Virtual ATI predictor Green Light/ COMPLETED VATI Greenlight STUDY SET | Exams Nursing | Docsity (2024)

Download Virtual ATI predictor Green Light/ COMPLETED VATI Greenlight STUDY SET and more Exams Nursing in PDF only on Docsity! Virtual ATI predictor Green Light/ COMPLETED VATI Greenlight STUDY SET A nurse is caring for a client who had a partial laryngectomy and is receiving continuous enteral feedings at 65 mL/hr through a gastrostomy tube. Which of the following findings requires immediate intervention by the nurse? The infusion pump for administering contimuous feeding is turned off. A nurse is assessing a client who has a magnesium level of 4.4 mEq/L. Which of the following findings should the nurse expect? Hypotension A nurse is providing dietary teaching to a client who has an increased cholesterol level. Which of the following foods should the nurse recommend? Egg whites A nurse is caring for a toddler who has respiratory syncytial virus. Which of the following actions should the nurse plan to take? Use a designated stethoscope when caring for the toddler. A nurse is assessing a client who has a chest tube following a thoracotomy. Which of the following findings requires intervention by the nurse? 1 cm of water present in the water seal A nurse is reviewing the medical history of a client who is taking garlic supplement. The nurse should identify that which of the following findings is a contraindication for taking this supplement? The client takes aspirin daily. A nurse is planning to provide community education about viral hepatitis. Which of the following should the nurse plan to include in the teaching? series of four hepatitis vaccines is recommended to prevent viral hepatitis. A nurse is reviewing the history and physical of a client who has right ventricular heart failure. Which of the following is an expected finding? Elevated pulmonary artery pressure A home health nurse is conducting an initial home visit for a client who has terminal breast cancer. The client has two school-age children and a limited support system. Which of the following is the priority nursing action? Inform the client of available community resources. A nurse is providing postoperative teaching to a client who has a newly- inserted pacemaker. Which of the following statements by the client indicates that the teaching has been effective? "I will use my cell phone on the ear opposite of my pacemaker." A nurse is caring for a client who has heart failure and has started taking a loop diuretic. Which of the following findings indicates the client is experiencing an adverse effect of the medication? Decreased reflexes A community health nurse is performing a vision screening on a 4- month-old infant. When shining a light source into the infant's visual field, which of the following is an expected finding? The infant closes their eyes. A nurse is planning discharge teaching for a client who is scheduled to receive intravenous infusions at home. Which of the following instructions should the nurse plan to include? Place the infusion pump cord against the baseboards. A nurse is caring for a client who has just returned to the unit following a bronchoscopy. Which of the following actions by the assistive personnel requires the nurse to intervene? Offers oral fluids to the client A nurse is assessing an infant who has water intoxication. Which of the following findings should the nurse expect? Generalized edema A nurse is caring for a client who is in labor and receiving electronic fetal monitoring. The nurse is reviewing the monitor tracing and notes early decelerations. Which of the following should the nurse expect? Head compression nurse in a pediatric unit is caring for a group of clients. For which of the following diseases should the nurse implement droplet precautions? Pertussis A client asks the nurse if it is safe to take a glucosamine supplement. The nurse should assess for which of the following potential contraindications? Shellfish allergy A nurse at the family planning clinic triages several clients over the phone. Which of the following clients should the nurse instruct to come to the clinic? A client who has started taking oral contraceptives and is experiencing bright red vagin*l breakthrough bleeding A nurse is caring for a client who has a hearing impairment. When speaking to the client, the nurse should incorporate which of the following communication methods? Rephrase sentences the client does not understand. A nurse in a mental health facility is interviewing a newly admitted client. Which of the following actions should the nurse take when conducting the interview? Lean in slightly when speaking to the client. A nurse is caring for a group of clients. Which of the following clients should the nurse assign to an assistive personnel? A client who had a stroke 2 days ago and needs help toileting A nurse manager at a public health clinic is concerned about the rising number of sexually transmitted infections in the community. The purpose of which of the following is to generate new ideas to address the public health concern? A brainstorming session with nurses A nurse is providing teaching about preventing mastitis to a client who is postpartum and breastfeeding her newborn. Which of the following instructions should the nurse include? "Try to have your baby empty your breasts with each feeding." A nurse is preparing to insert an indwelling urinary catheter for a female client. Identify the sequence of actions the nurse should take. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.) Apply sterile gloves and place cleansing balls in antiseptic solution. Attach prefilled syringe to indwelling catheter inflation hub. Cleanse the meatus with the dominant hand in a downward motion. Lubricate the catheter and place fenestrated drape over perineum. Insert the catheter until a flow of urine begins. A nurse is providing teaching to a client who is at 8 weeks of gestation and experiencing episodes of nausea and vomiting. Which of the following instructions should the nurse include? Eat a dry carbohydrate before getting out of bed. A nurse is caring for a client who is nulliparous and in the first stage of labor. The last internal assessment revealed 100% cervical effacement with 5 cm of dilatation. At the end of the last contraction, the nurse observes a large gush of fluid coming out of the client's perineal area. Which of the following is a priority action by the nurse? Check the FHR. A nurse is assessing a client who was brought to the emergency department by his adult child. The client has visible contusions on all four extremities. Which of the following actions should the nurse take? Report the incident to Adult Protective Services. A nurse is caring for a client who is postpartum and has a new prescription for methylergonovine for vagin*l bleeding refractory to fundal massage and oxytocin. When reviewing the client's medical history, the nurse should recognize which of the following diagnoses as a contraindication to the administration of methylergonovine? Hypertension A nurse is giving discharge instructions to a client who has a new ileostomy. The nurse should recognize that the teaching has been effective when the client states, "My stoma will drain liquid fluid continuously." At the start of an evening shift on a cardiac unit, a licensed practical nurse brings the nurse a list of client reports. Which of the following client reports should the nurse assess first? Indigestion postoperative following a bowel surgery and has an NG tube connected to low intermittent suction. Which of Abdominal rigidity A nurse is providing discharge teaching to a client who has schizophrenia and is starting therapy with clozapine. Which of the following is the highest priority for the client to report to the provider? Fever A nurse is discussing the Z-track administration of hydroxyzine with a newly licensed nurse. Which of the following statements indicates the newly licensed nurse understands the purpose of the technique? "This technique decreases the risk of subcutaneous infiltration." A nurse is caring for a client who has opioid use disorder and is experiencing withdrawal. Which of following findings should the nurse expect? Hyperreflexia A nurse is giving change-of-shift report about a client who is 36-hr postoperative to another nurse. Which of the following should the nurse include? relieved by position change A nurse is caring for a client who has been taking propranolol. Which of the following findings indicates a need to withhold the medication? Pulse 54/min A nurse is reviewing the medical records of four clients. Which of the following prescriptions represents correct documentation? Sucralfate 1 g PO 1 hr ac A nurse is evaluating the allergy profile of a client who has Graves' disease and is to undergo a thyroid scan. The nurse should identify which of the following allergies as a contraindication for the client to undergo a thyroid scan? lodine A home health nurse is assessing a client who reports a headache and appears confused and drowsy. The client has a kerosene space heater in use. Which of the following actions should the nurse take first? Open the client's windows. A nurse is teaching a newly licensed nurse about informed consent. Which of the following statements should the nurse include in the teaching? (Select all that apply.) witnessing the signing of the informed consent form, the nurse is indicating that the client voluntarily gave client who signs an informed consent form should understand the treatment plan." "A client who signs an informed consent form should be competent." "The nurse should disclose the purpose of the treatment before the client signs the consent form." A nurse is providing teaching to the guardian of a school-age child who has a new prescription for ferrous sulfate capsules PO. Which of the following instructions should the nurse include in the teaching? Administer the medication with a glass of orange juice. A nurse is providing grief counseling for the parents of a school-age child whose sibling recently died. Which of the following statements should the nurse make? "Bring the child to the funeral service before visitors arrive." A nurse is assessing a client who is receiving enteral feedings via a gastrostomy tube. The nurse should identify that which of the following findings Indicates fluid overload? Bounding pulses A nurse is caring for a client who is taking levothyroxine. Which of the following findings should indicate to the nurse that the medication is effective? Weight loss A nurse is planning care for a newborn who has hyperbilirubinemia and is to receive phototherapy. Which of the following interventions should the nurse include? Place the newborn 45 cm (18 in) from the light source. A nurse is preparing to witness a client's signature on an informed consent for a total knee arthroplasty. Which of the following client statements indicates the nurse should contact the surgeon? "I am thankful there are no serious complications from this type of surgery." A nurse is caring for a 7-year-old child who has severe dehydration. Which of the following findings should the nurse expect? Blood pressure 94/68 mm Hg A charge nurse is creating assignments for the next shift for several nurses and one of the nurses is pregnant. Which of the following clients should the charge nurse assign to a nurse who is not pregnant? An 80-year-old client who has alcoholic pancreatitis and is being treated for impetigo A nurse in a residential mental health facility is planning care for a new client who has obsessive compulsive disorder (OCD). Which of the following is appropriate for the nurse to include in the plan of care? Teach the client to meditate about obsessive thoughts. A nurse is caring for client who has schizophrenia. Which of the following findings is the nurse's priority? The client reports hearing voices. A nurse is preparing to administer eye drops to a client. Which of the following nursing actions is appropriate? Use