142 A nurse is collecting data from a who is breastfeeding a
142 A nurse is collecting data from a who is breastfeeding and… 142 A nurse is collecting data from a who is breastfeeding and reports a sudden onset of chills and a tender, red area on the right nurse should Identify that these manifestations indicate which of the following conditions? Mastitis mEngorgement Blocked milk ductTrush143A nurse is reinforcing dietary teaching with an adolescent is at 10weeks of gestation. Which of the following statements should the nurse make? a. You need to limit your sodium intake to less than 2 grams per day. b. You should consume more than 40 milligrams of fiber each day c. You need to drink 5 to 6 glasses of fluid each day d. You should consume 1,300 milligrams of calcium each day. 144A nurse is caring for an adolescent who has an allergy to penicillinWhich of the following prescriptions should the nurse clarify with the Doxycycline vibramycinCefazolin Gentamicin145 nurse is collecting data from a who has disorder. The nurse should identify that which of the following findings places the an increased risk for Injury due to mania? The client spends most of their day sleeping The is easily distracted by external stimuli The withdraws from group activities The onlyThe client will only eat finger foods.146 A nurse is collecting data from a client who is 1 day postoperative following a total hip arthroplasty and has deep-vein thromb following findings should the nurse expect in the affected extremity ? Absent dorsal pedal pulse Shiny, hairless skin Irregular, bulging veins Dull aching pains 147A nurse is discussing complementary therapies with a group of clients. The nurse should identify that massage therapy is indicated for the treatment of which of the following mental health disorders Depression disorder disorderSchizophrenia Obsessive compulsive disorder148 A nurse is assisting with discharge planning for a client following a myocardial infarction. Which of the following is an appropriate referral client ? Physical therapist for range of motion exercises Respiratory therapist for breathing exercises Dietitian for nutritional modifications Pharmacist for pain management guidelines149 A nurse is reinforcing teaching about epidural PCA with a client who is in active labor. Which of the following statements should the nurse include?The machine is programmed to prevent you from administering more than a safe dose-During medication administration, you will be able to move your legs freely This method of pain control will shorten the second stage of labor This type of anesthesia commonly causes a postpartum headache 150 A nurse is reinforcing teaching about colostomy care with a client. Which of the following client statements indicates an understanding of care for the colostomy ? I will cleanse the stoma site gently with an antiseptic solution . will contact my doctor right away if my stoma is redI willcut the water opening bigger thanmy stoma I will my empty the colostomy bag it is one half full151 nurse reinforcing teaching about foot care with a client who has diabetes mellitus. Which of the following statements by the client indicates an understanding of the teaching ? I will soak my feet in warm water every night I will apply a moisturizing cream between my toeI will be sure to wear cotton socks I will buy new shoes in the early morning hours152 A nurse is caring for a client who was diagnosed with hyperemesis gravidarumWhich of the following findings should the nurse anticipate Poor skin turgorIncreased blood pressure Decreased pulse rate Absence of ketones in urine153A 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 remove her own socks The toddler has a security blanket The toddler can say four words The toddler throws a ball without falling154 A nurse is caring for a client who receives insulin each morning at 0730. The nurse should anticipate the client’s insulin to peak around which of the following times? 1100 0830 1730 1400155 A nurse is assisting in the preparation of an inservice for a group of unit nurses about ethical principlesWhich of the following nursing should the nurse include as an example of fidelity ? nurse shares her time fairly among clientA nurse tell a client the truth A nurse keep a promise made to a client 156A nurse reinforcing teaching about the aging process with an older adult client. Which of the following information should the nurse inc A majority of older adults have dementia Most older adults are isolated from family and friends There is an increased rate of depression in older adults . Older adults have decreased interest in sexual activity157 A nurse is reinforcing teaching about nutrition with a client who had a stroke. Which of the following instructions should the nurse include? Place food in the side of your mouth when eating Refrain from drinking liquids while chewing food Use a straw to drink liquid down Lie and rest 30 minutes after eating158 A nurse is collecting data from a client who has preeclampsia and is receiving magnesium sulfate via a continuous IV infusion. following findings should the nurse report to the provider? 2+ deep tendon reflex Facial flushing Respiratory rate 13/min mUrine output 20 / hr159 A nurse on a mental health unit is discussing client rights with a group of coworkersWhich of the following statements should the A client must withdraw consent for treatment in writing if he is competent to do so. A client who is an immediate danger to herself or others cannot refuse antipsychotic medications Aclient who is involuntarily committed loses the right to refuse treatment who refuses treatment A client who refused to to group therapy can be discharged for noncompliance160 A nurse is providing change-of-shift report for a client who has COPD. Which of the following information should the nurse include in the New onset of restlessness after dinner Client had several visitors in the afternoon Output 400 over the past 8 hr Vital signs obtained at 1200161 nurse is reinforcing teaching with a who was diagnosed with diabetes mellitus and requires insulin injections. Which of the following client statements indicates an understanding of the teaching ? I should dispose of my used syringes in the household trash I will store my current bottle of insulin in