is reinforcing teaching with a newborn's parents about umbilical cord care. Which of the following statements by a parent indicates an understanding of the instructions?

"I will give our baby sponge baths until the cord falls off."

A nurse is caring for a client who is 1 day postoperative and is unable to ambulate. Which of the following actions should the nurse take to promote the client's venous return?

Maintain a sequential compression device.

A nurse is reinforcing discharge teaching with the parents of a school-age child who has severe hemophilia A. Which of the following statements by the parents indicates an understanding of the teaching?

"I will soak my child's toothbrush in warm water to soften it before my child uses it."

A nurse is delegating the collection of a sputum specimen to an assistive personnel (AP). At which of the following times should the nurse instruct the AP to collect the specimen?

As soon as the client awakens in the morning

A nurse is reinforcing teaching with a client who has a prescription for nitroglycerin sublingual tablets. Which of the following instructions should the nurse include in the teaching?

Take up to three tablets during a single angina episode.

A nurse is reinforcing teaching with a client who is receiving radiation therapy for cancer of the larynx. Which of the following statements made by the client indicates an understanding of the teaching?

"I should wear a soft scarf around my neck when I am outside."

A nurse is assisting with the plan of care for a client who has bipolar disorder and is in the manic phase. Which of the following activities should the nurse recommend for the client?

Walking outside with a staff member

A nurse is caring for a client who has a phobia of elevators. Which of the following should the nurse recognize as an indication that systematic desensitization has been effective for the client?

The client remains relaxed when thinking of the phobia.

A nurse is caring for a client who is in an inpatient mental health facility and has dependent personality disorder. Which of the following client behaviors should the nurse expect?

The client calls their partner to ask what they should wear each day.

A nurse is assisting with a discussion about STIs with a group of adolescents at a health fair. Which of the following statements should the nurse make?

"An infection with gonorrhea can result in infertility."

A nurse is preparing to insert an indwelling urinary catheter for a female client. Which of the following actions should the nurse take?

Open the outer package flap of the catheterization kit away from their body.

A nurse is collecting data from a client who has posttraumatic stress disorder (PTSD). Which of the following manifestations should the nurse expect?

Hypervigilance

A nurse is using an interpreter to reinforce discharge teaching with a client who speaks a different language than the nurse. Which of the following actions should the nurse take?

Observe the client's facial expressions during communication.

A nurse is observing an assistive personnel (AP) caring for a client. For which of the following actions by the AP should the nurse intervene?

The AP reports client information to the oncoming AP in the hallway.

A nurse is discussing alopecia with a client who is scheduled to begin chemotherapy. Which of the following statements should the nurse make?

"Your oncologist might prescribe a cold cap to wear during treatment to reduce hair loss."

A nurse is documenting client care in the medical record. Which of the following entries should the nurse make?

"Client remains NPO until x-ray procedure is complete."

A nurse is reinforcing teaching about self-administration of enoxaparin. Which of the following instructions should the nurse include?

Administer by subcutaneous injection.

A nurse is reinforcing discharge teaching with a client who has undergone vein ligation and stripping to treat varicose veins. Which of the following instructions should the nurse include in the teaching?

Walk for 1 to 2 hr each day.

A nurse is reinforcing teaching with a client who has a new prescription for prednisone for the treatment of Addison's disease. Which of the following instructions should the nurse include in the teaching?

"You will need to schedule a bone density test."

A nurse is reinforcing teaching with a client who has type 2 diabetes mellitus and reports waking during the night with tremors and anxiety. Which of the following information should the nurse include?

Eat a bedtime snack.

A nurse is contributing to the plan of care for a client who is postoperative following a rhinoplasty. Which of the following interventions should the nurse recommend?

Instruct the client to avoid the Valsalva maneuver.

A home health nurse is caring for a client who just returned home following a total knee arthroplasty. Which of the following actions should the nurse take first?

Determine the client's mobility status.

A nurse is reinforcing teaching with a client who has a new prosthesis for an above-the-knee amputation of the right leg. Which of the following instructions should the nurse include?

Apply the prosthesis immediately upon waking each day.

A nurse is caring for a client who takes prednisone daily for the treatment of chronic asthma. The nurse should plan to monitor the client for which of the following adverse effects?