aseptic technique and drop the medication into the conjunctival sac. A nurse is caring for a client who has schizophrenia. The nurse should expect the client to exhibit which of the following manifestations? (Select all that apply.) Repeats the words of others when speaking Speaks in word salad Has a blunt affect Experiences delusions A nurse is assessing a client who has a fentanyl patch in place for chronic pain. Which of the following findings should the nurse report to the A nurse is performing change-of-shift assessments for four clients. Which of the following findings should the nurse report to the provider first? A client who has gastroenteritis and is lethargic and confused A nurse is planning care for a client who has a gambling disorder. Which of following instructions should the nurse provide to the client? Participate in a 12-step program. A nurse notices smoke coming from a client's room and discovers a fire in the wastebasket. After moving the client to safety, which of the following is the priority action? Notify the facility A nurse is caring for a client who is receiving a blood transfusion at 125 mL/hr and develops a hemolytic reaction. Which of the following actions should the nurse perform? Infuse 0.9% sodium chloride V. A nurse is planning the discharge of an infant who has tetralogy of Fallot. The nurse anticipates the need for which of the following equipment? Pulse oximeter A nurse is teaching a client who has a new prescription for digoxin. Which of the following statements should the nurse include in the teaching? "Notify your provider if you experience muscle weakness." A nurse is monitoring a client during an IV urography procedure. Which of the following client reports is the priority finding? Swollen lips A nurse is teaching the guardian of an infant who has developmental dysplasia of the hip about a Pavlik harness. Which of the following instructions should the nurse include? Gently massage the skin under the straps once per day. A nurse in an inpatient mental health facility is caring for a client who has major depressive disorder and refuses to take her medication. Which of the following actions should the nurse take first? Identify the reason for the client's refusal. A nurse is performing an admission assessment for a client who is to undergo a colonoscopy. The client informs the nurse that he took his prescribed medications before coming to the clinic. Which of the following medications is the priority to report to the provider? Clopidogrel A nurse is assessing a client prior to performing a blood draw. The nurse should identify that an allergy to which of the following foods can indicate that the client has an allergy to latex? Avocados A nurse from the State Health Department is instructing a group of nurses regarding reportable infections. Which of the following infections should the nurse report to the Centers for Disease Control and Prevention? Lyme disease A nurse is caring for a client who has a prescription for atorvastatin. Which of the following client conditions is a contraindication this medication? Нерatitis C A nurse is preparing to administer an IV bolus of albumin 5% to a client who is receiving a continuous IV infusion. After confirming compatibility, which of the following actions should the nurse take? Occlude the IV tubing above the injection port. A nurse is planning care for a client who is postoperative following creation of an arteriovenous fistula in the left arm. Which of the following actions should the nurse include in the plan? Compare blood pressure in both arms every 2 hr. A nurse enters a client's room and finds the client lying on the floor in a puddle of water. Which of the following statements should the nurse document in an incident report? Client found lying on the floor near the bedside table. A client who is having suicidal thoughts tells the nurse, "It just does not seem worth it anymore. Why not end my misery?" Which of the following responses by the nurse is appropriate? "Do you have a plan to end your life?" A charge nurse is teaching a group of unit nurses about the policy for clients who have a history of methicillin-resistant Staphylococcus aureus (MRSA). Which of the following information should the nurse include? A client who has a history of MRSA can still transmit the infection, A nurse is caring for an adolescent who is receiving treatment for heart failure. Based on the client's chart findings, which of the following actions should the nurse plan to take? (Click on the "Exhibit" button for additional information about the client. There are three tabs that contain separate categories of data.) Withhold digoxin. A nurse is performing a skin assessment on a client who has risk factors for development of skin cancer. The nurse should understand that a suspicious lesion is asymmetric, with variegated coloring. A nurse is assessing a client who is gravida 2, para 1. The client is at 41 weeks of gestation and is receiving oxytocin for the augmentation of labor. The nurse should decrease the infusion rate for which of the following findings? Consistent contractions last 80 seconds. A nurse is assessing a client who has a complete heart block and is receiving transcutaneous pacing. Which of the following findings indicates to the nurse that the treatment is effective? Pedal pulses 2+ A nurse is caring for a client who experienced a stroke and has dysphagia. Which of the following findings should indicate to the nurse the client is at risk for aspiration? The client pockets food on one side of his mouth. A nurse is teaching the parent of a school-age child who has scabies about the application of permethrin 5% cream. The nurse should include which of the following as a potential adverse effect of the medication? Burning A nurse is creating a plan care for a client who has anorexia nervosa. Which of the following interventions should the nurse include in the plan? Monitor the client for 1 hr after meals. A nurse is performing triage following a natural disaster. Which of the following clients should the nurse identify as the highest priority to receive care? A dient who has a traumatic arm amputation A nurse performing a skin assessment for a client who is on bedrest. Which of the following actions should the nurse take prevent a pressure injury? Encourage client fluid intake of 2,500 ml daily. A nurse is teaching a group of farmworkers who work with pesticide about minimizing exposure. Which of the following information should the nurse include in the teaching? Change clothes after working in the field. A nurse is observing bonding between a client and her newborn. Which of the following actions by the client requires the nurse to intervene? Viewing the newborn's actions to be uncooperative A nurse is caring for a client following insertion of a subclavian prescription to initiate an IV infusion of Ringer's lactate at 150 ml per hr. Prior to starting the infusion, which of the following actions should the nontunneled percutaneous central venous catheter (CVC). The provider writes a nurse take? Review the chest x-ray report. A nurse is admitting a client who has antisocial personality disorder. Which of the following client behaviors should the nurse identify as consistent with this disorder? Uses others for personal gain 2 hrs post-op following an ileal conduit procedure bladder cancer Dusky-colored stoma Administering an INJ to a client even after the client states, "I don't want that injection. The last time I got that I was sore for a week." Battery A client ask the nurse if it is safe for him to take glucosamine supplement? Shellfish allergy Client following an open colectomy Uncontrolled pain A client has just returned to the nursing unit following cardiac catheterization. In the immediate postoperative post procedure period which of the following is the priority nursing actions? Immobilizing the affect extremity A client hopitialized for a bone marrow transplant is in protective isolation while undergoing total body radiation and intense chemotherapy. The clients sibling comes to visit but has obvious manifestations of an upper respiratory infection. Allow the sibling to visit after donning a sterile gown, mask, gloves but prohibits physical contact Client recovering from closed head injury assumes a decerbrate posture in response to stimuli D lying flat ?? (Extentend extremities) The client rigidly extends his arm Client reports chest pain. Which of the following lab findings indicates myocardial damage Client who has a left femur fracture and is skeletal traction. The clients reports pain due to muscle spasms in affected leg Realign the extremity in traction Client who has given birth to a stillborn Acknowledging the reality of the newborn's death Client who is 2 days postoperative following a lumbar laminectomy and is reporting nausea Admin an antiemetic (Aprepitant for nausea) Client who is 8hr postoperative following a right-modified radical mastectomy - which findings to report to provider? (SATA) Coughing Frothy, pink secretions Client who is receiving a controlled epidural analgesia infusion Covering the insertion site with a transparent dressing Client who reports the use of chondroitin and glucosamine Improve joint functioning Community health nurse is completing a newborn home visit and observes family members smoking cigarettes in the house Review the effects of secondhand smoke w/ family members A community health nurse is evaluating eligibility for home assistance for a client who is quadriplegic Determine the client living situation A community health nurse is planning to make home visits to several clients who all live within a few miles radius of the office - Who to see first? An infant who has failure-to-thrive and was discharged from a facility yesterday to a foster home on daily weights Creating and activity plan for a home bound older adult client. In the planning, the nurse considers the physiologic changes that may affect pulmonary function r/t the normal aging process Decreased blood oxygenation Delegates the following tasks to the AP bathe four clients, distribute fresh water, obtain morning vital signs Set a clear time frame for the completion of each task DI w/ severe head injury Urine output 250 Diagnosis of antisocial personality disorder Poor impulse control Diagnosis of complete placenta previa is admitted to the labor and delivery suite at 36wks gestation w/ contractions 5 min in frequency and 1 min in duration Prepare the client for c-section Dietary intervention for a client who is immobile due to pelvic and femur fractures Provide a high-protein diet Difficulty falling asleep at night Eat a bedtime snack (containing carbohydrates??) Disaster triage following a natural disaster Amputation Discharge teaching about disease prevention to a client who has active Tb Educating the client how to cover nose and mouth with tissues when coughing Discussing a living will with a client It communicates my wishes for end of life care Discussing care w/ newly licensed nurse for a client who practices orthodox Judaism - which food not given? Roast beef and ice cream Education about ECT major depressive disorder General anesthetic admin prior ECT treatments(This treatment are for pts who aren't responding to their pharmaceutical meds) Education to the mother of a toddler who has pertussis Pertussis booster An emergency department nurse triages a group of school children injured in a school bus crash A child who reports diplopia and nausea and was unconscious at the scene but is now awake Experiencing acute mania ... Provide high-calorie nutritional supplements (provide pt with portable nutritious food because pt may not be able to sit down) Gravida 2, para 1. The client is at 41 wks gestation and is receiving oxytocin for the augmentation of labor Contractions occur every 90 sec Haloperidol for the tx of schizophrenia Screen the client for Tardive Dyskinesia (inform pt to lower doses to decrease the chances of TD) health nurse is performing a vision