Nursing Practices and Procedures | Exams Nursing

2020 RN Comprehensive Predictor form B

180-Questions and Answers |Graded A+

• A nurse in an emergency department completes an assessment on an adolescent client that has conduct

disorder. The client threatenedsuicide to teacher at school. Which of the following statements should the nurse

include in the assessment?

• Tell me about your siblings

• Tell me what kind of music you like

• Tell me how often do you drink alcohol

• Tell me about your school schedule

• *A nurse is observing bonding to the client her newborn. Which of following actions by the client requires the nurse to

intervene?

• Holding the newborn in an en face position

• Asking the father to change the newborn's diaper

• Requesting the nurse take the newborn

nursery so she can restd) Viewing the

newborn’s actions to be uncooperative

• A nurse is caring for client who is taking levothyroxin. Which of the following findings should indicate that the

medication is effect ive? a) Weight loss (this drug act s as T4 and will normalize the effects of

hypothyroidism)

• Decreased blood pressure

• Absence of seizures

• Decrease inflammation

• A nurse is planning discharge teaching for cord care for the parent of a newborn. Which instructions would you include in

the teaching?

• Contact provider if the cord still turns black (it’s going to turn black)

• Clean the base of the cord with hydrogen peroxide daily (clean

with neutral pH cleanser)c) Keep the c ord dry until it falls of f

(cord should be kept clean and dry to prevent infection)

d) The cord stump will fall off in five days (cord falls off in 10-14 days)

• A nurse is assisting with mass casualty triage: explosion at a local factory. Which of the following client should the nurse

identify as the

priority?

• A client that has massive head trauma

Partial preview of the text

Download Nursing Practices and Procedures and more Exams Nursing in PDF only on Docsity!

2020 RN Comprehensive Predictor form B

180 - Questions and Answers |Graded A+

A nurse in an emergency department completes an assessment on an adolescent client that has conduct disorder. The client threatenedsuicide to teacher at school. Which of the following statements should the nurse include in the assessment?
- Tell me about your siblings
- Tell me what kind of music you like
- Tell me how often do you drink alcohol
- Tell me about your school schedule
*A nurse is observing bonding to the client her newborn. Which of following actions by the client requires the nurse to intervene?
- Holding the newborn in an en face position
- Asking the father to change the newborn's diaper
- Requesting the nurse take the newborn nursery so she can restd) Viewing the newborn’s actions to be uncooperative
A nurse is caring for client who is taking levothyroxin. Which of the following findings should indicate that the medication is effective? a) Weight loss (this drug acts as T4 and will normalize the effects of hypothyroidism)
- Decreased blood pressure
- Absence of seizures
- Decrease inflammation
A nurse is planning discharge teaching for cord care for the parent of a newborn. Which instructions would you include in the teaching?
- Contact provider if the cord still turns black (it’s going to turn black)
- Clean the base of the cord with hydrogen peroxide daily ( clean with neutral pH cleanser )c) Keep the cord dry until it falls of f (cord should be kept clean and dry to prevent infection) d) The cord stump will fall off in five days (cord falls off in 10 - 14 days)
A nurse is assisting with mass casualty triage : explosion at a local factory. Which of the following client should the nurse identify as the priority?
- A client that has massive head trauma

A client has full thickness burns to face and trunkc) A client with indications of hypovolemic shock d) A client with open fracture of the lower extremity
A nurse is a receiving report on four clients. Which of the following clients should the nurse assess first?
A client who has illeal conduit and mucus in the pouch
Client pleasant arteriovenous additional vibration palpated
A client whose chronic kidney disease with cloudy diasylate outflow
A client was transurethral resection of the prostate with a red tinged urine in the bag
A nurse is caring for a client just received the first dose of lisinopril. The following is an appropriate nursing intervention?
Place’s cardiac monitoring
Monitor the clients oxygen saturation level
Provide standby assist with the client from bed