the refrigerator I will hold the needle at a 15 angle to my skin I should use an injection site that from the previous site162 A nurse in a long-term care facility has received change of shift report about four clients. Which of the following clients should the nurse first? A who has heart failure and is incontinent of urine A client who has copd and dementia and was agitated during the night Shift a client who had hip arthroplasty 10 days ago and reportspain with ambulationA client who had a cerebrovascular accident 6 months ago and reports constipation163 A nurse is caring for a client who is using a non- rebreather mask for oxygen delivery. The nurse should identify which of the following as an Indication that the equipment is functioning properly? Air is heard escaping from around the mask The control meter is at the correct setting The attached reservoir bag is inflated The exhalation ports are covered during inspiration and expiration.164 A nurse is reinforcing discharge teaching with a client who had an above the knee amputation and has a prosthesisWhich of the following Instructions should the nurse include Keep initial pressure dressing in place for 1 week after surgery Leave the prosthesis in place when goingto bed Avoid extension of the hips when lying down. Clean the prosthesis using a damp, soapy cloth165 A nurse is caring for several who are receiving wellchild check-ups. The nurse should identify that the initial pertussis (DTaP) vaccine is indicated for which of the following clients? A2month-old Infant A4 month month old infant A 6 month old infant A 15 month old toddler 166 A nurse is preparing morning medications for a client who has a potassium level of 3.2 mEq/L. For which of the following withhold administration and notify the provider ? Atenolol Omeprazole Furosemide Potassium chloride167 A nurse caring for a client who had a progesterone – releasing intrauterine device () inserted 6 months ago . The client is concerned because e had periodic spotting since the Insertion . Which of the following responses should the nurse make? spotting is common with this type of contraception I will notify the provider so they can prescribe a pregnancy test Your periods should return to normal in the next few monthsI will necessary for the provider to remove the iud168a nurse in clinic is reinforcing teaching with a client who has a new prescription for a combination contraceptive transdermal p lowing should the nurse include in the teaching? The contraceptive effect will continue for6 months following discontinuation of the medication Start the first patch on the seventh day of the menstrual cycle “Apply the patch to the lower abdomen. Expect to have a headache during the first month169 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 urse take? Document in the client’s medical record every 15 min Offer toileting to the client every4hr. Remove the restraint when the client falls asleep Request that the provider an as-needed prescription for restraints170A nurse assisting in the development of an in-service for staff members about physical abuse of children. Which of the following children are at increasd risk for physical abuse? Children whose parents have college degrees Children who were born after 38 weeks of gestation Children whose parents aremarriedClient wholive in crowded homes171 A nurse is caring for a client who has a new prescription for furosemide and asks the nurse about the purpose of the medication. The nurse states This medication is a diuretic that removes excess from your bodyWhich of the following ethical concepts is the nurse exhibiting? AccountabilityAutonomy Veracity Justice 172a charge nurse in a long-term care unit is planning care for a group of clients. Which of the following care tasks should the nurse pla sistive personnel ? Evaluating the effectiveness of acetaminophen administered 30 min ago to a client who reported a headache Discussing upcoming dietary changes with a client who has a new prescription for a low – cholesterol diet Measuring urine output every 2 hr for a client recently diagnosed with a urinary tract infection inserting a temporary nasogastric tube for client who has a prescription for laboratory analysis of stomach contents173A nurse is reinforcing teaching about infection control with the guardian of a school-age child who has varicella. The n guardian that which of the following findings is an indication that the child is no longer contagious? Itching has subsided All vesicles have crusted over Temperature is less than 37.8 8 ^ 4 * (100 degrees) The antibiotics regimen is complete176A nurse is setting up a sterile field prior to performing a dressing change. Which of the following actions should the nurse take? Pour liquid by holding the bottle with the label facing the sterile field Prepare the sterile field 5 cm (2 in) below the level of the waist Pour liquids from 10 to 15 cm 4 to 6 in above the sterile field Open the outermost of the wrapper toward the body177 A nurse is caring for a client who has a chronic . In which phase of the therapeutic relationship should the nurse help the problem-solving skills? Preinteraction phase Working phase Orientation phase Termination phase178 A nurse is caring for a who has bipolar disorder and is experiencing maniaWhich of the following actions should the nurse take ? Frequently remind the of the expectations for her behaviorEncourage theclient participate in a group activity in the dayroom Allow the topick her own clothing Encourage the client to increase physical activity during the day179 A nurseis contributing to the plan of care for a 12-month- old infant following cleft palate repair. Which of the following actions should the Allow the infant to have soft foods Maintain elbow restraints on the infant Instruct the parents to feed the infant with a spoon Tell the parents to avoid brushing the infant’s teeth for two weeks180 A charge nurse is reinforcing teaching with a newly hired licensed practical nurse about scope of practice . Which of the following re should the nurse include in the teaching ? Coordinating care Providing direct client care Assessing a health status Providing client with discharge instructions Health Science Science Nursing NURSU 454
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