screening on a 4-month-old infant. When shining a light source into the infant's visual field - rx? Closes eyes Hearing impairment - incorporate which communication methods? Rephrase sentences the client doesn't understand Home health nurse is admitting a client who is prescribed peritoneal dialysis Clarify the clients actual and perceived health needs A home health nurse is conducting an initial home visit for a client who has terminal breast cancer. The client who has 2 minor children and a limited support system Ask the client about her understanding of the diagnosis A home-health nurse is providing teaching about self-administration of insulin to client who is newly diagnosed w/ diabetes mellitus I can use the same area as long as I rotate injection sites Home health nurse is reviewing treatment goals w/ a client who has diabetes mellitus evaluate lab tests to determine effective long-term management of blood glucose levels HbA1C Hyperthyroidism - which of the following rooms is appropriate for the nurse to assign this client? Cool room (reduced room temp) If something happens to me from which I cannot recover, I don't want to go on a ventilator: You're concerned that something may go wrong? Ileal conduit due to treatment for bladder cancer Cleanse w/ moisturizing soap Immediate postoperative period following thorac surgery, a nurse medicates a client for pain on a schedule Reduces the RR the LPN? Insert an indwelling catheter if the client has not voided in 3 hr A nurse educator is discussing modes of transmission w/ nursing students. Which of the following should the nurse educator include as an example of vector-borne transmission? West Nile virus from mosquito bite A nurse in a mental health clinic is observing clients in the day room. The nurse sits down to talk w/ an adolescent client who was admitted w/ clinical depression. After a few minutes of convo, the adolescent ask the nurse "why did you choose to talk to me out of this room full of kids?" You're curious why I am interested in you and not the others? A nurse in a mental health clinic is reviewing the hx and physical for a 17-yr old client who has a new dx of social phobia: Client reports minimal alteration in performance at a part-time job Nurse in an emergency department is assessing a client who has a nasal fracture. Clear fluid drainage from the nares A nurse in a pedi unit is caring for a group of clients. Which of the following diseases should the nurse implement droplet precautions? Pertussis A nurse in a provider's office is caring for a client who has Parkinson's Disease and has been taking levodopa for the past 5 wks. The client reports a new onset of muscle twitching - best response? This is a manifestation of drug toxicity & may require a dosage reduction A nurse in the emergency department is caring for a client following a motor vehicle crash - PRIORITY? Stabilize the cervical spine A nurse in the emergency department is caring for a client who has abdominal pain. Which of the following actions by the nurse demonstrates VERACITY? A nurse explains the potential risks of tx. (Veracity = truth/not withhold all info; Fidelity = keeping promises) A nurse in the emergency department is providing discharge teaching to a client who has a sprained ankle. For the first 24hr following sx, the nurse should instruct the client to do which of the following? Intermittently place ice on the ankle (30 mins - 1 hr??) A nurse in the PACU is caring for four post-op clients. The nurse realizes that coughing poses a risk to which of the following clients? Thyroidectomy (Coughing can cause incision to reopen & bleeding can occur) A nurse is admitting a client who has chronic gout - What med should the nurse admin? Allopurinol A nurse is admitting an infant who has bacterial meningitis. Nursing intervention? Minimize environmental stimuli A nurse is admitting an unidentified female who was brought to the emergency department: 3 months A nurse is analyzing cardiac rhythms of four telemetry clients in the coronary care unit: C looks normal but lots of artifact or Fibs in between QRS's A nurse is assessing a client 1 wk after a successful bone marrow transplant. The client reports peeling of skin on her hands and feet. The nurse should recognize this desquamation as an indication of which of the following complications? Graft vs host disease A nurse is assessing a client who has an IV infusing per gravity at 125ml/hr Blood is backing up in the IV tubing A nurse is assessing a client who is 2 hrs post-op following insertion of a chest tube connected to chest drainage system as depicted in the diagram above: Fluctuation of the fluid level chamber b (middle) A nurse is assessing a client who is post-op following abdominal sx. States "I feel like my incision ripped open." Place client in Low-Fowler's position A nurse is assessing a client w/ schizophrenia - what is a manifestation? Auditory hallucinations A nurse is caring for a client following insertion of a subclavian non-tunneled percutaneous central venous catheter - What should nurse do? Review the chest x-ray A nurse is caring for a client who has a partial laryngectomy and is receiving continuous enteral feedings at 65ml.hr through a gastrostomy tube (intervene??) The client is lying in a supine position A nurse is caring for a client who has newly implanted sealed internal radiation device to treat cervical cancer. Keep a 3 ft distance from the radiation implant A nurse is caring for a client who has a new prescription for lithium carbonate. PRIOR TO ADMINISTERING THE FIRST DOSE, WHICH OF THE following lab values should the nurse evaluate? Sodium A nurse is caring for a client who has a typical depression and is taking phenelzine - What can you eat? Low-fat yogurt A nurse is caring for a mother who was prescribed methadone during pregnancy (MN p. 183): -Tachypnea -Irritability - Tremor s or -Increased seizures, sleep pattern disturbance, higher birth wt A nurse is caring for an infant who is being treated for dehydration - indication for further education? -Flat anterior fontanel (Reason: Fontanels should be soft & flat; No tears = dehydration) A nurse is caring for a post-op client. Which of the following interventions will reduce the risk of DVT? Apply venous plexus foot pumps A nurse is caring for a preschool-age child who has a short-leg, plaster cast applied 1 hr ago. Support the affected leg on a pillow A nurse is discussing the z-track method to admin hydroxyzine hydrochloride w/ a newly licensed nurse - Understanding of teaching? This technique decreases the risk of subcutaneous infiltration A nurse is electronically documenting assessment findings for a client - How should document/assess pain? The client reports a pain level of 6 on a scale of 0-10 A nurse is giving change-of-shift report about a client who is 36-hr post-op to another nurse: Pain relieved by changing position A nurse is interviewing a client who presents with multiple injuries that are consistent with intimate partner abuse. After establishing trust and rapport, which of the following should the nurse say? "Let's talk about what happened to you" A nurse is planning care for a client who has a new diagnosis of HIV. I cant seem to gain any weight A nurse is planning care for a client who is comatose and has a stage II decubitus ulcer on the coccyx - What should nurse do? Provide the client with an alternating pressure mattress A nurse is planning care for a client who is prescribed a cane for ambulation. Which of the following nursing actions should the nurse include in the plan of care? Remind the client to place the cane on the unaffected side. Rationale: Keep the cane on the stronger side of the body 1- Move cane forward 15cm 2- Then, move weaker cane forward 3- Advance stronger cane A nurse is planning care for a newborn who has hyperbilirubinemia and is to receive phototherapy: Place the newborn 45cm or 18 in from the light source A nurse is planning teaching for a client who is at 10 weeks of gestation and has a history of urinary tract infections UTI: Empty bladder before & after sexy time A nurse is planning to change the dressings on a school-age child who has sustained multiple burns: Apply the dressings in a proximal to distal pattern A nurse is planning to provide community education about viral hepatitis - What info should include? Clients who have a hx of viral hepatitis are unable to donate blood A nurse is preparing the auscultate a client's apical pulse at the point of maximal impulse (PMI): 5th intercostal space at the left midclavicular line A nurse is preparing to administer potassium chloride intravenously to a client who has hypokalemia. The client is receiving a current infusion of 0.9% sodium chloride at 125ml/hr. Which of the following actions should the nurse plan to take? Dilute the solution prior to the infusion. Rationale: Dilute K+ and give no more than 40mEq/L of IV solution to prevent vein irritation A nurse is providing teaching for a client who has a new prescription for lithium carbonate - (Need for further education???) Take medication w/ milk. Rationale: Taking lithium with food would help with decreasing GI distress A nurse is providing teaching to the parent of a preschooler who was newly diagnosed with a latex allergy - What foods to avoid? Bananas A nurse is reviewing the employee health program for new employees. Which of the following diagnostic assessments should the nurse recommend for all the new employees to screen for the presence of tuberculosis? Mantoux test A nurse is reviewing medical records for four clients - Which of the following represents appropriate documentation? Carafate 1g PO 1hr AC A nurse is reviewing the hx and physical of a client who has right ventricular heart failure: Hepatomegaly (liver enlargement) A nurse is teaching a client who has a new dx of GERD - Include in teaching? Sleep w/ HOB elevated A nurse is teaching a client who has a new prescription for digoxin. Which of the following should the nurse include in the teaching? Notify your provider if you experience muscle weakness! A nurse is teaching a client who has left-leg weakness how to use a standard walker (further education?) Moves the left leg and walker ahead together A nurse is teaching a client who has a low literacy level about home management of diabetes mellitus: Show the client an educational video A nurse is teaching a family about home hospice care: Hospice care improves the quality of life through palliative care A nurse is teaching a prenatal class about evidence of effective breastfeeding to a group of parents - What include in teaching? (SATA) -Swallowing sounds are audible -Stools are yellow and seedy after 7 days -Maternal breasts become soft following feedings A nurse is writing a plan of care for a client who is home bound and has stage 2 Alzheimer's Disease. Which of the following should the nurse include in the plan of care? Assist with money management A nurse manager is making staffing assignments for the med surg unit. Which of the following clients is appropriate to assign to a float nurse from the postpartum unit? A client who is 2 days posto-op following a colon resection A nurse manager is presenting an in-service for newly licensed nurses about advance directives: Advanced directives must benotarized to be legally implemented A nurse manager is presenting info to the nursing staff regarding the appropriate use of client restraints - What should be included? (SATA) -Nurse should pad the bony prominences. -Providers prescription should include the type of restraint to use. -Remove or replace restraints frequently to ensure good circulation to the area A nurse notices smoke coming from aclients room and discovers a fire in the wastebasket. After moving the client to safety what nurse do next? Recovering from an acute myocardial infarction - left sided heart failure: Bilateral lung crackles Recovery room is assessing a client who has a new chest tube. The nurse finds that the water seal is no longer tidaling - What could