1 of 47

Encourage foods high in potassium
A nurse is caring for a client who is in labor and his seat is receiving electronic fetal monitoring. The nurse is reviewing the monitor tracing and notes early decelerations. Which the following should the nurse expect?
Feta hypoxia
Abrupto placentae
Post maturity
Head Compression
A nurse is caring for a client who has chronic kidney disease. The nurse should identify which of the following laboratory values as in an indication for hemodialysis?
glomerular filtration rate of 14 mL/ minute
BUN 16 mg/DL
serum magnesium 1.8 mg mg/dl
Serum phosphorus 4.0 mg/dL
A nurse is caring for an infant who has a prescription for continuous pulse oximetry. The following is an appropriate action for the nurse to take?
Placed infant under radiant warmer
Move the probe site every 3 hours
Heat the skin one minute prior to placing the program
Placed a sensor on the index finger
A nurse in a mental health facility receives a change of shift report on for clients. Which of the following clients should the nurse plan to assess first?
Client placed in restraints to the aggressive behavior
A new limited client pleasures history of 4.5 kg weight loss in the past two months
Client is receiving a PRN dose of health heard all two hours ago for increased anxiety
Applied he’ll be receiving his first ECT treatment today
A nurse working at the clinic is teaching a group of clients who are pregnant on the use of nonpharmacological pain management. Which ofthe following statements by the nurse is an appropriate description of the use of hypnosis during labor?
Hypnosis focuses on the biofeedback as a relaxation technique
Hypnosis promotes increased control of her pain perception during contractions
Hypnosis uses therapeutic touch to reduce anxiety during labor
Hypnosis provides instruction to minimize pain

A nurse is caring for a client who is preparing his advance directives. Which is the following statements by the client indicates an understanding of advanced directives? select all that apply
- I can’t change my instructions once a minute
- My doctor will need to approve my advance directives
- I need an attorney to witness my signature on the advance directivesd) I have the right to refuse treatment e) My health care proxy can make medical decisions for me
A nurse is caring for a client who is at 32 weeks gestation and has a history of cardiacdisease. Which of the following positions should the nurse place the client to best promoteoptimalcardiacoutput?
- The chest
- Standing
- Supine
- Left lateral
A nurse is caring for a group of clients. Which of the following clients should the nurse assign to an AP?
Client who has chronic obstructive pulmonary disease and needs guidance on incentive spirometry
- Client who has awoken following a bronchoscopy and requests a drink
- Client who had a myocardial infarction 3 days ago reports chest discomfort
- Client who had a cerebrovascular accident two days ago and needs help toileting
- Nurse providing discharge teaching to the client who has schizophrenia and is starting therapy with clozapine. Which of the following is the highestpriority for the client toreport to the provider?
- Constipation
- blurred vision
- Fever
- Dry Mouth
A nurse observes an AP providing care to a child who is in skeletal traction. Which of the following action requires intervention?
- Providing a high protein snack
- Assisting the child to reposition
- Placing weights as a child’s bed
- Massaging pressure points-causes skin breakdown
of 47
A nurse is planning to delegate to an AP the fasting blood glucose testing for a client who has diabetes mellitus. Which of the following action should the nurse take?
Determine if the AP is qualified to perform the test.
Help the AP performed the blood glucose test
Assign the AP to ask the client is taking his diabetic medication today
Have AP check the medical record for prior blood glucose test results
A nurse is assessing client brought to the hospital psychiatric emergency services by a law enforcement officer. The client has disorganized , incoherentspeech with looseassociations and religiouscontent. You should recognize the signs and symptoms as being consistent with which of the following?
Alzheimer’s disease
Schizophrenia
Substance intoxication
Depression

