Nursing Guidelines for Various Client Scenarios | Exams Nursing | Docsity (2024)

Download Nursing Guidelines for Various Client Scenarios and more Exams Nursing in PDF only on Docsity! 1 RN Comprehensive Predictor Form A 1. A nurse in a pediatric unit is preparing to insert an IV catheter for 7-year-old. Which of thefollowing actions should the nurse take? A. (Unable to read) B. Tell the child they will feel discomfort during the catheter insertion. C. Use a mummy restraint to hold the child during the catheter insertion. D. Require the parents to leave the room during the procedure. 2. A nurse is caring for a client who has arteriovenous fistula Which of the following findingsshould the nurse report? A. Thrill upon palpation. B. Absence of a bruit. C. Distended blood vessels D. Swishing sound upon auscultation. 2 3. A nurse is providing discharge teaching for a client who has an implantable cardioverter defibrillator which of the following statements demonstrates understanding of the teaching? A. “I will soak in the tub rather and showering” B. “I will wear loose clothing around my ICD” C. “I will stop using my microwave oven at home because of my ICD” D. “I can hold my cellphone on the same side of my body as the ICD” 5 6. A nurse is caring for a client who is in active labor and requests pain management. Which ofthe following actions should the nurse take? A. Administer ondansetron. B. Place the client in a warm shower. C. Apply fundal pressure during contractions. D. Assist the client to a supine position. 7. a nurse in an emergency department is performing triage for multiple clients following a disaster in the community. To which of the following types of injuries should the nurse assignthe highest priority? A. Below-the knee amputation B. Fractured tibia C. 95% full-thickness body burn D. 10cm (4in) laceration to the forearm 8. a nurse manager is updating protocols for the use of belt restraints. Which of the followingguidelines should the nurse include? 6 A. Remove the client’s restraint every 4hr B. Document the client’s condition every 15 min C. Attach the restrain to the bed’s side rails D. Request a PRN restrain prescription for clients who are aggressive 9. A nurse is teaching an in-service about nursing leadership. Which of the following informationshould the nurse include about an effective leader? 7 A. Acts as an advocate for the nursing unit. B. (Unable to read) for the unit C. Priorities staff request over client needs. D. Provides routine client care and documentation. 10. A nurse is reviewing the laboratory findings of a client who has diabetes mellitus and reportsthat she has been following her (unable to read) care. The nurse should identify which of the following findings indicates a need to revise the client’s plan of care. A. Serum sodium 144 mEq/ B. (Unable to read) 10 A. Provide chicken with cream sauce. B. Avoid serving fish with fins and scales. C. Provide unleavened bread. D. Avoid serving foods containing lamb. 14. A nurse is caring for a client who has a pulmonary embolism. The nurse should 11 identify theeffectiveness of the treatment A. A chest x-ray reveals increased density in all fields. B. The client reports feeling less anxious. C. Diminished breath sounds are auscultated bilaterally D. ABG results include Ph 7.48 PaO2 77 mm Hg and PaCO2 47 mm Hg. 15. A nurse in an emergency department is assessing a client who reports ingesting thirty diazepam tablets (Unable to read) a respiratory rate of 10/min. After securing the client’s airwayand initiating an IV, which of the following actions should the nurse do next. 12 A. Monitor the client’s IV site for thrombophlebitis. B. Administer flumazenil to the client. C. Evaluate the client for further suicidal behavior. D. Initiate seizure precautions for the client. 15 care proxy in situations that require a durable power of attorney for heal care (DPSHC). Which of thefollowing information should the charge nurse include? A. “The proxy should make health care decisions for the client regardless of the client’sability to do so.” B. “The proxy can make financial decisions if the need arises.” C. “The proxy can make treatment decisions if the client is under anesthesia.” D. “The proxy should manage legal issues for the client.” 20. A nurse in the PACU is caring for a client who reports nausea. Which of the followingactions should the nurse take first? 