Gastric ulcer formation

A nurse is collecting data from a client who reports recent methamphetamine use. Which of the following manifestations should the nurse expect?

Dilated pupils

A nurse is contributing to the plan of care for a client who has a continent urinary diversion. Which of the following interventions should the nurse plan to implement to facilitate urinary elimination?

Use intermittent urinary catheterization for the client at regular intervals.

A nurse is reviewing the procedure for endotracheal suctioning with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?

"I should apply sterile saline to lubricate the suction catheter."

A nurse is reinforcing teaching about strategies to promote eating with a client who has COPD. Which of the following instructions should the nurse include in the teaching?

Drink high-protein and high-calorie nutritional supplements.

A nurse is receiving change-of-shift report for four clients. Which of the following clients should the nurse see first?

A client whose urinary output was 100 mL for the past 12 hr

A nurse is assisting in the care of an adolescent. Select the 4 findings that require follow-up.

- capillary refill

- pedal pulse

- skin temp

- pain

The nurse is reviewing the client's medical record. Which of the following actions should the nurse take after the adolescent returns from surgery?

Select all that apply.

- elevating the adolescent's affected limb at chest level

-monitoring neurovascular status every hour

-removing the indwelling urinary catheter when it is no longer indicated

The nurse is continuing to care for the adolescent. Complete the following sentence by using the lists of options.

- compartment syndrome

- pain level

The nurse is continuing to care for the adolescent. For each potential provider's prescription, click to specify if the potential prescription is anticipated or contraindicated for the adolescent.

ANTICIPATED

- Prepare the adolescent for surgery

- Remove the splint.

CONTRAINDICATED

- Elevate the right leg above heart level.

- Apply ice to the affected extremity.

The nurse is continuing to care for the adolescent. The nurse is assisting with preparing the adolescent for a fasciotomy. Which of the following findings should the nurse report to the provider prior to surgery?

The adolescent's parents have concerns regarding the surgery

The nurse is collecting data from the adolescent 4 hr following the fasciotomy. Click to highlight the findings below that indicate an improvement in the adolescent's condition.

- Extremity pulse +3.

- Capillary refill 2 seconds.

- Right extremity is warm to the touch

- Adolescent reports no numbness or tingling

- Adolescent reports pain as 2 on a scale of 0 to 10.

A community health nurse is helping to reinforce teaching about hepatitis A with a group of employees at a childcare facility. Which of the following characteristics should the nurse identify as an external factor that can impede learning for the participants?

Poor lighting in the learning setting

A nurse is performing vision testing for a client following a head injury. Which of the following findings should the nurse identify as a problem with pupil accommodation?

Lack of change in pupil size when the client looks from a far to a near object

A nurse enters a client's room and sees smoke coming from a wastebasket next to the bed. Which of the following actions should the nurse take first?

Assist the client to a nearby waiting area.

A nurse is assisting with an in-service about hepatitis A for a group of staff nurses. The nurse should include that hepatitis A is transmitted through which of the following methods?

Consumption of contaminated food

A nurse is talking with a client who says the provider agreed to initiate a do-not-resuscitate (DNR) prescription. After leaving the client's room, which of the following actions should the nurse take first?

Check for documentation that the provider spoke with the client about the DNR.

A nurse in a pediatric clinic is collecting data from a toddler. Which of the following findings should the nurse identify as a possible indication of physical neglect?

The toddler is inadequately dressed for the weather.

A nurse in a pediatric clinic is collecting data from a school-age child whose injuries are inconsistent with the guardian's stated cause. Which of the following actions should the nurse take?

Report the suspected child maltreatment to the appropriate agency.

A nurse in a long-term care facility is reviewing standard precaution guidelines with an assistive personnel (AP). The nurse should instruct the AP to use which of the following to clean up a blood spill?

Chlorine bleach solution

A nurse is caring for a client who has a head injury. Using the Glasgow Coma Scale to collect data, the nurse should obtain which of the following information?

Motor response

A nurse is assisting with monitoring a client who is at 40 weeks of gestation and is in active labor. The nurse recognizes late decelerations on the fetal monitor tracing. Which of the following actions should the nurse take?

Place the client in a lateral position.

A nurse is assisting a client who is postoperative to sit on the side of the bed. Which of the following actions should the nurse take?

Elevate the head of the client's bed.