be problem? The tubing may be kinked Rationale: Tidaling is expected. Cessation of tidaling in water seal chamber signals lungs re-expansion or obstruction. Continuous bubbling indicates an air leak. Referral for a speech language pathologist: Client who has difficulty swallowing Reviewing data of four young children who are receiving treatment. Which of the following should alert the charge nurse to the possibility of child abuse? A 3-month old infant who has a skull fracture from reportedly rolling off the changing table "Reviewing" medications for a group of clients labor and delivery (which would you NOT give?) Phenytoin for seizure disorder Rising number of sexually transmitted infections in the community???? ????? School nurse scabies Red itchy papules on child's groin area Several client measurements were obtained with morning vital signs - pt priority*?? A 4-year old who has closed head injury and heart rate of 60 Tetralogy of Fallot: Pulse oximeter Urinalysis done for a preschool age child: Pyelonephritis ???? PRIORITY action for post-op ileus? Monitor bowel sounds Idenfy risks for fat embolism syndrome (FES): Older adults (70 or older) and hip/pelvis fractures are common causes (turn upside down)? Disorder of eye post-op risk? Bleeding and infection VATI Greenlight 2 hrs post-op following an ileal conduit procedure bladder cancer Dusky-colored stoma Administering an INJ to a client even after the client states, "I don't want that injection. The last time I got that I was sore for a week." Battery Admitting a client to the medical-surgical unit. Which of the following actions should the nurse first take? Observe the client's level of mobility Adolescent client who has no previous history of a seizure disorder and is admitted after having a 3-min tonic-clonic seizure 2 wks after sustaining a mild concussion. EEG Explain that the client may not have coffee prior to the EEG Adolescent who has cystic fibrosis and has a prescription for pancrelipase Take w/ meals After evaluating the morning lab results on several clients, the provider writes prescriptions for 4 clients assigned to the nurses care? Infuse 10 meQ/l potassium chloride IV over 1 hr to a client who has potassium of 3.2 After making morning round, the charge nurse on a surgical unit delegates the follow tasks to the AP. Set up a room for an expected postoperative admission AP reports to the nurse that another ap has spent the entire morning on the phone and has not completed the morning assignment Redirect the AP to discuss the issue with the other AP Assessing client who systemic lupus erythematous SLE which of the following is an expected findings Dry, raised facial rash At the start of an evening shift on a cardiac unit, a LPN brings the nurse a list of client reports Indigestion Benefit from a three-way indwelling catheter Prone to development of blood clots un the urine Caring for a client who has a new prescription for chlorpromazine by IM injection Check orthostatic BP 1 hr after admin Caring for a client who was involved in a motor-vehicle crash. The client reports shortness of breath and chest pain and asks the nurse "Am I dying?" Admin pain meds Charge nurse creating assignments for next shift for several nurses and one of the nurses is pregnant - which pt the nurse should NOT be assigned to? 60 yr old who is recovering from shingles Charge nurse on pediatric unit is making assignments for a float nurse from the medical unit. Pt to see first? 10 yr old who has pneumonia & is receiving respiratory txs Education to the mother of a toddler who has pertussis Pertussis booster An emergency department nurse triages a group of school children injured in a school bus crash A child who reports diplopia and nausea and was unconscious at the scene but is now awake Experiencing acute mania ... Provide high-calorie nutritional supplements (provide pt with portable nutritious food because pt may not be able to sit down) Gravida 2, para 1. The client is at 41 wks gestation and is receiving oxytocin for the augmentation of labor Contractions occur every 90 sec Haloperidol for the tx of schizophrenia Screen the client for Tardive Dyskinesia (inform pt to lower doses to decrease the chances of TD) health nurse is performing a vision screening on a 4-month-old infant. When shining a light source into the infant's visual field - rx? Closes eyes Hearing impairment - incorporate which communication methods? Rephrase sentences the client doesn't understand Home health nurse is admitting a client who is prescribed peritoneal dialysis Clarify the clients actual and perceived health needs A home health nurse is conducting an initial home visit for a client who has terminal breast cancer. The client who has 2 minor children and a limited support system Ask the client about her understanding of the diagnosis A home-health nurse is providing teaching about self-administration of insulin to client who is newly diagnosed w/ diabetes mellitus I can use the same area as long as I rotate injection sites Home health nurse is reviewing treatment goals w/ a client who has diabetes mellitus evaluate lab tests to determine effective long-term management of blood glucose levels HbA1C Hyperthyroidism - which of the following rooms is appropriate for the nurse to assign this client? Cool room (reduced room temp) If something happens to me from which I cannot recover, I don't want to go on a ventilator: You're concerned that something may go wrong? Ileal conduit due to treatment for bladder cancer Cleanse w/ moisturizing soap Immediate postoperative period following thorac surgery, a nurse medicates a client for pain on a schedule Reduces the RR Infection control nurse is reviewing care procedures for four clients A client who has varicella zoster is placed in a negative pressure room In-home assessment for an older adult client who is at risk for falls. Which of the following assessment findings should the nurse identify as a potential hazard? A comp. chair wheels In patient psychiatric unit is setting short-term goals for an adolescent who was admitted for tx of anorexia nervosa The client will develop personalized meal plan Involuntarily admitted to psychiatric unit following a failed suicide attempt - experimental tx Witness consent before medication administration Lab data on client who has dehydration Elevated BUN Lab values on a client who has taken an overdose of acetaminophen - organ damage ALT Mastitis of left breast - does this mean that i must stop nursing my baby? No, you can continue to nurse from both your breasts medical unit received change-of-shift report ... 68 yr old Morning lab values to several clients ... Client who is prescribed digoxin and furosemide Pt w/ Neutropenia (MS pg. 543) Remove fresh flowers from a client's room Newborn nursery is performing assessments on four neonates that are all less than 24 hr old - which pt is priority? Pinna below the outer canthus of the eye (The eye should be even with the upper tip of the pinna of the newborn's ear; MN p. 158) Pt is Nulliparous and in the first stage of labor. The last internal assessment revealed 100% cervical effacement w/ 5cm of dilation. At the end of last contraction, the nurse observes a large gush of fluid coming out of clients perineal area. What should nurse do first? Check FHR!! A nurse at a public health clinic is caring for a group of clients. Which of the following should the nurse identify as a reportable dx to the CDC? Hepatitis A A nurse at the family planning clinic triages several clients over the phone - Thyroidectomy (Coughing can cause incision to reopen & bleeding can occur) A nurse is admitting a client who has chronic gout - What med should the nurse admin? Allopurinol A nurse is admitting an infant who has bacterial meningitis. Nursing intervention? Minimize environmental stimuli A nurse is admitting an unidentified female who was brought to the emergency department: 3 months A nurse is analyzing cardiac rhythms of four telemetry clients in the coronary care unit: C looks normal but lots of artifact or Fibs in between QRS's A nurse is assessing a client 1 wk after a successful bone marrow transplant. The client reports peeling of skin on her hands and feet. The nurse should recognize this desquamation as an indication of which of the following complications? Graft vs host disease A nurse is assessing a client who has an IV infusing per gravity at 125ml/hr Blood is backing up in the IV tubing A nurse is assessing a client who is 2 hrs post-op following insertion of a chest tube connected to chest drainage system as depicted in the diagram above: Fluctuation of the fluid level chamber b (middle) A nurse is assessing a client who is post-op following abdominal sx. States "I feel like my incision ripped open." Place client in Low-Fowler's position A nurse is assessing a client w/ schizophrenia - what is a manifestation? Auditory hallucinations A nurse is caring for a client following insertion of a subclavian non-tunneled percutaneous central venous catheter - What should nurse do? Review the chest x-ray A nurse is caring for a client who has a partial laryngectomy and is receiving continuous enteral feedings at 65ml.hr through a gastrostomy tube (intervene??) The client is lying in a supine position A nurse is caring for a client who has newly implanted sealed internal radiation device to treat cervical cancer. Keep a 3 ft distance from the radiation implant A nurse is caring for a client who has a new prescription for lithium carbonate. PRIOR TO ADMINISTERING THE FIRST DOSE, WHICH OF THE following lab values should the nurse evaluate? Sodium A nurse is caring for a client who has a typical depression and is taking phenelzine - What can you eat? Low-fat yogurt A nurse is caring for a client who has cirrhosis of the liver: Monitor for abdominal ascites Nurse is caring for a client who has end stage liver disease. The daughter of the clients ask about her father's DNR request. Tell me your feelings bout your father's prognosis. A nurse is caring for a client who has heart failure and has started taking a loop diuretic: Decreased reflexes A nurse is caring for a client who has just returned to the unit following a bronchoscopy: Offer oral fluids to the client A nurse is caring for a client who is manic. Which of the following activities is appropriate for the nurse to suggest? Taking walks (physical activity) A nurse is caring for a client who is postoperative and at risk for development of DVT - Risk factor? Prolonged bed rest A nurse is caring for a client who is receiving enteral nutrition. What lab level should be reported? Serum sodium of 128 A nurse is caring for a client who is receiving gentamicin. Which of the following findings indicates the client is developing toxicity? Tinnitus P-pee (furosemide) A-abx & aspirin C-cancer (tamoxifen) T-tinnitus A nurse is caring for a client who is receiving IV antibiotics and tests positive for C. diff - PRIORITY? Place client on contact precautions A nurse is caring for a client who will be receiving a transfusion of platelets - Effectiveness? Decrease in bleeding from puncture sites A nurse is caring for a client with fractured ribs, has developed thrombophlebitis, and is being treated with a heparin drip. The client develops hematuria and has an aPTT of 100 seconds - What nurse do next?? Turn off heparin drip A nurse is reviewing the employee health program for new employees. Which of the following diagnostic assessments should the nurse recommend for all the new employees to screen for the presence of tuberculosis? Mantoux test A nurse is reviewing medical records for four clients - Which of the following represents appropriate documentation? Carafate 1g PO 1hr AC A nurse is reviewing the hx and physical of a client who has right ventricular heart failure: Hepatomegaly (liver enlargement) A nurse is teaching a client who has a new dx of GERD - Include in teaching? Sleep w/ HOB elevated A nurse is teaching a client who has a new prescription for digoxin. Which of the following