A nurse is caring for a child who has infectious mononucleosis .. Which of the following findings are associated with this diagnosis? Select all that apply
- splenomegaly
- Koplik spots (this is associated with measles)
- Malaise
- Vertigo
- Sore throat
Nurse is performing dressing change for client was a sacralwound using negative pressure wound therapy. Which The following actions should the nurse take first?
- Apply skin preparation to wound edges.
- Normal saline
- Don sterile gloves
- Determine pain level
- A nurses caring for client recovery from the bowelsurgery who has nasogastrictube connected to low intermittent suction. Which the following assessment findings should indicate to the nurse that the NG tube may not be functioning properly?
- Drainage fluid is greenish-yellow
- aspirate pH of 3
- Abdominal rigidity
- air bubbles noted in the NG tube
A nurse is preparing to administer TPN with added fat supplements to a client who has malnutrition. Which of the following action should the nurse take?
- Piggyback 0.9 sodium chloride with TPN solutionb) Check for an allergy to eggs
- Discuss the TPS solution for 12 hours
- Monitor for hypoglycemia
A charge nurse is discussing the use of applying ice to a client’s injuredknee with a newly licensed nurse. Which of the following should the nurse identify as a benefit? (A/C?)
- Systemic analgesic effect
- increase in your metabolism
- Decreased capillary permeability
- Vasodilation
Nurse is developing discharge care plans for client has osteoporosis. To prevent injury the nurse should instruct the client to
- Perform weight bearing exercises
- Avoid crossing the legs beyond the midline
- Avoid sitting in one position for prolonged periods
- Split affected area
A nurse on acute med-surgical unit is performing assessments on a group of clients. Which is highest priority? a) The client has surgical hypoparathyroidism and positive Trousseau’s sign
- A client who was Clostridium difficile with acute diarrhea
- A client who is acute kidney injury and urine with a low specific gravity
of 47
The client who has oral cancer and reports a sore on his gums

The client was a prescription for chemotherapy and an absolute neutrophil count of 75/mm
Nurses caring for client was in end-stage osteoporosis and is reporting severe pain. Clients respiratory rate is 14 per minute. Which of thefollowing medications should the nurse expect to be the highest priority to administer to the client?
Promethazine
Hydromorphone
Ketorolac
of 47
Amitriptyline
A nurse is caring for a client who has DVT. Which of the following instructions the nurse include in the plan of care?
Live with the clients fluid intake to 1500 mL per day
Massage place affected extremity to relieve pain
Apply cold packs of clients affected extremity
Elevate the client’s affected extremity when in bed
A nurse is caring for a client who is receiving oxytocin IV for augmentation of labor. The client’s contractions are occurring every 45 seconds with a nine seconds duration in the fetal heart rate is 170 to 180/minute. Which of the following actions should nurse take?
Discontinue oxytocin infusion
Increased oxytocin infusion
Decreased oxytocin infusion
Maintain oxytocin infusion
A nurse is admitting a client who is in labor and at 38 wks of gestatio n to the maternal newborn unit. The client has a history of herpes simplex virus 2. Which of the following questions is most appropriate for the nurse to ask the client?
Have your membranes ruptured?
How far apart are your contractions?c) Do you have any active lesions? d) Are you positive for beta strap?
Nurse is providing teaching for child prescribed ferroussulfate. Which of the following instructions should the nurse include?
Take with meals
Take at bedtime
Take with a glass of milk
Take with a glass of orange juice
Four clients present to the emergency department. The nurse should plan to see which of the following clients first?
A 6 year old client whose left shoulder is dislocated
A 26 year old client for sickle cell disease and a severe joint pain
A 76 year old client was confused, febrile and has foul smelling urine - uti
A 50 - year old client who has slurred speech, is disoriented, and reports a headache - stroke
A nurse is completing a dietary assessment for client who is Jewish and observes kosher dietary practices. Which of the following behaviors should the nurse expect to find?
Leavened bread maybe eaten during Passover.
Shellfish is commonly consumed in the diet.
Meat and dairy products are eaten separately.
Fasting from meat occurs during Hanukkah.

