Which action should the nurse take first to effectively care for a dying child?

1. A nurse is assisting with the care of a client who is 6 hrs postoperative following a right total arthroplasty. Which of the following actions should the nurse take?

• Remove the clients dressing when it becomes saturated
• Check the clients pedal pulses every hr
• Place an abductor wedge under the clients right knee
• Maintain a head of the clients bed in a high-fowler position.

1. A nurse is reinforcing teaching with the parents of a child who has ADHD and is taking methylphenidate. Which of the following statements by the parents indicates that the medication is effective?

• “Our child has lost some weight since his last appointment”
• “Our child has increased his caloric intake”
• “Our child is able to complete his homework on time”
• “Our child has a better grasp of reality”

1. A nurse is assisting with the admission of a client who has varicella zoster. Which of the following interventions should the nurse plan to implement?

• Administer aspirin if the client develops a fever
• Have visitors remain at least 0 meter (3 ft) away from the client

1. A nurse is assisting with a community health program for caregivers of clients who have Alzheimer's disease. Which of the following information should the nurse include?

• Use confrontation to manage the client’s Behavior
• Provide a stimulating environment for the client
• Limit the number of choices for the
• Use written signed to assist a client with locating the bathroom

1. A nurse is caring for a client who has been given methylergonovine intramuscularly for a postpartum hemorrhage. the nurse should monitor for which of the following adverse effects?

• Diarrhea
• Uterine relaxation
• Hematuria
• Elevated blood pressure

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

• "This must be very frightening for you. Let's talk more about it"
• "Why do you feel the staff is the FBI"
• "The psychiatric staff is not FBI. They are here to help you" a
• "What makes you think the staff is following you?"

1. A nurse is completing post-mortem documentation for a client. Which of the following information should the nurse include in the documentation?

• Copy the clients advance directive
• Location of the identification tag on the client's body
• Cause of the client's death
• Last set of the client's vital signs

1. A nurse is collecting data from a 9-year-old child during a Well child visit. Which of the following findings should the nurse expect?

• Grasps concept of cause and effect
• Displays emotional Detachment from parents
• Expresses conflict over Independence and control
• Demonstrate self-centered thinking

1. a nurse is reviewing the medical record of a client. For which of the following events should the nurse write an incident report? (Select all that apply)

• A client received an 0900 daily medication at 1000
• A client fell when ambulating to the bathroom alone
• A client who has infection refuse the evening meal
• A client received the first dose of an antibiotic 1 hour before the collection of blood for culture and sensitivity testing
• An approximate amount of urine was recorded after the urine leaked from the client's catheter bag

10 nurse is preparing to complete a sterile dressing change for a client’s wound. Which of the following actions should the nurse take first?

• Open the flap on the stereo kid nearest to the nurse and place the flap on the work surface
• Open the side flap of the steroid kid allow it to lie flat on the work surface
• Apply sterile gloves
• Open the outermost flap of the steroid get away from the nurse's body

11 nurse is caring for a client who has terminal cancer. which of the following responses by the client's school-age brother should the nurse expect?

• Regresses to an earlier development level
• Alienates himself from his peers
• Believes his bad behavior is causing his brother's death
• Believes that his brother's death will be reversible

12 nurse is caring for a client who has an indwelling catheter within the urinary drainage system. which of the following actions should the nurse take

• Instruct the client to hold the drainage back and waist height when ambulating
• Secure the tubing with adhesive tape to the lower abdomen
• Collect a sterile specimen from the urinary drainage bag

1. A nurse is assisting with the planning of an in-service about updates in one care for nursing staff which of the following sources should the nurse identify as providing the best evidence based information?

• A peer-review journal article
• An entry on a nursing addressing wound healing
• Information from a wound care product vendor
• First hand experience with wound care products

19 nurse is reinforcing teaching with a client who has a new prescription for propranolol. The nurse should include which of the following as a potential adverse effect of this medication?

• Increased urinary output
• Decreased heart rate
• White patches on the tongue
• Sudden weight loss

20 nurse is reinforcing teaching with a client who is at 12 weeks of gestation and has hyperemesis gravidarum. Which of the following client statements indicates an understanding of the nurse’s instruction?