A nurse is preparing to perform venipuncture to obtain a blood sample from a client. Which of the following actions should the nurse take?

Select a site in the antecubital fossa.

A nurse is collecting data from a client who has chronic pancreatitis and is receiving pancrelipase. Which of the following client findings indicates a therapeutic effect of this medication?

Reports a decrease in the number of stools

A nurse is monitoring a client who is receiving IV fluids. For which of the following findings should the nurse stop the infusion?

Edema above the catheter insertion site

A nurse is reinforcing teaching with a client who has dumping syndrome about measures to reduce manifestations. Which of the following instructions should the nurse include in the teaching?

Avoid foods with a high sugar content.

A nurse is collecting data from a client who has hypokalemia. Which of the following findings should the nurse expect?

Muscle weakness

A nurse is collecting data from a school-age child who has hypoglycemia. Which of the following findings should the nurse expect?

Sweating

A nurse is reinforcing teaching about confidentiality with a client who has a new diagnosis of HIV. Which of the following information should the nurse include in the teaching?

"Your HIV status will be shared with members of your health care team."

A nurse is caring for a client who is refusing a prescribed medication. Which of the following actions should the nurse take first?

Identify the client's concerns about receiving the medication.

A nurse is reinforcing teaching with a client about how to replace their two-piece ostomy pouching system. The client tells the nurse that removing the skin barrier is painful. Which of the following strategies should the nurse suggest?

Hold the skin taut while removing the barrier.

A nurse is caring for a client who is experiencing acetaminophen toxicity. Which of the following medications should the nurse plan to administer to the client?

Acetylcysteine

A nurse is caring for a newborn who is 1 hr old. The client who gave birth received fentanyl 30 min before delivery. For which of the following adverse effects should the nurse monitor the newborn?

Respiratory depression

A nurse is caring for a client who has asthma and has been taking montelukast for 1 month. Which of the following findings should indicate to the nurse that the client is complying with this medication regimen?

The client takes the medication once daily at bedtime.

A nurse is preparing to administer medications to a client who is NPO and is receiving enteral feedings through an NG tube. Which of the following prescriptions should the nurse clarify with the provider?

Metoprolol ER 50 mg per NG tube BID

A nurse notices an assistive personnel (AP) taking a nap in the break room during meal time. The nurse also notes that the AP is drowsy while performing routine tasks. Which of the following actions should the nurse take?

Report the observations about the AP to the unit's nurse manager.

A nurse in an inpatient mental health facility is caring for a newly admitted client who has alcohol use disorder. During a therapy session, the client asks about Alcoholics Anonymous (AA). Which of the following responses should the nurse make?

"What is your current understanding about the purpose of AA?"

A nurse is reinforcing preoperative teaching with a client who will receive morphine through a PCA pump after surgery. Which of the following information should the nurse include?

"You should increase your fluid intake while receiving this medication through the PCA pump."

A nurse is collecting data from a 5-year-old child at a well-child visit. The parent reports that the child is having frequent nightmares. Which of the following statements by the parent indicates to the nurse that the child is experiencing sleep terrors rather than nightmares?

"My child goes back to sleep right away."

A nurse is caring for a client who is recovering from a motor-vehicle crash. The client's employer calls to ask if the client's injuries will prevent them from returning to work. Which of the following responses should the nurse make?

"I cannot give you this information. You will need to speak with your employee."

A nurse is reinforcing teaching with a client about taking warfarin to treat atrial fibrillation. Which of the following statements by the client indicates an understanding of the teaching?

"If I forget to take a dose, I can take it later on the same day."

A nurse is receiving change-of-shift report for a group of clients. The nurse should plan to implement which of the following time-management strategies?

Prepare a priority list of client needs for the shift.

A nurse is assisting with performing a nonstress test for a client who is at 39 weeks of gestation. Which of the following instructions should the nurse reinforce with the client?

"You should depress the button on the handheld marker when you feel your baby move."

A nurse is reinforcing discharge teaching about car seat safety with the guardian of a newborn. Which of the following statements by the guardian indicates an understanding of the teaching?

"I will secure the car seat in the car by using the seatbelt."

A nurse is observing an assistive personnel (AP) apply antiembolic stockings for a client. Which of the following actions by the AP demonstrates an understanding of how to perform this skill?

Applying the stockings before the client gets out of bed