should the nurse include in the teaching? Notify your provider if you experience muscle weakness! A nurse is teaching a client who has left-leg weakness how to use a standard walker (further education?) Moves the left leg and walker ahead together A nurse is teaching a client who has a low literacy level about home management of diabetes mellitus: Show the client an educational video A nurse is teaching a family about home hospice care: Hospice care improves the quality of life through palliative care A nurse is teaching a prenatal class about evidence of effective breastfeeding to a group of parents - What include in teaching? (SATA) -Swallowing sounds are audible -Stools are yellow and seedy after 7 days -Maternal breasts become soft following feedings A nurse is writing a plan of care for a client who is home bound and has stage 2 Alzheimer's Disease. Which of the following should the nurse include in the plan of care? Assist with money management A nurse manager is making staffing assignments for the med surg unit. Which of the following clients is appropriate to assign to a float nurse from the postpartum unit? A client who is 2 days posto-op following a colon resection A nurse manager is presenting an in-service for newly licensed nurses about advance directives: Advanced directives must benotarized to be legally implemented A nurse manager is presenting info to the nursing staff regarding the appropriate use of client restraints - What should be included? (SATA) -Nurse should pad the bony prominences. -Providers prescription should include the type of restraint to use. -Remove or replace restraints frequently to ensure good circulation to the area A nurse notices smoke coming from aclients room and discovers a fire in the wastebasket. After moving the client to safety what nurse do next? Co said: Notify the facility operator I found: Activate fire alarm A nurse plans to ambulate a client on the third day after cardiac sx. Premedicate the client w/ the prescribed analgesic A nurse supervisor receives notification of a disaster in the community and the possibility for multiple admissions to the facility - Which ppl can be discharged? (SATA) - 1 day post op -laparoscopic -cholecystectomy -temp 98 A client who has an abdominal wound and is receiving negative pressure wound therapy Report to the nurse manager Rationale: negative pressure wound therapy is used to reduce edema A nurse volunteers to assist after witnessing a mass casualty incident involving a train derailment. Which of the following clients should the nurse immediately and completely immobilize? Pt w/ Glasgow coma???? A nurse who typically works on the postpartum unit is assigned to float to the maternal newborn unit. The nurse is very anxious about floating and uncomfortable with the assignment the charge nurse has selected - What should nurse do? Ask the charge nurse to assign an experienced nurse to act as a resource A nurse working in an inpatient mental health facility observes a client who is agitated and threatening staff members in the day room - What should do? Accompany the client awayfrom the common area Nutritional assessment on a client who has a calcium deficiency Osteogenesis OCD - Further education?? Teach the client to meditate about obsessive thoughts An older adult client tells the nurse, "I thought immunizations were for kids." The nurse informs the client that older adults should receive which of the following immunizations? (turn upside down)? Disorder of eye post-op risk? Bleeding and infection VATI Final A nurse is reinforcing teaching with a postpartum client. Which of the following should the nurse explain as the most important reason for staff to wear identification? Reducing the risk of newborn abduction A nurse is reinforcing teaching with a client who plans to bottle feed her newborn. Which of the following statements indicates an understanding of the instructions? I will feed my baby six to eight times a day A nurse is reinforcing teaching with a client diagnosed with osteoarthritis who reports joint pain,swelling, and stiffness. Which of the following client statements indicates understanding of the teaching? I will exercise my joints as much as i can when they are inflamed A nurse is reinforcing teaching with a client who is scheduled for a mammogram. Which of the following instructions should the nurse include in the teaching? Refrain from using deodorant on the morning of the test A nurse is preparing a clients insulin regimen. Which of the following insulin's can be mixed? Insulin aspart, regular insulin, insulin lispro A nurse is reinforcing discharge teaching with a client who is postoperative following laser surgery for open-angle glaucoma. Which of the following statements by the client indicates an understanding of the instructions? I will take a stool softener to prevent constipation A nurse is caring for a client who had a stroke and is having difficulty swallowing. The nurse should recommend a referral to which of the following members of the interprofessional team? Speech therapist A nurse is reinforcing teaching with a client who is 12 hr postpartum and has an episiotomy. Which of the following instructions should the nurse include? Change the perineal pad with each void A nurse is collecting data from a child who has acute Glomerulonephritis. Which of the following findings should the nurse expect? Periorbital edema A nurse is preparing to administer a liquid medication to a 6-month-old infant who is crying. Which of the following actions should the nurse take to reduce the risk of aspiration? Administer using a needless syringe in the buccal cavity A nurse is reinforcing teaching with a client who has peptic ulcer disease. Which of the following statements by the client indicates an understanding of the teaching? I will plan to have my meals at regular intervals A nurse in long-term care facility has received change-of-shift report about four clients. Which of the following clients should the nurse attend to first? A client who has COPD and dementia and was agitated during the night shift A nurse is collecting data from a client who has substance use disorder and reports recently taking opioids. Which of the following findings should the nurse identify as a manifestation of opioid intoxication? Pinpoint pupils A nurse in a urgent care clinic is collecting data from a client who reports having diarrhea for the past 3 days. Which of the following findings indicates hypokalemia? Muscle weakness A nurse is contributing to the discharge plans for four clients. The nurse should identify that which of the following clients requires an interdisciplinary care conference? A client who has hemiparesis and lives alone A nurse is reinforcing teaching with an adolescent who has a new prescription for cefazolin. For which of the following findings should the nurse instruct the adolescent to monitor and report to the provider? Depression A nurse is reinforcing teaching with a group of expectant parents regarding the proper use of a car seat. Which of the following statements by a parent indicates an understanding of the teaching? I can place a rolled towel on each side of my newborns head until he can hold his head up A nurse is caring for a school-age child who has epistaxis. Which of them following actions should the nurse take? Apply pressure at the bridge of the child's nose A nurse is caring for four clients. Which of the following clients statements should the nurse attend to first? My heartburn pain is going into my jaw now A nurse in a providers office is talking on the phone with the parent of a school-age child who has varicella. All vesicles have crusted over A nurse is collecting data from a client who hgb is 8.8 mg/dL. Which of the following statements should the nurse expect? I feel tired all the time A nurse is administering a cleansing enema to a client who reports mild cramping during instillation of the solution. Which of the following actions should the nurse take? Slow the rate of instillation A nurse receives report on four clients. The nurse should first collect data about the client who has which of the following? A decreased level of consciousness and vomiting A nurse is setting up a sterile field prior to performing a dressing change. Which of the following actions should the nurse take? Open the outermost flap of the wrapper toward the body A nurse is caring for a client who has bipolar disorder and is experiencing mania. Which of the following actions should the nurse take? Frequently remind the client of the expectations for her behavior A nurse is caring for a client who has viral pneumonia. Which of the following actions should the nurse take? Administer Azithromycin A nurse who orienting to a medical-surgical unit is having difficulty finishing client care tasks during his shift. Which of the following suggestions should the nurse's preceptor make to help the nurse with time management? Try to complete a task before moving on to the next. A nurse is caring for an older adult client who is postoperative following a total hip arthroplasty. The nurse is preparing to change the client's dressing. Which of the following actions should the nurse take to demonstrate sensitivity to age-related changes? Use paper tape for securing the new dressing. A nurse working in an inpatient mental health facility is assisting with the plan of care for a client who has anorexia nervosa. Which of the following should the nurse recommend to include in the plan of care? Maintain continuity of staff members. A nurse is assisting with an admission interview for a client who has schizophrenia. He tells the nurse that he is receiving special audible messages from the Central Intelligence Agency that no one else is able to hear. The nurse should identify that the client is having which of the following alterations in perception? Hallucination A nurse is reinforcing teaching with a postpartum client about bathing her newborn. Which of the following statements should the nurse include? "Wash your newborn's head under a stream of running water." A nurse is caring for a client who has heart failure and reports difficulty limiting sodium in his diet. Which of the following recommendations should the nurse provide? Replace bottled salad dressing with homemade vinegar and oil dressing. A nurse is reinforcing teaching about nonpharmacological pain relief with a client who is 6 hr postpartum following a vagin*l delivery. The client has an episiotomy and swelling of the labia. Which of the following instructions should the nurse include? 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 does which of the following? States that he will treat hypoglycemic reactions with 15 g of carbohydrates 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? Contact security personnel to place the money in the facility safe. A nurse on a medical-surgical unit is planning care for a group of clients. Which of the following tasks is appropriate to delegate to an assistive personnel? Administer a large-volume enema to a client. A nurse is reviewing the medical record of a client who has sustained a full-thickness burn and is in the emergent phase of the burn. Which of the following findings should the nurse expect? Hypercalcemia A nurse is collecting data from an 18-month-old toddler at a well-child visit. Which of the following findings should the nurse report to the provider? The toddler can say four words. A nurse delegates a task to an assistive personnel (AP) and the AP refuses the assigned task. Which of the following actions should the nurse take first? Perform the task. A nurse on a medical unit is observing an assistive personnel (AP) delivering food trays. Which of the following actions by the AP requires intervention? Providing a ham and cheese sandwich to a client who follows a kosher diet A nurse is reinforcing teaching with a client who has a vitamin C deficiency. Which of the following foods should the nurse include as having the highest vitamin C content? 