16 A. Turn the client on their side. B. Administer an analgesic C. Administer antiemetic D. Monitor the client’s vital signs. 17 21. A nurse is caring for a client who has a history of depression and is experiencing a situationalcrisis. Which of the following actions should the nurse take first? A. Confirm the client’s perception of the event B. Notify the client’s support system C. Help the client identify personal strengths D. Teach the client relaxation techniques 22. A nurse is caring for a client who has bipolar disorder and is experiencing acute mania. Thenurse obtained a verbal prescription for restraints. Which of the following should the actions should the nurse take? 20 A. Place the client upright on a donut-shaped cushion B. Teach the client to shift his weight every 15 min while sitting C. Turn and reposition the client every 3 hr while in bed D. Assess pressure points every 24 hr 21 25. A nurse is caring for a client who is dilated to 10 cm and pushing. Which of the followingpain-management (Unable to read) a safe option for the client? A. Naloxone hydrochloride. B. Spinal anesthesia. C. Pudendal block. D. Butorphanol tartrate. 26. A nurse is caring for a client who has left hom*onymous hemianopsia. Which of thefollowing is an appropriate nursing intervention? a. Teach the client to scan the right to see objects on the right side of her body. b. Place the bedside table on the right side of the bed. c. Orient the client to the food on her plate using the clock method. d. Place the wheelchair on the client’s left side. 27. A nurse is assessing a client who has major depressive disorder. Which of the followingfindings should the nurse identify as the (Unable to read) (Most important?) A. The client changes the subject when future plans are mentioned. B. The client talks about being in pain constantly. C. The client sleeping over 12 hr. each day. 22 D. The client reports giving away personal items. 28. A nurse is providing teaching about immunizations to a client who is pregnant. The nurseshould inform the client that she can receive which of the following immunizations during pregnancy? (Select all that apply) A. Varicella vaccine. 25 A. A client who has a prescription for warfarin and states “I will need to limit how muchspinach I eat”. B. A client who has gout and states, “I can continue to eat anchovies on my pizza.” C. A client who has a prescription for spironolactone and states “I will reduce my intake offoods that contain potassium”. D. A client who has (Unable to read) and states “I’ll plan to take my calcium carbonate witha full glass of water”. 31. A hospice nurse is visiting with the son of a client who has terminal cancer. The son reportssleeping very little during the past week due to caring for his mother. Which of the following responses should the nurse make? A. “I can give you information about respite care if you are interested.” 26 B. “You should consider taking a sleeping pill before bed each night” C. “It must be difficult taking care of someone who is terminally ill” D. “You are doing a great job taking care of your mother” 31. A nurse is assessing a child who is being treated for bacterial pneumonia. The nurse notes anincrease in the child’s glucose. The nurse should identify this finding as an adverse effect of which of the following medications 27 A. Methylprednisolone. B. Ondansetron. C. Guaifenesin. D. Amoxicillin. 32. The nurse is providing teaching about folic acid to a client who is prima gravida. Which ofthe following information should the nurse include in the teaching? A. “You should take folic acid to decrease the risk of transmitting infections to your baby” B. “You should consume a maximum of 300 micrograms of folic acid every day”. C. “You can increase your dietary intake of folic acid by eating cereals and citrus fruits”. 30 Exhibit 1 Blood pressure: 102/56 mm Hg. Heart rate: 95/min Respiratory rate: 18/min Temperature: 37.4C (99.3F) Exhibit 2 Medication Administration RecordClozapine 150 mg PO twice daily Benztropine 0.5 mg PO twice daily as needed for tremors.Exhibit 3 31 Nurse’s notes: Client reports feeling dizzy when changing positions, Reports weight gain of 1kg (2.2 lb.) in thepast month. Also reports a sore throat for the past 3 days and dry mouth. Client ate 75% of breakfast and reports slightly nauseous. A. Dietary intake B. Heart rate. C. Sore throat. D. Blood pressure. 