Comprehensive predictor Test A

A nurse is caring for a group of clients, which of the following can be assigned to an assistive personnel?

a. Collecting a stool specimen to test for occult blood.

A nurse is working on a unit for clients with dementia. Which of the following client situations requires the nurse to write an incident report?

c. A client is found lying on the floor next to a chair

A nurse is discharging a client who was admitted for newly diagnosed type 2 diabetes mellitus. The client is independent and lives alone. Which of the following should be included in the discharge plan?

c. Refer the client to a diabetic support group.

A nurse is caring for a client who has type 2 diabetes mellitus and a blood glucose level of 60 mg/dL. For which of the following findings should the nurse monitor?

a. Clammy Skin

A female client who is an abusive marriage has discusses with the nurse strategies to prevent this abuse. which of the following client statements indicate an understanding of an appropriate strategy?

a. "I need to recognize the signs that my husband is becoming abusive." c. "I need to identify what triggers my husband's anger to prevent his abuse."

A charge nurse in a long-term care facility is preparing to administer noon insulin to a client. The nurse observes that the assistive personnel (AP) has no documented the client's blood glucose level. Which of the following actions should the charge nurse take first?

d. Determine if the AP has completed the assignment.

A client is scheduled for an outpatient colonoscopy. which of the following actions is a nursing responsibility in the informed consent process?

a. Verify that there is a signed and witnesses consent form in the client's chart.

A nurse smells alcohol on the breath of an assistive personnel (AP) during report. Which of the following actions should the nurse take?

c. Report the situation to the nurse manager.

A nurse from a medical-surgical unit is floating to a postpartum unit. Which of the following clients is an appropriate assignment for the nurse to accept?

b. A client who had a cesarean delivery 24hr ago.

A nurse in a provider's office is collecting data from a parent of an infant who is being screened for cystic fibrosis. Which of the following supports a diagnosis of cystic fibrosis?

a. Frothy stools.

When caring for an assigned group of clients, the nurse should wear gloves when

a. performing oral hygiene.

A nurse is preparing a client for surgery. The client tells the nurse that he is concerned about the safety of a large sum of money in his wallet. Which of the following actions is appropriate for the nurse to take?

b. contact security personnel to place the money in the facility safe.

A nurse is caring for a client who is receiving heparin. Which of the following is the appropriate route of administration?

d. Subcutaneously.

A nurse is reinforcing teaching about car seat safety to the parents of a newborn. The nurse should instruct the parents to place the car seat in a?

c. Rear-facing position in the back seat.

A nurse is caring for a client and recognizes the client's rights to confidentiality have been breached in which of the following situations?

a. A hospital risk manager includes information from a client's medical record in

A nurse is caring for a client who had a femoral-popliteal bypass graft 2 days ago. When monitoring peripheral pulses, the nurse is unable to locate a pulse on the affected leg. Which of the following actions should the nurse take?

c. Notify the charge nurse of the finding.

A nurse is caring for a full-term newborn who was circumcised 6 hrs. ago. Which of the following findings indicates that the newborn is experiencing pain?

b. Furrowed Brow

A nurse is reinforcing teaching with a client about organ donation. Which of the following client statements indicated a need for further teaching?

c. "My doctor should decide if my organs will be donated."

A Client who is prescribed metoprolol (Lopressor) for hypertension tells the nurse, "I don't want to take this medication because it makes me tired all the time." Which of the following is the appropriate response?

c. "Let's talk with your doctor about other options."

A nurse is preparing to administer an IM injection to a client. To reduce the risk of neddlestick injury, the nurse should?

b. dispose of the used needle immediately in a puncture-proof sharps container.

A nurse is contributing to the discharge plan for a client following surgery. Which of the following findings indicate the need for an interdisciplinary care conference?

d. The client requires assistance to pay for dressing supplies.

A client who is 24 hours postoperative suddenly develops chest pain, dyspnea, anxiety, diaphoresis, and cough. Which of the following actions should the nurse take first?

c. Elevate the head of the client's bed.

A nurse is caring for a 17-year old client who is admitted for an emergency appendectomy. Which of the following is an appropriate action by the nurse in obtaining informed consent?

a. Obtain verbal consent from the client while waiting for the parents to arrive. b. Witness the signature of the client's parent when he arrives. c. Have the client's older sibling give consent if a parent is not available. d. Delay the procedure if the provider cannot contact the parents.

A nurse has delegated care to an assistive personnel. At the end of the shift, the AP asks the nurse to enter data for her because the AP has forgotten her password and needs to leave. Which of the following actions should the nurse take?

a. Tell the AP to contact the IT department for charting assistance.