1 cup raw broccoli A nurse is assisting with triaging clients in a mass casualty situation. The nurse should recommend that which of the following clients receive care first? A client who has diminished breath sounds and paradoxical chest movement A nurse is working in an urgent care clinic when a client who does not speak the same language arrives with a laceration that will require suturing. Which of the following actions appropriate for the nurse to take? Ask an assistive personnel who speaks the same language as the client to assist in obtaining informed consent. A nurse is collecting data from a client who has dehydration and is receiving continuous IV therapy. Which of the following findings indicates effectiveness of the IV therapy? BUN 16 mg/dL A nurse is caring for a child who has terminal cancer. Which of the following responses by the child's siblings should the nurse expect? The school-age sister is concerned about the impact of her sibling's death on herself A nurse is caring for a client who attempted suicide. Which of the following actions should the nurse take? Serve meals with plastic utensils. A nurse is removing a female client's indwelling urinary catheter. Which of the following actions should the nurse take? Withdraw the fluid from the catheter's balloon. A nurse is collecting data from a parent of a preschooler at a well-child visit. Which of the following findings is a contraindication to a measles, mumps, and rubella (MMR) immunization? Long-term use of immunosuppressants A home health nurse is reinforcing teaching with a client about kitchen safety. Which of the following instructions should the nurse reinforce about using a fire extinguisher? Sweep the extinguisher from side to side to put out the fire. A nurse is caring for a client who is asking about the technique of effleurage and its use in labor and delivery. Which of the following responses should the nurse make regarding this technique? "It is a light stroking of the skin during a uterine contraction." A nurse is preparing to administer required immunizations to a toddler during a well-child visit. The parent asks the nurse how many baby aspirins he should administer if the toddler develops a fever. Which of the following responses should the nurse make? "You should follow the label directions based on your child's weight." A nurse is caring for a client who is in mechanical restraints after becoming violent with a staff member. Which of the following actions should the nurse take? Request that the provider write an as-needed prescription for restraints. A nurse is reinforcing teaching with an older adult client who has a new prescription for digoxin for heart failure. Which of the following effects should the nurse include as an expected outcome of this medication? Increased heart rate A nurse is assisting with the plan of care for a client who has Alzheimer's disease. Which of the following actions should the nurse recommend for the plan of care? Give directions using simple phrases. A nurse is caring for a client in a provider's office. The client asks about the purpose of a living will. Which of the following is the appropriate response by the nurse? "It expresses your wishes regarding health care when you can no longer communicate." A nurse is planning to administer an ophthalmic medication to a client. Which of the following actions will minimize systemic absorption of the medication? Wait 5 min after instillation before instilling the drops in the other eye. Place the client in a room that is ventilated to the outside. A nurse is caring for a client who was recently admitted to an inpatient mental health unit. The client tells the nurse that he is not coming out of his room anymore because other clients on the unit make fun of him. Which of the following responses by the nurse is appropriate? "You feel upset by the responses of others." A nurse is caring for a client who is receiving total parenteral nutrition. Which of the following laboratory results indicates a possible complication of this therapy? Serum calcium 12.5 mg/dL A nurse in the newborn nursery is planning to obtain blood from a newborn by a heel stick. Which of the following actions should the nurse plan to take? Apply a heat pack 5 to 10 min prior to the procedure. A nurse from a medical-surgical unit is floating to a postpartum unit. Which of the appropriate assignment for the nurse to accept? A client who had a cesarean delivery 24 hr ago 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? Rationalization A nurse working at a crisis hotline call center receives a call from a client who states, "I cannot take it. My life is over." Which of the following is the priority response by the nurse? Are you thinking of harming yourself?" A nurse is reinforcing teaching with the parents of a newborn who had a circumcision. Which of the following client statements indicates understanding of the teaching? "I will apply petroleum jelly to the penis with each diaper change." 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? "You will need to contact your mother directly about her condition." A nurse is caring for a 17-year-old client who admitted for an emergency appendectomy. Which of the following is an appropriate action by the nurse in obtaining informed consent? Delay the procedure if the provider cannot contact the parents. A nurse is reinforcing teaching about home care with the parents of a child who has a seizure disorder. Which of the following instructions should the nurse include? Call EMS if a seizure lasts 5 min or more. A nurse in a mental health unit asks a client who has schizophrenia, "How are you?" Which of the following responses should the nurse identify as the speech alteration of echolalia? "How are you?" A nurse is reinforcing teaching with the family of a client who is receiving palliative care for terminal cancer. Which of the following guidelines should the nurse emphasize about appropriate pain control measures? Administer pain medication on a regular schedule. A nurse in an acute mental health facility observes a client having a panic attack. Which of the following interventions should the nurse implement first? Instruct the client to use abdominal breathing. A nurse is collecting data from a 3-month-old infant who is 6 hr postoperative following a cleft palate repair. Which of the following pain rating tools should the nurse use? FLACC scale A nurse is caring for a client who has a new prescription for furosemide. The client asks the nurse about the purpose of the medication. The nurse tells the client, "This medication is a diuretic, and you should monitor your weight while taking it." Which of the following ethical concepts is the nurse exhibiting? Veracity A nurse is expressing concern about his assignment with the charge nurse. The nurse states that he has more work to do than anyone else. Which of the following statements by the charge nurse demonstrates the conflict resolution strategy of competing? "We will take a look at the assignments together and attempt to modify the workload you are concerned about." A nurse working on a mental health unit is meeting with a client who has been on the unit for 2 days. The nurse greets the client and asks, "What has been happening with you today?" Which of the following therapeutic techniques is the nurse using? Focusing A nurse discovers a fire in a trash can in a client's room. Which of the following actions should the nurse take first? Walk the client to the waiting room. A nurse is caring for a client who is postoperative following a femoral cardiac catheterization. Which of the following actions should the nurse take during the first 30 min? Compare the bilateral peripheral pulses. A client who has inoperable cancer tells the nurse that she does not want to pursue the recommended treatment. She asks if the provider can force her to have the treatment. Which of the following is an appropriate response by the nurse? "You have the right to refuse the recommended treatment plan." A nurse is reinforcing teaching with a client who is about to undergo a thoracentesis. Which of the following statements by the client indicates A nurse is contributing to the plan of care for a school-age child who has sickle-cell disease and is experiencing a vaso-occlusive crisis. Which of the following should the nurse recommend to include in the plan of care? Perform passive range-of-motion exercises. A nurse is collecting data from a client who has hepatitis A. Which of the following findings should the nurse expect? Abdominal pain A nurse is reinforcing teaching about self-administration of nasal drops with a client. Which of the following positions should the nurse recommend for instillation of the drops? Supine A nurse is collecting data from a client who has preeclampsia and is receiving magnesium sulfate via a continuous IV infusion. Which of the following findings should the nurse report to the provider? Urine output 20 mL/hr A nurse is orienting a newly licensed nurse to a medical-surgical unit. Which of the following actions should the nurse take to verify that the newly licensed nurse understands the procedure for measuring a client's blood glucose level? Have the nurse perform a return demonstration. A nurse is receiving change-of-shift report on a group of clients. Which of the following clients should the nurse see first? A client who is exhibiting flight of ideas A nurse in the newborn nursery is collecting data about a newborn's Moro reflex. Which of the following actions should the nurse take to elicit this reflex? Strike the crib surface on which the newborn is lying. A nurse is caring for a client who has a new prescription for a protective safety restraint. Which of the following actions should the nurse take? Secure the restraint with an easy-to-release tie. A nurse is caring for a client who has a chronic illness. In which phase of the therapeutic relationship should the nurse help the client develop problem- solving skills? Working phase A nurse is monitoring a client who is receiving a blood transfusion. Which of the following findings indicates the client is experiencing an allergic reaction? Urticaria A nurse is assisting in the care of a client who is experiencing a postpartum hemorrhage. Which of the following medications should the nurse plan to administer? Methylergonovine A nurse is caring for an older adult client who has pneumonia. When reinforcing teaching about the diagnosis and age-related changes with the client's family, which of the following alterations should the nurse include? Increased elasticity of the thoracic cage A nurse is collecting data from the guardian of a toddler during a well-child visit. The guardian expresses concern to the nurse because his child has a poor appetite, but drinks a quart of milk each day. The nurse should identify that this practice places the toddler at risk for which of the following conditions? Lactose intolerance A nurse is applying a condom catheter to a male client who is incontinent. Which of the following is an appropriate technique to use? Leave space between the tip of the penis and the end of the condom catheter. A nurse is assisting in the preparation of an in-service for a group of unit nurses about ethical principles. Which of the following nursing actions should the nurse include as an example of fidelity? A nurse keeps a promise made to a client. A nurse is caring for a school-age child who is scheduled for a bone marrow aspiration biopsy. The child asks the nurse, "Will this be painful?" Which of the following is an appropriate response by the nurse? "There will be some pain, but I can give you medicine to make you more comfortable." 