A nurse is in an ER caring for client of multiple wounds due to a motor vehicle crash. Which of the following interventions are appropriate? Select all that apply
- Apply direct pressure to bleeding wounds
- Clean rest last rations and abrasions with hydrogen peroxidec) Cover wounds with a sterile dressing d) Administer 650 mg aspirin PO as needed for pain e) Determine date of last tetanus toxoid vaccination.
A nurse is providing teaching for a client has a new prescription for methadone. Which of the phone following client statements indicates need for further teaching?
- I understand the methadone tends to slow my breathing
- I understand the methadone may cause me to have difficulty sleeping
- I will avoid alcohol while I’m taking this medication
of 47
I’ll change positions gradually especially from lying down to standing
Which of the following client is appropriate for the nurse to refer to speech therapy for swallowingevaluation?
- Premature infant with a poor suck reflex and failure to thrive
- An older adults who has difficulty taking in fluids
- Adolescent who anorexia who is cachectic
- A middle aged adults was gastroesophageal reflux disease
A nurse is caring for a group of clients. Which of the following client should nurse assess first?
- A client whose benign prostatic hyperplasia and is unable to urinate
- The client was heart failure and report shortness of breath while ambulating
- A client who is open cholecystectomy and has green drainage from the T-tube
- A client whose abdominal pain and is vomiting coffee ground emesis
The nurses assessing client with posttraumaticstress disorder. Which of the following findings to the nurse expect to find?
- Dependence on family and friends
- Loss of interest in usual activities
- Ritualistic behavior
- Passive aggressive behavior
A nurse working in a long-term care facility is caring for an older adult client has dementia .The clients often agitated and frequently wanders the halls. Which of the following intervention should the nurse include in the plan of care?
- Give the client several choices when scheduling activities.
- Confront the client regarding unacceptable behavior
- Maintain Nutritional requirements by offering finger foods
- Stimulate the client by leaving the television on throughout the day
A nurse on a mental health unit receives report on four clients. Which of the following client should the nurse attend to first?
- A client who has begun to demonstrate catatonic behavior

Varicella
Streptococcal pharyngitis
A nurse assesses an older adult client with the decrease caloric intake and weight loss. Which of the following findings should the nurse report to the provider immediately?
The clinic experiences coughing and wheezing after eating.
The client reports abdominal pain at a five on a scale of 0 to 10.
The client experience is a drop in oxygen saturation to 91% while eating.
The client reports a burning sensation in epigastric area.
A nurse and an assistive personnel are caring for a group of clients. Which of the following tasks is appropriate for the nurse to delegate an AP?
Applying condom catheter for client for spinal cord injury
Administrative oral fluids to client was dysphasia
Documenting the report of pain from client who is postoperative
Reviewing active range of motion exercises with a client who is had a stroke
A nurse from the state health department this is instructing a group nurses regarding reportable infections. Which of the following infectionsshould the nurse report to the CDC?
Candida albicans
Herpes simplex virus 2
of 47
Nurses caring for a client whose 1 day postop following a Hypophysectomy for the removal of the pituitary tumor. Which of the following findings requires further assessment by nurse?
Glascow scale score a 15
Blood drainage on initial dressing measuring 3 cm
Report of dry mouth
Urinary output greater than fluid intake
A client with the left leg cast is using crutches for ambulation. The nurse recognizes client needs further instruction of the client
Flexes elbows at 30 degrees when using the handgrips b) Maintains 3 to 4 finger width between the crutch pad and axilla
Places the crutches 6 inches in front and side of each foot when standing.
Pushes up from a chair with crutches on the unaffected side.
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.
Wear an N95 respiratory mask while caring for the toddler.
Remove the disposable gown after leaving the toddler’s room
Place the toddler in a room with negative air pressure.

A nurse is admitting to a client to emergency department and initiates continuous cardiac monitoring. Which of the following ECG with strips indicates sinus tachycardia? b)
A nurse is planning care for client to prevent complications of immobility. With the following actions should the nurse including the planof care?
Massage lower extremities daily to prevent DVT
Limit intake of Food high in calcium to prevent renal calculi.
Encourage client to lie supine prevent constipation.
Remove anti embolism stockings for 3 hours each day to decreased skin breakdown.
of 47
Increased dietary fiber to prevent constipation.
Rise slowly when sitting up from bed.
Take this medication each morning.
Addresses planning to provide teaching to young adult client who is insomnia. Which of the following should the nurse include in the teaching?
Exercising an hour before bedtime
Take a short nap today
Keep bedroom cool at night
Consume a high carbohydrate snack at bedtime.
A nurse is caring for client who has a stool culture that is positive for Clostridiumdifficile. Which of the following infection controlprecautions is appropriate?
Wear a face shield prior into entering the room.
Place the client private room.
Place the client in a negative pressure room.