32 36. A charge nurse is educating a group of unit nurses about delegating client tasks to assistivepersonnel A. “The nurse is legally responsible for the actions of the AP”. B. “An AP can perform tasks outside of his range if he has been trained”. C. “An experienced AP can delegate to another AP”. 35 B. A client who has somatic symptom disorder and reports chronic pain. C. A client who has depressive disorder and reports feeling hopeless. D. A client who has bipolar disorder and impaired social interactions. 40. A nurse is preparing to measure a temperature of an infant. Which of the following actionshould the nurse take? A. Place the tip of the thermometer under the center of the infant’s axilla. B. Pull the pinna of the infant’s ear forward before inserting the probe. C. Insert the probe 3.8 cm (1.5in) into the infant’s rectum. D. Insert the thermometer in front of the infant’s tongue. 36 41. A nurse is planning care for a client who has bipolar disorder and is experiencing mania.Which of the following interventions should the nurse include in the plan? A. Encourage the client to spend time in the day room B. Withdraw the client’s TV privileges is the does not attend group therapy C. Encourage the client to take frequent rest periods 37 D. Place the cline in seclusion when he exhibits signs of anxiety 42. A nurse is admitting medications to a group of clients. Which of the following occurrencesrequires the completion of an incident report? A. A client receives his antibiotics 2hr late B. A client vomits within 20min of taking his morning medications C. A client requests his statin to be administered at 2100 D. A client asks for pain medication 1hr early 43. A nurse is caring for a client who is 24 hr. postpartum and is breast feeding her newborns.The client asks the nurse to warm up seaweed soup that the client’s partner brought for her. Which of the following responses should the nurse make? 40 C. Discourage physical activity during the day D. Engage the client in activities that increase sensory stimulation 46. The nurse is reviewing the medical record of a client who is requesting combination oral contraceptives. Which of the following conditions in the client’s history is a contradiction to theuse of oral contraceptives? A. Hyperthyroidism. 41 B. Thrombophlebitis. C. Diverticulosis. D. Hypocalcemia. 47. A nurse is admitting a client who has schizophrenia and experiences auditory hallucinations. The client states, “It’s hard not to listen to the voices.” Which of the following questions shouldthe nurse ask the client? A. “Do you understand that the voices are not real?” B. “Why do you think the voices are talking to you?” C. “Have you tried going to a private place when this occurs?” D. “What helps you ignore what you are hearing?” 48. A charge nurse is teaching a group of newly licensed nurses about the correct use ofrestraints. Which of the following should the nurse include in the teaching? A. Placing a belt restraint on a school-age child who has seizures. 42 B. Securing wrist restraints to the bed rails for an adolescent. C. Applying elbow immobilizers of an infant receiving cleft lip injury D. Keeping the side rails of a toddler’s crib elevated. 49. A nurse is reviewing ABG laboratory results of a client who is in respiratory distress. The results are pH 7.47, PaCo2 32 mm Hg. HCO3 22 mm Hg. The nurse should recognize that the client is experiencing which of the following acid-base imbalances? 45 B. “We should establish our roles in the initial session.” C. “Let me show you simple relaxation exercises to manage stress.” D. “We should discuss resources to implement in your daily life.” 51. A nurse in a pediatric clinic is teaching a newly hired nurse about the varicella rooster.Which of the following information should the nurse include? A. Children who have varicella are contagious until vesicles are crusted. B. Children who have varicella should receive the herpes zoster vaccination. C. Children who have varicella should be placed in droplet precaution. D. Children who have varicella are contagious 4 days before the first vesicle eruption. 52. A staff nurse is observing a newly licensed nurse suction a client’s tracheostomy. Which ofthe following requires intervention by the staff nurse? A. Waits 2 minutes between suctions. B. Encourages the client to cough during suctioning. C. Apply suctioning for 15 seconds. D. Inserts the catheter without applying suction. 