A nurse is reinforcing discharge teaching to a client following a gastrectomy. To prevent dumping syndrome, which of the following foods should the nurse instruct the client to avoid?

a. Ice Cream

A nurse is caring for a client admitted with shortness of breath who will be undergoing arterial blood gas testing. Which of the following client statements indicated an understanding of the purpose of drawing arterial blood gases?

d. "This will indicate how much acid is building up in my blood."

A nurse manager is seeking ways to increase cost-effectiveness on the unit. In which of the following client care situations should the nurse manager intervene?

a.

A nurse is collecting data from a client who reports recent weight loss and a Chronic cough that is now producing blood-streaked sputum. For which of the following should the nurse expect the client to have diagnostic testing?

a. Lung Cancer D. Emphysema.

A nurse is caring for an older adult client with a decreased level of consciousness. Which of the following is an appropriate intervention related to the client's mouth care?

c. uses a sponge toothette to cleanse the inside of the mouth.

A nurse in a long-term care facility not that the assistive personnel lack knowledge of blood glucose monitoring. The nurse should bring this observation to the attention of which of the following personnel?

a. Charge Nurse.

A nurse is reinforcing discharge teaching for a client admitted with an acute myocardial infarction. Which of the following activities is appropriate for the client to participate in during the first two weeks following discharge?

d. Walking.

A nurse is reinforcing teaching for a client undergoing radiation therapy to the neck. Which of the following should the nurse include?

d. Avoid exposing the neck to the cold.

A nurse is providing anticipatory guidance to the parent of a 6-year old child. Which of the following statements by the parent indicated an understanding of appropriate safety precautions for the child?

b. "I will encourage my child to wear a bicycle helmet whenever bike riding."

A nurse is collecting data from a client who presents to the clinic reporting vomiting. Which of the following findings indicate that the client is experiencing a fluid volume deficit?

c. Orthostatic hypotension.

A nurse is caring for a client who is receiving warfarin (coumadin) for deep vein thrombosis. The nurse observed that the client's INR is 3.8. Which of the following actions should the nurse take?

d. Withhold the ordered dose of the medication.

A nurse is reinforcing teaching with the parents of a 4-month-old infant during a home visit. Which of the following findings in the infant's room indicates a need for further teaching?

d. The infant is lying in the crib with a stuffed animal.

A nurse is caring for a client who has hepatitis B. When caring for the client, which of the following actions places the nurse at highest risk for acquiring hepatitis B?

a. Performing oral hygiene.

A nurse is reinforcing dietary teaching with a client whose prepregnancy BMI was 30.5. The nurse evaluates that the client understands the teaching when she states she will gain?

a.?

A nurse is reinforcing teaching with school staff about streptococcal infection of the pharynx. The nurse should instruct the staff that the period of contagion for children who have this infection is which of the following?

b. from onset of symptoms until 24hrs of antibiotic therapy.

A nurse is caring for a client who is 2 days postoperative following a partial bowel resection. The client reports that the "felt something pop" when he sneezed. The nurse observes an evisceration. After calling for assistance, which of the following actions should the nurse take first?

c. Cover the wound with sterile saline-soaked gauze.

A nurse is caring for a client who is in balanced skeletal traction for a leg fracture. Which of the following should the nurse expect to be included in the care plan?

c. Increase counter traction every 24 hr. d. Inspect the ropes, knots, and pulleys every 8 hrs.

A nurse is using contact precautions while caring for a toddler. Which of the following actions should the nurse take?

b. Use a designated stethoscope for the toddler.

A client's daughter calls the nurse requesting information about her mother's condition. The client's chart does not specify that information can be released to the daughter. Which of the following is an appropriate response by the nurse?

d. "You will need to contact your mother directly about her condition."

A nurse is reviewing the immunization records of a 9-year-old child during a routine physical exam. Which of the following should indicate to the nurse the child is not current with the minimum required immunization?

a. One MMR vaccine.

A nurse is reinforcing teaching with a new mother on facility security measure. Which of the following statements by the mother indicates that the teaching was effective?

c. "I will have an identification band that matches the one my baby wears."

A nurse is reinforcing teaching with a client who is at 10 weeks' gestation and has a medical history of mild hypertension. The nurse should remind the client to call the clinic if she?

d. develops edema of the ankles.

A nurse is caring for a client who has been placed in restraints. Which of the following is appropriate?

b. Monitor the client's skin integrity on a regular schedule.

A nurse is working on a mental health unit is reviewing policies for client seclusion. For which of the following is seclusion appropriate?

a. Aggressive behavior.

A nurse in a long-term care facility has received a change-of-shift report on four clients. Which of the following clients should the nurse attend to first?

d. A client who has COPD and dementia and was agitated during the night shift.

A nurse is applying a condom catheter to a male client who is incontinent. Which of the following is an appropriate technique to use?

a. Leave space between the tip of the penis and the end of the condom catheter.