Remove dirty linens from the room after double bagging.b) Wear a dosimeter film badge while in the client’s room
Limit each of the clients is yours to one hour per day.
Ensure family members remain at least 3 feet from the client.
A nurses for Caring for four clients. Which of the following client should the nurse care for first?
A client to receive a chemotherapy treatment or first national
A client who has an appendectomy to these don’t has diminished all soundsc) A client is hypothyroidism and his stuporous d) A client who is a burn requiring a sterile dressing change
The nurses planning care for newly admitted adolescent who has bacterial meningitis. Which the following instructions is appropriate for the nurse to include in the plan of care?
Initiate droplet precautions for the client
Assisted client to supine position
Performing Glasgow coma scale every 24 hrs
Recommend prophylactic acyclovir there for the clients family.
Nurse is giving discharge instructions to client has new ileostomy. The nurse should recognize that the teaching has been effective whenthe client states.
I want sure that my medications are enteric coatedb) My stoma will drain liquid fluid continuously
I will change my pump system every two weeks
My stoma size will stay the same even after healed
A nurse in a provider’s office is interviewing a client who is requesting an oral contraceptive. Which of the following findings in the client’s history is a contraindication to use in combination oral contraceptives?
thyroid disease
Allergy to penicillin
of 47
impaired liver function
abnormal blood glucose
The nurses providing teaching to a client who has mild persistent asthma has been prescribed montelukast. Which of the following statements to the nursing put in teaching?
This medication can be used to help you when have an acute asthma attack
This medication should be taken before exercise and physical activity
This medication can be taken for 10 days and then gradually discontinued
This medication helps decrease swelling and mucus production
I nurse on the medical surgical unit is receiving reports on four clients. Which of the following client should the nurse assess first?
A client who is receiving warfarin and has and INR of 3.
A client who has an acute kidney injury, a creatinine of 4 mg/dL, and a BUN 52 mg/dL
A client who had a NG tube inserted 6 hr ago and has abdominal distention
A client who is 4 hr postoperative following a thyroidectomy and reports fullness in the back of the throat
A nurse is assessing a client who has pericarditis. Which of the following findings is priority a) Paradoxical pulse pg. 389 under complications
dependent edema

Pericardial friction rub
Substernal chest pain
A charge nurse is providing teaching to a new licensed nurse on how to cleanup surfaces contaminated with blood. Which of thefollowing agents said the nurse include in the teaching?
Hydrogen peroxide
Chlorhexidine
Isopropyl alcohol
Chlorine bleach
*A nurse is preparing to feed a newly admitted patient with dysphagia. Which of the following actions in response take?
instruct the client to lift her chin when swallowing
discourage the client from coughing during feedings
Sit at or below the clients eye level during feedings.
Talk with the client during her feeding.
A nurses caring for a client who repeatedly refuses meals. The nurse overhears an assistive personnel telling the client. “If you don't eat, I’ll put restraints on your wrists and feed you.” The nurse should intervene and explain to the AP that this statement constitutes which of the following torts?
Assault
Battery
Malpractice
Negligence
A charge nurse is evaluating the time management skills for new licensed nurse. The charge nurse should intervene when a newly licensed nurse does which of the following?
Re-Evaluate priorities halfway through the shift
Delegate changing sterile dressing for licensed practical nurse
Groups activities for the Same client d) Works on several tasks simultaneously
A nurse is planning to delegate client assignments to the assistive personnel. which of the following task is appropriate for the nurse to delegate?
Just the flow rate of the clients oxygen tankb) Collecting urine sample
Measuring the clients pain level
of 47
Monitoring blood glucose levels
A nurse is assessing a client wasn’t following vital signs: Oral temperature of 37.2°C (99 F). Apical pulse rate of 80/min, radial pulse rate 62/min, respiratory rate of 16/min, and blood pressure of 132/40 mm Hg. What is the clients pulse pressure?
Systolic presssure subtracted by diastolic pressure (132 - 40) = 92
A nurse if caring for a group of clients in a medical surgical unit. Which of the following situations requires completion of an incident report?