46 53. A nurse is teaching at a community health fair about electrical fire prevention. Which of thefollowing information should the nurse include in the teaching? A. Use three pronged grounded plugs. B. Cover extension cords with a rug. C. Check the tingling sensations around the cord to ensure the electricity is working. 47 D. Remove the plug from the socket by pulling the cord. 54. A nurse is providing care for a group of clients. Which of the following client’s should thenurse identify as having the highest risk for developing a pressure injury? A. A client who has a T-tube following an open cholecystectomy. B. A client who had a knee 2 days ago following a sports injury. C. A client who has dementia and is incontinent of urine and feces D. A client who has a myocardial infarction and is receiving thrombolytic therapy. 50 58. A nurse is caring for a client wo has severe hypertension and is to receive nitroprusside viacontinuous IV infusion. Which of the following actions should the nurse plan to take? 51 A. Keep client’s calcium gluconate at the client’s bedside B. Monitor blood pressure every 2 hr. C. (Limit or remove?) IV bag from exposure to light. D. Attach tan inline filter to the IV tubing. 59. A nurse is caring for a client who is experiencing mild anxiety. Which of the followingfindings should the nurse expect? A. Feelings of dread B. Heightened perceptual field C. Rapid speech 52 D. Purposeless activity 60. A nurse is reviewing the laboratory report of a client who has been having lithium carbonatefor the past 12 months. The nurse notes a lithium level of 0.8 mEq/L. Which of the following orders from the provider should the nurse expect? A. Withhold the next dose. 55 B. Clamp the chest tube during ambulation. C. Report continuous bubbling in the water seal chamber. D. Strip the chest tube every 4 hr. to maintain patency. 64. A nurse is caring for a client who is receiving morphine 4 mg via IV bolus every 4 hr. PRN.The nurse should monitor for which of the following adverse effects? A. Productive cough. B. Urinary retention. C. Rhinitis 56 D. Fever. 65. A nurse is interviewing the partner of a client who was admitted in the manic phase of bipolar disorder. The partner states “I don’t know what to do. Everything has been happening soquickly.” Which of the following by the nurse is therapeutic? A. “Can you talk about what happens with your partner at home?” 57 B. “Why do you think your partner’s symptoms are progressing so quickly?” C. “You should make sure your partner takes the prescribed medication.” D. “You did the right thing by bringing your partner in for treatment.” 66. A nurse is providing dietary teaching to a guardian of a preschooler who has a new diagnosisof celiac disease. Which of the following statements by the guardian indicates an understanding of the teaching? A. “I will put my child on a gluten-free diet”. B. “I will administer digestive enzymes with meals and snacks”. C. “Provide my child with some high fiber foods.” D. “I will give my child whole wheat toast and milk for breakfast”. 67. A nurse is caring for a client who is to receive a transfusion of packed RBCs. Which of thefollowing actions should the nurse take? A. Prime IV tubing with 0.9% sodium chloride. B. Use a 24-gauge IV catheter C. Obtain filter less IV tubing. D. Place blood in the warmer for 1 hr. 60 A. “Drink 2 liters of warm water per day”. B. “Empty your bladder every 6 weeks.”. C. “Soak in a warm bath everyday”. D. “Take an oral estrogen tablet”. 61 71. A nurse is receiving change-of-shift report for a group of clients. Which of the followingclients should the nurse plan to assess first? A. A client who has sinus arrhythmia and is receiving monitoring B. A client who has a hip fracture and a new onset of tachypnea C. A client who has epidural analgesia and weakness in the lower extremities D. A client who has diabetes and a hemoglobin A1C of 6.8% 72. A nurse is providing dietary teaching to a client who has a new diagnosis of irritable bowelsyndrome. Which of the following recommendations should the nurse include? A. Consume food high in bran fiber B. Increase intake of milk products C. Sweeten foods with fructose corn syrup D. Increase foods high in gluten 73. A nurse is caring for a 1-day-old newborns who has jaundice and is receiving phototherapy.Which of the following actions should the nurse take? A. the infant 30 ml (1 oz) glucose water every 2 hr. 62 B. Keep the infants head covered with a cap. C. Ensure that the newborn wears a diaper. D. Apply lotion to the newborn every 4 hr. 74. a nurse is teaching a group of newly licensed nurses about client advocacy. Which of thefollowing statements by a newly licensed nurse indicates an understanding of the teaching? 