• I will wait 1 hr after getting up in the morning to have breakfast
• I will eat or drink something every 2 to 3 hours throughout the day
• I will eat a low protein snack 30 mins before going to bed each night
• I will try to eat balanced meals instead of only foods that appeal to my taste

21. A nurse is assisting for the plan of care for the client who has burns to his lower

extremities, which of the following actions should the nurse include in the plan?

 Clean the most contaminated wound first

 Use hydrogen peroxide for wound cleaning

 Apply dressing with sterile gloves

 Perform dressing changes every other day

22. A nurse is reinforcing teaching with the family of the client who is terminally ill about the

grief process, which of the following information should the nurse include in the

teaching?

 The stages of grief occur in sequential order

 The grieving process should be complete within one year

 Anticipatory grieving prolongs the grief process

 Anger towards the health care staff is expected

23. A nurse is reinforcing teaching with a parent of a child who has ADHD and is taking

methylphenidate which of the following statements by the parents indicated the

medication is effective

 our child has increased his daily caloric intake

 our child is able to complete his homework on time

 our child has lost some weight since his last appointment

 our child has a better grasp of reality

24. A nurse is reinforcing teaching with a client who is at 12 weeks of gestation and has

hyperemesis gravitation, which of the following client statements indicates and

understanding of the nurse’s instructions.

 I will eat or drink something every 2-3 hours throughout the day

 I will try to eat balances meals instead of foods that appeal to my taste

 I will wait 1 hour before getting up in the morning before having breakfast

 I will eat a low protein snack before going to bed each night

25. A nurse is collecting data from a client who uses a continuous positive airway pressure

cpap machine at night for sleep apnea. the nurse should identify which of the following

indicates proper use

 the mask fits loosely so air can escape

 the therapeutic dose of albuterol is being inhaled

 there is one finger width between he straps and the face

 the mask is secured over the client’s mouth and the nose is uncovered

26. A nurse is receiving change of shift report on four clients, which of the following clients

should the nurse see first

 a patient with sickle cell disease and with hyperbilirubinemia

 a client who has cirrhosis and hematemesis

 a client who is 1 day postoperative and reports pain on a scale of 7 from 0-

 a client who had a hernia repair 4 hours ago and is reporting nausea

27. A nurse is participating in a performance improvement program which of the following

actions should the nurse take to evaluate the effectiveness of the program

 perform chart audits

 review the client’s policy and procedure manual

 identify data collection methods

 define the program

28. A nurse is assisting with preparing a client who is to have a central venous catheter

inserted for administration of TPN. which of the following should the nurse take?

 place the client in sims position for catheter insertion

 prepare the client for a chest x ray to verify catheter placement

 use clean technique when changing the catheter dressing

 verify the amount of TPN solution the client is receiving every 4 hours

 label the door to the bathroom with a symbol

1. A nurse is collecting data from a client who has a long leg cast that was applied 2 days ago. The client’s foot is pale with a weak pedal pulse, and the client reports foot numbness. Which of the following actions should the nurse plan to take first?

-Administer Opioid Pain Medication -Apply An Icepack The Affected Extremity -Check for pain with passive movement of the affected extremity

-Elevate the affected extremity with several pillows

-Check for pain with passive movement of the affected extremity

1. A nurse is reinforcing discharge teaching with a client who had a right total hip arthroplasty. Which of the following instructions should the nurse indicate?

o “You Should Avoid Crossing Your Legs For 3 Months.” o “You should avoid putting a pillow between your legs when bed.” o “You Should Avoid Exercising For The Next 6 Weeks.” o “You Should Avoid Lying On Your Right Side.”

o “You Should Avoid Crossing Your Legs For 3 Months.”