A nurse is assessing for allergies before administering Propofol to a client placed on the mechanical ventilator. Which of the following allergies is a contraindication to the medication? - Eggs - Milk - Shrimp - Peanuts
A nurse is assessing a client diagnosed with schizophrenia. The nurse asks the client to interpret the following statement, “When the cat’s away, the mice will play”. The client response was, “The mice come out when the cat is not around”. The nurse should document this finding which of the following in the client’s chart? - Echolalia - Associative looseness - Neologisms - Concrete thinking
A nurse in the telemetry unit is receiving the laboratory findings for adult male client who’s been treated for myocardial function. Thefollowing is an expected finding for the client? - Troponin 1 (TNI) 8 ng/ml - Brain natriuretic peptide (BNP) 10 ng/L - Alanine aminotransferase (ALT 45 unit/L - High density lipoprotein (HDL) 75 mg/dl
A nurse is teaching a client about nutritional intake. The nurse should include which of the following in the teaching?
- "Carbohydrates should be at least 45% of your caloric intake."
- "Protein should be at least 55% of your calorie intake."
- "Carbohydrates should be at least 30% of your caloric intake."
- "Protein should be at least 60% of your caloric intake."
A nurse is caring for a client who has a prescription for vancomycin1 g IV every 12 hr. The client is scheduled to have the morning dose at 0700. The nurse should schedule the trough level to be drawn at which of the following times? a. 2100 b. 0900 c. 1300 d. 1800
A nurse is planning an education session for a client who has type 1 diabetes mellitus. Which of the following should the nurse plan to include when teaching the client to monitor for hypoglycemia? - diaphoresis - polyuria - abdominal pain - thirst
A nurse in an urgent-care clinic is collecting admission history from a client who is 16 weeks of gestation and has bacterial vaginosis. The nurse should recognize that which of the following clinical findings are associated with this infection? - Frequency and dysuria - Profuse milky white discharge - Hematuria
of 47
A nurse receives a change-of-shift report. Which of the following clients should the nurse attend to first? a. A client who reports tingling in the fingers following a thyroidectorny
- A client who has dark, foul-smelling urine with a urine output of 320 mL in the last 8 hr
- A client who is in a long leg cast and reports cool feet bilaterally
- A client who has a productive cough and an oral temperature of 36° C (96.80 F)
A nurse is caring for a client who has lactose intolerance and has eliminated dairy products from his diet. The nurse should instruct the client to increase consumption of which of the following foods? - spinach - peanut butter - ground beef - carrots
A client who is 8 hr postpartum asks the nurse if she will need to receive Rh immune globulin. The client is gravida 2, para 2, and her blood type is AB negative. The newborns blood type is B positive. Which of the following statements is appropriate? - You only need to receive Rh immune globulin if you have a positive blood type."b. You should receive Rh immune globulin within 72 hours of delivery." - "Both you and your baby should receive Rh immune globulin at your - week appointment." - "immune globulin is not necessary since this is your second pregnancy."
A nurse is caring for the mother of an adolescent who was killed in a motor-vehicle crash after a school event. The mother states, I never should have let him take the car. Its all my fault!" Which of the following responses by the nurse is appropriate? - You had no way of knowing this would happen." - Most parents blame themselves when losing a child." - Tell me why you feel this is your fault." - You appear to be feeling overwhelmed"
A nurse is educating a client about caloric intake and weight reduction. Which of the following client statements indicates an understanding of the teaching? - “If I eat 500 fewer calories per day, I should lose 1 pound per week.” - “ If I eat 500 fewer calories per day, I should lose 1 pound per week." - "If I eat 450 fewer calories per day, I should lose 2 pounds per week." - "If I eat 250 fewer calories per day, I should lose 2 pounds per week." - "If I eat 300 fewer calories per day, I should lose 1 pound per week.”
A nurses is teaching post-operative care with the parents of a toddler following a cleft palate repair. Which of the following should be included in the teaching? - Provide an orthodontic pacifier for comfort. - Offer fluids by using a straw. - Cleanse suture line with a cotton tip swab. - Remove elbow splints periodically to perform range of motion.
A nurse is caring for four clients. Which of the following tasks can the nurse delegate to an assistive personnel? a. Perform chest compressions during cardiac resuscitation.
- Perform a dressing change for a new amputee.
- Assess effectiveness of antiemetic medication.
- Provide discharge instructions