65 A. “ It keeps the alveoli open and prevents atelectasis.” B. “It allows preset pressure delivered during spontaneous ventilation.” C. “It guarantees minimal minute ventilator.” D. “It delivers a preset ventilatory rate and tidal volume to the client 77. A nurse is caring for an infant who has coaction of the aorta. Which of the following shouldthe nurse identify as an expected finding? A. Weak femoral pulses B. Frequent nosebleeds 66 C. Upper extremity hypotension D. Increased intracranial pressure\ 67 78. a nurse is auscultating for crackles on a client who has pneumonia. Which of the followinganterior chest wall locations should the nurse auscultate? 70 B. Increased urinary frequency C. Dry cough D. Metallic taste in mouth 81. A nurse is caring for a client who has a new temporary synchronous pacemaker. Which of 71 the following should the nurse report to the provider? 72 A. The client’s pulse oximetry level is 96%. B. (Unable to read) C. The client develops hiccups. D. The ECG shows pacing spikes after the QRS complex. 82. A nurse is preparing discharge information for a client who has type 2 diabetes mellitus.Which of the following resources should the nurse provide to the client? A. Personal blogs about managing the adverse effects of diabetes medications B. Food label recommendations from the Institute of Medicine C. Diabetes medication information from the Physicians’ Desk Reference D. Food exchange lists for meal planning from the American Diabetes Association 82. A nurse is providing teaching about patient-controlled analgesia (PCA) to a client. Which ofthe following statements should the nurse include in the teaching? A. “The PCA will deliver a double dose of medication when you push the button twice.” B. “You can adjust the amount of pain medication you receive by pushing on the keypad.” C. “Continuous PCA infusion is designed to allow fluctuating plasma medication levels.” D. “You should push the button before physical activity to allow maximum pain control.” 75 85. A nurse is caring for a client who is receiving intermittent feedings via a feeding via a feeding pump and is experiencing dumping syndrome. Which of the following actions should thenurse take? A. Administer a refrigerated feeding. B. Increased the amount of water use to flush the tubing. C. (Unable to read) rate of the client’s feedings. D. Instruct the client to move onto their right side. 86. A nurse in an emergency department is caring for a client who received a dose of penicillin and is now anxious, flushing, tachycardic and has difficulty swallowing. Which of the followingactions is the nurse’s priority? A. Monitor the client’s ECG B. Take the client’s vital signs. C. Administer oxygen D. Insert an IV line. 87. A nurse is caring for a client who has Raynaud’s disease. Which of the following actionsshould the nurse take? 76 A. Provide information about stress management. B. Maintain a cool temperature in the client’s room. C. Administer epinephrine for acute episodes. D. Give glucocorticoid steroid twice per day. 88. A nurse is reviewing the medical history of a client who has angina. Which of the followingfindings in the client’s medical history should identify as a risk factor for angina? 77 A. Hyperlipidemia. B. COPD C. Seizure disorder D. Hyponatremia. 89. A nurse is caring for a client who is 12 hr. postpartum and has a third-degree perineal laceration. The client reports not having a bowel movement for 4 days. Which of the followingmedications should the nurse administer? A. Bisacodyl 10 mg rectal suppository. 80 A. Develop a safety plan with the client B. (Unable) options for reporting the incident. C. Refer the client to a community support group. D. Determine if the client has any injuries. 93. A nurse is caring for a client who is in active labor and note the FHR baseline has been 100/min for the past 15 min. The nurse should identify which of the following conditions as apossible cause of fetal bradycardia? 81 A. Maternal fever B. Fetal anemia C. Maternal hypoglycemia D. Chorioamnionitis 94. A nurse is assessing a school-age child who has a urinary tract infection. Which of thefollowing findings should the nurse expect? A. Periorbital edema. B. Decreased frequency of urination. C. Enuresis. 