A nurse is assisting a client to move up in bed. Which of the following actions should the nurse take?

b. Ask the client to flex the hips and knees.

A nurse is supervising an assistive personnel (AP). During the morning meal, the nurse observes the AP accidentally spill a cup of coffee on a client. Which of the following actions should the nurse take?

c. Reinforce safe meal setup techniques.

A nurse is reinforcing teaching to a first-time mother about toddler safety. The nurse should recognize the client's understanding of the teaching when the client states, "I will?

a. Install gates at the top and bottom of the stairs."

A nurse is preparing a sterile field to perform a dressing change. Which of the following actions should the nurse take?

a. Place sterile objects at least 2.5 cm (1 inch) from the edge of the sterile field.

A nurse is collecting data from an adolescent client who is a victim of sexual abuse. The nurse recognizes the use of the defense mechanism of suppression when the client states,

d. "I guess I have to take some of the blame because of the way my friends and I dress."

A client is prescribed 2g of ampicillin. The pharmacy dispenses this medication in 500 mg tablets. Which of the following should the nurse give the client?

d. 4 tablets.

A nurse is providing home care to a client and is reinforcing teaching regarding home safety. Which of the following by the client indicates a need for further teaching?

c. "I will walk barefoot to prevent slipping." d. "I will check my smoke alarms once a month."

A Client with emphysema asks the nurse why he has difficulty exhaling. Which of the following statements by the nurse is appropriate?

d. "Your windpipe is inflamed and constricted."

A nurse is caring for a client who was admitted 12 hours ago and is experiencing acute alcohol withdrawal. Which of the following is an expected finding for the client?

b. Irritability.

A nurse is caring for a client who is in active labor and is accompanied by her partner. The client and her partner tell the nurse they were unable to attend childbirth preparation classes. Which of the following responses by the nurse supports the partner's involvement during labor?

b. "Breathing with your partner will help her to relax during contractions."

A nurse is planning tracheostomy care for a client in a long-term care facility. Which of the following actions should the nurse plan to take first?

d. Remove the tracheostomy inner cannula.

A nurse in a provider's office is reinforcing teaching with the parents of a school-age child who has an active case of pediculosis capitis. Which of the following should be included in the teaching?

a. Wash the bed linens in hot water. d. Clean the child's toys with 1:10 bleach solution.

A nurse caring for the mother of a newborn finds the client crying in her room. The client tells th nurse, "I don't think I can handle caring for a baby." Which of the following nursing interventions is appropriate?

c. Encourage the client to share her feelings.

A nurse is assisting with the care of a 36-year-old client who is at 16 weeks of gestation an is scheduled for an amniocentesis. The nurse recognizes that the client understands the amniocentesis is performed to identity?

d. chromosomal abnormalities.

A nurse is caring for client who is requesting assistance with smoking cessation. For which of the following medications should the nurse anticipate having to reinforce teaching?

d. Nicotinic Acid (niacin)

A nurse is caring for a client who is 12hr postpartum. The nurse observes an increase in vaginal bleeding. Which of the following actions should the nurse plan to take first?

a. Massage the fundus. d. Obtains the client's vital signs.

A nurse is caring for a client with diabetes mellitus who has an order for daily morning insulin before breakfast. The client refuses his blood glucose check at 0700. Which of the following actions should the nurse take?

a. Reinforce client teaching.

A nurse in a long-term care facility is reviewing a client's laboratory results. The client's potassium level is 5.8 mEq/L. Which of the following findings should the nurse expect?

b. Abdominal cramps.

A nurse is collecting data during a well-child visit of a 12-month-old infant. Which of the following statements made by the parent indicates a need for further evaluation?

d. "My child can't go from a lying to a sitting position."

A nurse is caring for a client who is receiving IV therapy. The nurse suspects fluid infiltration. Which of the following findings should the nurse expect at the insertion site?

b. Edema.

A nurse is caring for a client who is newly diagnosed with type 1 diabetes mellitus. The nurse should recognize that the client needs a referral for diabetic education when the client?

c. states that he will treat hypoglycemic reactions with 15 g of carbohydrates.

A nurse is reinforcing discharge instructions regarding umbilical cord care to the mother of a newborn. Which of the following statements by the mother indicates the teaching was effective?

a. "I will wait until the cord falls off to give my baby a tub bath."

A nurse in a long term care facility is planning to perform hygiene care for a newly admitted male client with Parkinson's disease who is ambulatory. Which of the following is an appropriate statement by the nurse prior to starting routine care?

d. "Do you usually take your bath in the morning or in the evening?"

A client who is participating in an anger management session explains that his recent behaviors are related to his job loss. Which of the following defense mechanisms is the client using?

d. Rationalization.

A nurse is reinforcing teaching with a new mother of a full-term newborn about breastfeeding. The newborn is 5 days old. Which of the following statements by the mother indicates an understanding of the teaching?

c. "I should have my baby latch on to my nipple and areola during feeding."