A nurse working in a mental health facility observes a client who has bipolardisorder walk over to a table occupied by other clients and knock their game off the table. Which of the following is an a ppropriate response by the nurse? - Apologize to the others for your behavior." - I am disappointed that you continue to act out when you are angry."c. Come outside with me for a walk." d. If you dont calm down, you will have to go into seclusion."
A nurse is caring for a client who has human immunodeficiency virus (HIV) with neutropenia. Which of the following precautions should the nurse take while caring for this client - Wear an N95 respirator while caring for the client.b. Use a dedicated stethoscope for the client. - Insert an indwelling urinary catheter to monitor urinary output. - Monitor the client’s vital signs every 8 hr.
of 47
A nurse is caring for a group of clients in a long-term care facility. Which of the following situations should the nurse recognize as a safetyhazard?
A client’s wrist restraints tied to the bed rails
A clients bedside table placed across the foot of the bed
A meal tray left at the bedside from breakfast
A call light extension cord pinned to the bedspread
A nurse is caring for a client in a mental health facility. The clients daughter is crying and tells the nurse that she feels guilty for leavingher father in the hospital. Which of the following is an appropriate response?
I’d like to know more about what’s bothering you."
"Why are you feeling this way"
"You did the right thing by bringing him here."
"I’m sure your father doesn’t blame you."
A nurse is planning care for a client following gastric bypass surgery. The nurse should include which of the following dietary instructions when preparing the client for discharge?
start each meal with a protein source.
Consume at least 25 g of fiber daily.
Check your blood glucose level before each meal.
Limit your meals to three times per day.
149 A nurse is assessing a client who has a chest tube followinga thoracotomy. Which of the following findings requires interventio n bythe nurse?
Tidaling with spontaneous respirations
Drainage collection chamber is 1/3 full
1 cm of water present in the water seal chamber
Suction chamber pressure of - 20 cm H
A provider has written a do not resuscitate order for a client who is comatose and does not have advance directives. A member of the clients family says to the nurse, “I wonder when the doctor will tell us what’s going on" Which of the following actions should the nurse take first
Request that the provider provide more information to the family.
Refer the family to a support group for grief counseling.
Offer to answer questions that family members have.

Ask the family what the provider has discussed with them.
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
scaly and red
asymmetric, with variegated coloring
firm and rubbery
brown with a wart-like texture
A nurse is interviewing an older adult client about the physiological changes he has been experiencing. Which of the following changes should the nurse recognize is normally associated with the aging process?
Decreased sense of taste
Decreased blood pressure
Increased gastric secretions
Increased accommodation to near vision
A nurse in an intensive care unit is planning care for a client who has alcohol withdrawal syndrome. Which of the following should thenurse include in the plan of care?
Administer disulfiram.
Provide frequent orientation to time and place.
of 47
Engage the client in group therapy.
Perform gastric lavage.
A nurse is assessing a client’s cardiovascular system. Identify where the nurse should place the diaphragm of the stethoscope to best hear the closing of the aortic heart valve. (Selectable areas or Hot Spots" can be found by moving your cursor over the artwork until the cursor changes appearance, usually into a hand. Click only on the Hot Spot that corresponds to your answer.) a. Top left site
A nurse is caring for a client who is experiencing mild anxiety. Which of the following findings should the nurse expect?
feelings of dread
rapid speech
purposeless activity
heightened perceptual field
A nurse is delegating tasks to an assistive personnel. Which of the following instructions demonstrates appropriate communication of the task?
"Take a blood glucose fingerstick on the client in room 102 before breakfast and then place the glucometer into the docking station."
"Obtain a blood pressure reading from the client in room 116 after lunch and report a systolic level less than 90."
"Assist the client in room 110 to ambulate once around the unit and stop if she gets short of breath."

Nursing Practices and Procedures, Exams of Nursing

Related documents

Partial preview of the text

Download Nursing Practices and Procedures and more Exams Nursing in PDF only on Docsity!

2020 RN Comprehensive Predictor form B

180 - Questions and Answers |Graded A+

1 of 47