82 D. Diarrhea. 85 B. “A nurse will draw blood from your baby’s inner elbow.” C. “Your baby will be given 2 ounces of water to drink prior to the test.” D. “This test will be repeated when your baby is 2 months old.” 98. A nurse is providing discharge teaching to a client who is postoperative following a colon resection and has a new ascending colostomy. Which of the following statements by the clientindicates an understanding of the teaching? A. “My stool will become fully formed within 3 weeks” B. “My skin will need to be cleaned with alcohol before I apply a new pouch” C. “I should avoid eating popcorn and fresh pineapple” D. “I should expect bruising around the stoma” 99. A nurse is admitting a client who had a stroke and exhibits facial drooping, drooling and 86 hoarseness. Which of the following is the nurse’s priority? A. Refer the client to a speech language pathologist. B. Monitor the client’s prealbumin levels C. Measure the client’s weight. D. Place the client on NPO status. 87 100. A nurse is providing teaching to a client who has heart failure and a new prescription forfurosemide. Which of the following statements should the nurse make? A. “Taking furosemide can cause your potassium levels to be high” B. “Eat foods that are high in sodium” C. “Rise slowly when getting out of bed” D. “Taking furosemide can cause you to be overhydrated” 101. A nurse is planning a teaching session for a client who is postoperative following a colonresection. Which of the following actions should the nurse take first? A. Providing written material for the client to read B. Plan a short instruction about coughing and deep breathing. C. Determine the client’s current pain level. D. Instruct the client about dietary restrictions. 90 B. The client wipes back to front when toileting. C. The client washes her perineum first when bathing. D. The client brushes her teeth twice daily. 91 107. A nurse is preparing to assess a 2-week-old newborn. Which of the following actions shouldthe nurse plan to take? A. Obtain the newborn’s body temperature using a tympanic thermometer. B. (Unable to read) FACES pain scale. C. Auscultate the newborn’s apical pulse for 60 seconds. D. Measure the newborn’s head circumference over the eyebrows and below the occipitalprominence. (NOT) 108. A nurse is caring for a client who has pneumonia and has gained 4.2 kg (9.3 lb) over the last5 days. The client’s laboratory values this morning are the following: WBC 10,000/mm3, RBC 5.2 million/mm3, platelets 250,000/mm3, BUN, and serum creatinine 2.1 mg/dL. The nurse should report these finding to which of the following members of the interdisciplinary team? 92 A. Dietitian B. Infection control nurse C. Nephrologist D. Cardiologist 109. A nurse is caring for an infant who is in contact isolation and received a blood transfusion. Which of the following actions is appropriate for the nurse to take to 95 D. Use words with three or four syllables. 110. A nurse is creating for a client who has aids. The client states, “My mouth is sore when Ieat.” Which of the following instructions should the nurse provide? A. “Add salt to season” B. “Ice chips” C. “Rinse your mouth with an alcohol-based mouthwash” D. “Eat foods served at hot temperatures” 111. A nurse is caring for a client who is at 33 weeks of gestation following an amniocentesis.The nurse should monitor the client for which of the following complications? A. Vomiting B. Hypertension 96 C. Epigastric pain D. Contractions 112. A nurse is caring for a client who is at 38 weeks gestation, is in active labor, and hasruptured membrane. Which of the following actions should the nurse take? A. Insert an indwelling urinary catheter. B. Apply fetal heart rate monitor. 97 C. Initiate fundal massage. D. Initiate an oxytocin IV infusion. 113. A home health nurse is preparing to make an initial visit to a family following a referral from a local provider. Identify the sequence of steps the nurse should take when conducting a home visit. (Move the steps into the box on the right. Placing them in the order of performance) A. Identify family needs interventions using the nursing process. B. Record information about the home visit according to agency policy. C. Contact the family to determine availability and readiness to make an appointment D. Discuss plans for future visits with the family. E. Clarify the reason for the referral with the provider’s office. E C A B D (My choice)