37 nurse is caring for a client who has continuous bladder irrigation following a transurethral resection of the prostate. The nurse notices clots and dark red blood in the catheter collection bag. Which of the following actions should the nurse take?

o Clamp the urinary catheter tubing o Irrigate the bladder with 20 to 30 mL of 0% sodium chloride irrigation

o Replace the indwelling urinary catheter with a smaller diameter catheter

o Allow the tubing to hang below the drainage bag

-Irrigate the bladder with 20 to 30 mL of 0% sodium chloride irrigation

38 nurse is caring for a client who reports having a decrease in fetal movement following an external cephalic version 6 hr ago. The nurse identifies the fetus is in the right occiput anterior position. The nurse should place the fetal heart monitor on which of the following sites to auscultate the fetal heart rate?

- Lower left

39 nurse in an acute care setting is preparing to administer medications to a client. Which of the following actions should the nurse verify the client's identity?

o Verify the client’s identity with a family member

o Ask the client the name of the facility o Ask the client to state her first name o Verify the client’s identity using a photograph

o Verify the client’s identity using a photograph

40 nurse is participating in a performance improvement program. Which of the following actions should the nurse take to evaluate the effectiveness of the program?

o Define the problem o Identify data collection methods o Perform chart audits o Review the facility’s policy and procedure manual

-Identify data collection methods

41 nurse is assisting in the care of a client who has an arteriovenous (AV) shunt in his right arm. Which of the following actions should the nurse take?

o Give IV fluids through the AV shunt o Obtain blood pressure from the right arm o Check a bruit over the shunt on a regular basis

o Avoid range of motion in the right arm

-Avoid range of motion in the right arm

42 nurse is collecting data from a preschooler who has severe dehydration. Which of the following findings should the nurse expect?

o Jugular vein distention o Moist Mucous Membranes o Weight loss 10% o Capillary Refill For 2 Seconds

o Weight loss 10%

43 nurse is caring for a client who has a vacuum-assisted closure system to treat a pressure ulcer. Which of the following actions should the nurse take?

o Cover the wound with a transparent film extending outward 5cm(2in)

o Replace The Wounds Dressing Every 12 Hr o Use an adhesive remover to remove tape before applying dressing

o Pack The Wound Tightly With Sterile Gauze

1. A nurse is RT with the family of a client who is terminally ill about the grief process. WOTF information should the nurse include in the teaching?

Anger towards the health care staff is expected

Anticipatory grieving prolongs the grief process The grieving process should be complete within a year

The stages of grief occur in sequential order

1. A nurse in the long term facility is caring for an older adult client who has a history of hypertension. WOTF findings should the nurse recognize as an indicative sign of a Transient Ischemic Attack?

Epigastric Pain Seizure activity Sudden loss of vision in one eye

Pain radiating down the left arm

1. A nurse is reinforcing discharge teaching to the family of the client who has Alzheimer’s Disease. The client has wandering behaviour and the family is concerned about safety at home. Which of the following instructions should the nurse include?

Replace door knobs with ones containing simple locks

Keep the client’s shoes at the front door Contact Law enforcements if unable to locate the client

Obtain a medical bed with side rails to use at night.

1. A nurse is providing skin care for a 14-year-old adolescent who is in skeletal traction for a fractured femur. Which of the following actions should the nurse take? Select all that apply.

Massage reddened bony prominences

Check skin every 2 hours Cleanse skin with soap-free agents

Use a draw sheet to move client

Elevate the HOB to a 90 degree angle

1. A nurse is providing care for a client who has cystic fibrosis. Which of the following effects is a

therapeutic effect of administering pancreatic enzymes? Reduced fat in the stools

Decreased sodium excretions

Improved respiratory function

Improved absorption of vitamin B and C

1. A nurse is assisting a client move up in bed. Which of the following action should the nurse take? Place the bed in the lowest position Stand with feet together Ask the client to flex her hips and knees Raise the head of the bed
2. A nurse is caring for an adolescent who had a child and is requesting the most reliable method of

birth control. Which of the following should the nurse recommend?

Spermicide

Injectable progesterone

Oral contraceptives

Condoms

1. What safety measures must be implemented for a 12 month old infant? Lock the doors and cabinets Turn pot handles inward Provide finger foods Provide a non skid soles

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