A nurse is reinforcing teaching to the parent of a child who has been prescribed ferrous sulfate (Feosol) in liquid form. Which of the following statements made by the parent indicates the teaching was effective?

a. "I will give the iron through a straw."

A nurse is preparing to administer 0.9% sodium chloride 1,000 mL IV to infuse over 8 hr. The nurse should set the IV pump to deliver how many mL/hr?

d. 150 mL/hr

A nurse is reinforcing teaching to a group of adolescent males. Which of the following statements made by a student indicates a need for further teaching?

d. "I should perform a self-exam of my testes once a year."

An infant is admitted to a pediatric unit following a motor-vehicle crash with a subsequent head injury. For which of the following should the nurse monitor to identify increased intracranial pressure?

a. Decreased motor response.

A nurse is caring for a client who is terminally ill and requires ongoing palliative care. Which of the following interventions is consistent with the goals of this type of care?

b. Allowing the family overnight visitation.

A nurse in an inpatient psychiatric unit is a caring for a client who was raised in an Asian culture. Which of the following communication techniques demonstrates cultural sensitivity?

d. Holding eye contact for brief instances.

A nurse is caring for a client who has an order for a 12-lead ECG. Which of the following actions should the nurse take?

b. Instruct the client to take slow, deep breaths.

A newly admitted client tells the nurse that he does not have an advance directive. Which of the following is the appropriate action for the nurse to take?

b. Provide the client with written information about advance directives.

A nurse is observing a client who is in the manic phase of bipolar disorder. The client states, "Don't need to eat today. Where's the money? Time to write that speech." The nurse should document this as which of the following?

c. Flight of ideas.

A nurse is reinforcing dietary teaching to a client who has end-stage renal failure. Which of the following instructions should the nurse include in the teaching?

a. Decrease calcium intake. c. Decease sodium intake.

A nurse is assisting with the admission of a client who attempted suicide. When the nurse processes the client's belongings, which of the following items should the nurse remove from the client's suitcase?

b. Perfume d. Emery Boards.

A nurse is collecting data from a client at an urgent care clinic. The client tells the nurse that she hasn't been able to sleep since the death of her father 2 days ago. Which of the following is the nurse's priority action?

c. Discuss coping skills that have worked for the client previously.

A nurse is planning care for a client who is 6 hours postoperative following a right knee arthroplasty. Which of the following interventions should the nurse include in the client's care plan?

b. Place a pillow under the client's surgical knee.

A nurse in pediatric clinic is reviewing the history of a 11-year-old child. Which of the following immunizations should the nurse anticipate administering?

a. rotavirus c. meningococcal conjugate

A nurse is caring for a client who was recently diagnosed with paranoid schizophrenia and is taking risperidone (risperdal). Which of the following statements by the family indicates a need for further teaching?

a. "Our son's symptoms will stop as soon as he begins his medications."

A nurse is caring for a newly postoperative client who has unilateral breath sounds and asymmetrical chest expansion. The nurse should recognize these findings are indicative of which of the following and should be reported to the provider?

a. atelectasis.

A nurse is planning care for a client with delirium. Which of the following should the nurse recognize as interfering with the client's recovery?

c. providing the client with activities that vary daily.

A nurse is caring for a client who has paranoid schizophrenia and believes that she is being followed by FBI agents who are pretending to be psychiatric staff. Which of the following responses should the nurse make?

b. "The psychiatric staff are not FBI. They are here to help you."

A nurse is monitoring a client who is in labor. Which of the following findings needs further evaluation?

b. Uterine contractions lasting 100 to 120 seconds.

A nurse is taking the vital signs of an adult client who has just been transferred from the PACU to the clinical unit. Which of the following findings should the nurse recognize as the most significant?

c. Temperature 36 C (96.8 F)

A nurse observes a client who has Alzheimer's disease and is experiencing aphasia. Which of the following behaviors should the nurse expect?

c. Difficulty understanding spoken words.

A nurse in a long-term care facility is caring for an older adult client who has a history of hypertension. Which of the following is indicative of transient ischemic attacks?

a. pain radiating down the left arm c. sudden loss of vision in one eye.

A nurse is caring for a client experiencing alcohol withdrawal. Which of the following medications should the nurse anticipate administering?

d. Lorazepam (Ativan)

A nurse is caring for a client who has borderline personality disorder. The client states, "I look forward to seeing you in the morning because the night nurse treats me badly." Which of the following behaviors is the client likely demonstrating?

a. Splitting

A nurse is planning a health-promotion program for high school students. Which of the following facts about cigarette smoking is likely to be most effective in changing the adolescents' attitudes towards smoking?

c. Smoking causes unattractive stains on the teeth and hands.