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? Perfume A nurse is assisting with a group therapy session in which a client begins to monopolize the group's time. Which of the following interventions is appropriate? Schedule one-on-one discussion time with the client. A nurse is caring for a client who is 3 days postoperative following abdominal surgery and has a Penrose drain. Which of the following actions should the nurse take? Reposition the sterile safety pin when the surgeon advances the drain. A nurse is caring for a toddler who is admitted to the pediatric unit and is 2 hr postoperative following a tonsillectomy. Which of the following findings is a sign of hemorrhage? Frequent swallowing A nurse in a long-term care facility is observing an assistive personnel (AP) who is performing hand hygiene. Which of the following actions by the AP requires intervention? Holding his hands up and elbows down while washing his hands A nurse is establishing a baseline postoperative assessment for a client who is recovering from a right femoropopliteal bypass graft. Which of the following findings in the assessment of the client's right leg should be of the most concern to the nurse? The client's pedal pulse in the right foot is not palpable. "I need to take this medication for the rest of my life." A nurse is preparing to administer purified protein derivative (PPD) to a client. The nurse should use which of the following routes? Intradermal A nurse in a clinic is reinforcing teaching with a client who has a new prescription for a combination contraceptive transdermal patch. Which of the following should the nurse include in the teaching? Apply the patch to the lower abdomen," A nurse is reinforcing teaching with a parent about appropriate snacks for a toddler. Which of the following foods should the nurse include? Graham crackers A nurse is caring for a client who has COPD. The client tells the nurse, "I get short of breath during meals. It is too much trouble to eat." Which of the following instructions should the nurse suggest? "Have several small meals during the day." A nurse is caring for a school-age child whose family adheres to a vegan diet in the home. The nurse should recognize the child is at risk for deficiency of which of the following? Vitamin D A nurse working in a long-term care facility is assisting with the plan of care for a client who has Alzheimer's disease. The nurse notes that the client wanders the halls at night and says she is looking for the bathroom. Which of the following interventions should the nurse recommend to include in the plan of care? Label the client's bathroom door. A nurse is reinforcing discharge teaching with an older adult client's family about safety precautions when administering a tap water enema to the client. Which of the following should the nurse include in the instructions? Instruct the client to bear down during rectal tube insertion. A client who is prescribed metoprolol for hypertension tells the nurse, "I don't want to take this medication because makes me tired all the time." Which of the following is the appropriate response? "Let's talk with your doctor about other options." A nurse is preparing to catheterize a client's bladder to check for residual urine. The nurse should schedule this procedure at which of the following times? Right after the client voids A nurse on a mental health unit is discussing client rights with a group of coworkers. Which of the following statements should the nurse include? "A client must withdraw consent for treatment in writing if he is competent to do so." A nurse is collecting data from a client who has diabetes mellitus. Which of the following findings indicates the client might be experiencing diabetic ketoacidosis? Anuria A nurse is reinforcing teaching with the parent of a toddler who has difficulty falling asleep. Which of the following instructions should the nurse include? Establish a bedtime routine. A nurse is caring for a client who is receiving warfarin 5 mg PO daily. Which of the following laboratory values should the nurse check prior to administering the medication? (Select all that apply.) PT Serum potassium INR Serum sodium BUN VATI Comprehensive Predictor NCLEX Questions Low-residue diet Dairy products & eggs, such as custard and yogurt (Rat) A low-residue diet consists of foods that are low in fiber and are easy to digest such as eggs, custard, yogurt and ripe bananas - NOTE Legumes such as lentils and black beans are high in fiber and are not considered low in residue. A RN is caring for a patient who weighs 80 kg and is 5 ft 3 in tall. Calculate the BMI and determine if the patients BMI indicates a healthy weight, underweight, overweight, or obese. Use the formula (wt. in lbs)/(ht in in^2) multiply by 703 to get the BMI. BMI is 31 (obese) (Rat) A BMI greater than 30 indicates obesity. A BMI of 25-29.9 indicates overweight. A BMI of 18.5-24.9 is a normal/healthy BMI. A BMI <18.5 indicates underweight. A RN admits a female patient who weighs 246 lbs with a height of 5 ft 4 in. Calculate the BMI of the female patient. Use the formula (lbs)/(in^2) multiply by 703 BMI 42 indicates the patient is obese A RN is reviewing discharge instructions regarding car seat safety to the parent of a newborn. Which of the following instructions will the nurse include in the discharge teaching (SATA) A. Position the infant rear-facing in the backseat. B. Be sure the car seat is at a 90 degree angle C. Be sure the care seat is at a 45 degree angle D. Position the car seat behind the passenger or drivers seat A - Activate the alarm C - Contain/confine the fire by closing doors and windows and turn off all oxygen sources and any electrical devices. Ventilate the patient who are on life support by using a bag-valve mask E - Extinguish the fire with a general/appropriate fire extinguisher (Class A) A RN discovers that she administered an antihypertensive medication to a patient in error. Identify the appropriate sequence of steps that the RN should take using the following actions. A. Call the MD B. Check the VS C. Notify the risk manager D. Complete an incident report E. Instruct the patient to remain in bed until further notice (A, B, C, D, E) A. Call the MD B. Check the VS C. Notify the risk manager D. Complete an incident report E. Instruct the patient to remain in bed until further notice Note - If the question was a priority question, what would the RN do first? First, I would check the VS. Next, notify the MD. Third, complete an incident report. Fourth, instruct the patient to remain in bed and lastly notify the risk manager. A RN is discussing disaster planning with the board members of a hospital. Which of the following actions should the RN take? A. Incident commander B. Medical command physician C. Triage officer D. Media liaison Medical command physical - (RAT) oversee's the use of resources (equipment and personnel) NOTE - the incident commander manages the incident and key leaders within the facility NOTE - Expect the triage officer to prioritize the treatment of patients coming in for treatment NOTE - Expect the media liaison to communicate with members of the media and press on behalf of the facility A RN prepares the ER to admit patients who were exposed to inhalation anthrax during a bioterrorism attack. Which antibiotic is used to treat patients who have been exposed to inhalation anthrax? Ciprofloxacin (Cipro) will treat and prevent the spread of anthrax (RAT) Ciprofloxacin and doxycycline IV/PO is used following exposure. Treatment includes one or two additional antibiotic (vancomycin, penicillin and anthrax antitoxin) A RN at a mental health clinic is caring for four patients. The RN should recognize the following patients is using dissociation as a defense mechanism? A patient who was abused as a child describes the abuse as if it happened to someone else What are the signs and symptoms of hypoglycemia? Use the mnemonic He IS TIRED! He - Headache IS - Irritability/ Sweating T - Tachycardia I - Irritability R - Restlessness E - Excessive Hunger D - Dizziness The RN is working with a new MD . The RN is preparing the patient for the administration of an epidural. The RN consult the MD for the verification of which medication ordered? Heparin (RAT) Heparin can cause spinal hematoma - the risk for hematoma at the puncture site for spinal or epidural medication administration is increased while taking heparin. NOTE - Factors that further increase risk include taking other anticoagulants or antiplatelet medications, Hx of spinal problems or surgery or use of an indwelling epidural catheter. NURSING CONSIDERATIONS - In patients who have spinal or epidural anesthesia: Assess insertion site for indications of hematoma formation (redness, swelling). Monitor sensation and movement of lower extremities. Notify MD of abnormal findings. A nurse is caring for a patient who is receiving chemotherapy. The patient's absolute neutrophil count (ANC) is less than 1,000/mm3. What precautions should the nurse institute? Neutropenic Precautions (RAT) The risk of serious infection increases as the ANC falls. An ANC lass than 1,000/mm^3 indicates a weak immune system and the need to initiate neutropenic precautions. A charge RN is teaching a group of unit nurses about the policy for patients who have a history of MRSA. Which of the following information should the nurse include? A. A patient who has a history of MRSA will need antibiotics B. A patient who has a Hx of MRSA can develop immunity to the infection C. A patient who has a Hx of MRSA requires a protective environment D.A patient who has a Hx of MRSA can still transmit the infection D. A patient who has a Hx of MRSA can still transmit the infection Identify the diseases the nurse should report to the CDC Staphylococcus aureus (VISA/VRSA) Viral hemorrhagic fever Vancomycin-intermediate and vancomycin- resistant Typhoid fever Toxic shock syndrome (TSS) Tetanus - ECT can be used during manic episodes/rapid cycling, when the patient is a danger to self or others. The nurse is preparing a client for a surgical procedure with regional anesthesia and is reviewing the medication list. The client reports that he took his warfarin last night. What action should the nurse take? - The nurse should notify the MD - Collect labs to read the INR; an INR of 1.1 or below is normal; for a person taking warfarin an INR range of 2.0 - 3.0 is an effective therapeutic range. A RN in the labor and delivery unit is caring for a patient who is undergoing external fetal monitoring. The RN observes that the FHR begins to slow after the start of a contraction and the lowest rate occurs after the peak of the contraction. Which os the following actions should the RN take first? Place the patient in lateral position (RAT) This is a late deceleration and is associated with fetal hypoxemia due to insufficient placental perfusion, placing the patient in the lateral position is the 1st action the RN should take (NOTE) Late decelerations are associated are also with insufficient placental perfusion. Placing the patient in the lateral positions is the 1st action the nurse should take - also administer 8-10 L of O2 but position change is 1st. Hint: Think VEAL CHOP "L" Late decelerations "P" Placental insufficiency A RN is caring for a newborn with a small gestational age (SGA). Which of the following findings is associated with this condition? Wide skull sutures (RAT) Small "newbies" aka premies have wide skull sutures due to inadequate bone growth. Head circumferences smaller than the normal newborn and there is reduced brain capacity. (NOTE) SGA newborns have sunken abd not abd that protrude; they also have loose dry skin and a thin yellowish umbilical cord that looks dull and dry. A RN is preparing to measure the fundal height of a patient who is at 22 WOG. At which location should the RN expect to palpate the fundus? Slightly above the belly button (RAT) Anything between 20-22 WOG is approximately at the level/slightly above the belly button & anything <20 WOG is below the belly button. Monitor for supine hypotension (NOTE) 3 cm above the belly button means the fundal height indicates the gestation to be >22 WOG. A RN is admitting a patient who has a diagnosis of preterm labor. The nurse anticipates a order by the MD for which of the following medications (SATA) Indomethacin - relaxes & suppresses the uterus and is commonly used in preterm labor Mag Sulfate - used to prevent seizures & is a tocolytic (meaning that is stops/halts preterm labor contractions) "the baby needs a little more time to bake". (NOTE) Oxytocin is incorrect - we don't want to cause contractions we want to stop them. Hydrops fetalis caused by chronic intrauterine anemia ie. Rh isoimmunization, caused by blood incompatability. Ex. Rh neg mom with a Ph pos baby. The Rh pos blood enters mom - note: this is what hydrops fetalis is A patient reports awaking from sleep by contractions that are occurring every five minutes and lasting 30 - 40 seconds. Which of the following questions should the nurse ask to assess for true labor vs false labor? "Have you noticed any bloody show or fluid coming from your vagin*" (RAT) True labor has nothing to do with the start of contractions A patient in the early postpartum period is talkative and enjoys recounting the details of her labor and birth. The RN recognizes that the behaviors must likely indicate which the following? The taking in phase of the maternal postpartum adjustment (RAT) Positive mom-infant bonding is incorrect - the bonding describes behaviors r/t maternal adaptation to mothering the newborn, not specifically newborn-mother interaction which would be indicative of positive bonding. A RN is caring for a neonate who exhibits abstinence syndrome (NAS) and demonstrates clinical manifestations of the condition. Which assessment finding is associated with this condition? Hypothermia (RAT) NAS is the result of the neonate withdrawing from drugs as the neonate is detached from the maternal supply. (NOTE) baby's with NAS will not present with diminished/decreased DTR's but increased DTR's instead, increased muscle tone, increased hypersensitivity to sound and external stimuli Thirty minutes after admissions to the nursing an infant appeared jittery and exhibits a weak high pitched cry. Which of the following would be the nurses priority action? Performs a heel stick (RAT) the infant may be experiencing hypoglycemia and a heel stick will allow the nurse to test the BS to assess glucose. (NOT) A drug screen is not the priority action A RN is performing a fundal assessment in the patient's second postpartum day. Which of the following should the RN expect if the patient is experiencing normal involution? The fundus will present one cm below the belly button The patient asks the nurses to explain the difference between true and false labor. Which of the following is an example of true labor? In true labor the uterus will dilate and efface (NOTE) It is not true that the presenting part is engaged; most of the time when the patient is in true labor the presenting part is engaged - and is not a solid indication that this is true labor. A RN is caring for a patient who has been prescribed mag sulfate as tocolytic therapy. Several hours after the infusion was started, contractions ceased. Which of the following is the best analysis os this data? The drug is having a therapeutic effect (RAT) It is incorrect to assess DTR's; while DTR's should be assessed with a patient receiving mag sulfate this is not required based on this data. A patient who is 32 weeks pregnant presents to the ER with bright red vagin*l bleeding for the last 3 hours. The patient reports feeling fetal movement since the bleeding started. Which of the following is the nurses priority action? Assess maternal VS (NOTE) Do not assess the fetal heart tones; since the mother is feeling the baby move this is not necessary. community leaders about infectious disease, the RN should explain that a vector is of which of the following? A. A mode of transmission for the disease B. A microorganism that causes the infection C. An environment where the pathogen can survive D.A patient who is susceptible to the infection A. A mode of transmission for the disease (RAT) Think of a vector as a car the vector is there the bacteria/microorganism resides to get to the host. A RN is caring for a patient who has osteoporosis and a new order for calcium supplements. Which of the following foods should the RN recommend to promote calcium absorption? A. Fortified milk B. Ripe bananas C. Steamed broccoli D. Green leafy vegetables A. Fortified milk (RAT) Provides nearly 2.5 mcg of Vit D, which promotes calcium absorption from the GI tract. Adults up to age 70 require 600 IU of Vit D/per day and 800 IU thereafter. Therefore, fortified milk is a good source of Vit D. A RN is preparing a patient for cardiac catheterization Which of the following pieces of information should the RN give the patient before the procedure? (SATA) A. "You'll have to lie flat for several hours after the procedure." B. " You'll receive medication to relax you before the procedure." C. " You'll feel a cool sensation after the injection of the dye." D. " You'll have to keep your leg straight after the procedure." E. "You'll have to limit the amount of fluid you drink for the first 24 hr." A. "You'll have to lie flat for several hours after the procedure." D. " You'll have to keep your leg straight after the procedure." E. "You'll have to limit the amount of fluid you drink for the first 24 hr." A RN is preparing an in-service presentation about the management of a MI. Death following a MI is often a result of which of the following complications? A. Cardiogenic shock B. Dysrhythmias C. HF D. Pulmonary edema B. Dysrhythmias (RAT) F-fib is one of the most common causes of death following a MI. Therefore the nurse should monitor EKG's carefully for these alterations in the heart rhythm and report and treat them STAT. (NOTE) Cardiogenic shock, HF and pulmonary edema are complications of MI, but is not the most common cause of death following MI. Other complications include emboli and pericarditis. A RN is planning care for a patient who has deep partial-thickness and full- thickness thermal burns over 40% of his total body surface and is in the acute phase f burn injury. Which of the following interventions should the RN include in the plan? A. Initiate ROM exercises B. Use clean technique to provide wound care C. Place the patient on a low-protein diet D. Maintain the patient on bed rest A. Initiate ROM exercises (RAT) to maintain mobility and to prevent contracture A charge nurse is observing a newly licensed RN irrigate a patient's ear, which is impacted with cerumen. Which of the following actions requires the charge RN to intervene? A. Visualizing the eardrum before irrigating B. Instilling 50 mL of fluid with each irrigation C. Using firm, continuous pressure while irrigating D. Warming the irrigation fluid to at least 37C (98F) B. Instilling 50 mL of fluid with each irrigation (RAT) When irrigating a patient's ear the RN should use no more than 5 - 10 mL of irrigating fluid at a time to decrease the chance of stimulating the vestibular nerve of the inner ear, which would result in N&V or dizziness. A RN is preparing an in-service program about the stages of AKI. Which of the following pieces of information should the RN include about prerenal azotemia? A. Prerenal azotemia begins prior to the onset of s/s B. Interference with renal perfusion causes prerenal azotemia C. Prerenal azotemia is irreversible, even in the early stages D. Infections and tumors cause prerenal azotemia B. Interference with renal perfusion causes prerenal azotemia (RAT) Prerenal azotemia refers to elevations in BUN and Creat resulting from problems in the systemic circulation that decrease flow to the kidneys. The decreased renal flow stimulates salt and water retention to restore volume and pressure - Prerenal axotemia results from interference with renal perfusion, such as from HF or hypovolemic shock. A RN at a LTC facility notes a patient with dementia is having problems with orientation. Which of the following actions should the RN take to improve the patients level of orientation? A. Encourage the patient to make choices about meals and activities B. Use written signs to label specific rooms (RAT) An arthroscopy helps with diagnosing musculoskeletal d/o such as RA, osteoarthritis, and internal joint injuries A RN is caring for a patient who has a TBI and assumes a decerebrate posture in response to noxious stimuli. Which of the following reactions should the RN anticipate when drawing a blood sample? A. The patient rigidly extends his arms B. The patient internally flexes his wrists C. The patient curls into a fetal position D. The patient internally rotates his legs A. The patient rigidly extends his arms (RAT) a patient who exhibits decorticate posturing internally flexes the wrists and arms and extends and plantar-flexes the legs A RN is performing a physical assessment of a patient. Which of the following actions should the nurse take to assess the patients tissue perfusion? A. Perform a Romberg test B. Check nails for Beau's lines C. Palpate for respiratory excursion D. Perform a blanch test D. Perform a blanch test (RAT) The blanch test is used to check capillary refill, which is an indicator of peripheral circulation and tissue perfusion (NOTE) Beau's lines are depressions in the nail from temporary disturbance of nail growth. Beau's lines are caused by systemic illness or injury and are not indicators of tissue perfision A RN is performing a straight urinary catheterization for a female patient who has urinary retention. Which of the following actions indicates the RN is maintaining sterile technique? A. Applying sterile gloves to open the catheter package B. Wiping the labia minora in an anteriorposterios direction C. Spreading the labia with the dominate hand D. Using a cotton ball to wipe right and left labia majora B. Wiping the labia minora in an anteriorposterios direction (NOTE) The RN should use the nondominate hand to spread the labia and provide the optimal view of the urethral meatus A RN is caring for a patient who is postoperative and has paralytic ileus. Which of the following abdominal assessments should the RN expect? A. Frequent BS with gas B. Absent BS with distention C. Hyperactive BS with diarrhea D. Normal BS with increased peristalsis B. Absent BS with distention (RAT) Paralytic ileus is an immobile bowel. In this disorder, BS are absent and the abdomen is distended. A RN is providing teaching about nutritious diets to a group of adult women. Which of the following statements should the RN include? A. "Include at least 3 g of Na in your daily diet." B. "Limit wine consumption to 239 mL daily." C. "Include 2.5 cups of veggies in your daily diet." D. "Limit water intake to 1.5 L each day." C. "Include 2.5 cups of veggies in your daily diet." (RAT) Instruct women to consume 2.5 cups of veggies and 2 cups of fruit in the diet. (NOTE) The recommended amount of ETOH for women is a drink per day, which is equivalent to 350 mL (12 oz) of beer, 148 mL (5 oz) of wine, or 44 mL (1.5 oz) of hard ETOH that is over 80 proof. What do you know about a Pulse ? A pulse of 4+ is bounding and does not disappear with moderate pressure. Pulse strength ranges from absent (0) to bounding (4+). A RN is assessing a patient who is experiencing stress and anxiety regarding a recent diagnosis. Which of the following findings should the RN expect ? A. Increased BP B. Decreased BS level C. Decreased O2 use D. Increased GI motility A. Increased BP (RAT) Stress and anxiety can cause the BP to increase and the HR to increase as a result of the SNS stimulation A RN is preparing to insert an NG tube for a patient who has a bowel obstruction. Which of the following actions should the RN take first ? A. Give the patient a glass of water B. Assist the patient into a sitting position C. Explain the procedure to the patient D. Measure the length of tubing to be inserted C. Explain the procedure to the patient A RN is assessing a patient who is undergoing a physical examination. Following the inspection, which of the following techniques should the RN use next when assessing the RN's abdomen ? A. Auscultation B. Light palpation C. Percussion