A nurse is reinforcing teaching with a client who has a prescription for simvastatin

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1.     A nurse is assisting with discharge teaching for a client who is postoperative following the repair of a detached retina. Which of the following instructions should the nurse include in the teaching?

·        "You should bend from the waist to pick up objects.

·        You can remove your eye patch during the day."

·        "You can take a stool softener to prevent constipation."

·        "You can apply a warm moist, compress to your forehead to reduce pain."

2.     A nurse is collecting data from a client who has acute cholecystitis. Which of the following findings should the nurse expect?

·        Discomfort with urination

·        Increased abdominal discomfort prior to meals

·        Pain radiating to the jaw

·        Pain in the right upper abdomen

3.     A nurse is reviewing client confidentiality with a group of newly licensed nurses. Which of the following situations should the nurse include as an example of a breach in confidentiality?

·        A facility risk manager includes information from a client's medical record in a written report

·        A nurse tells the chaplain that a client has a new diagnosis of cancer.

·        A nurse discusses a client's postoperative complications during shift report.

·        A social worker reads a client's chart as a follow-up to a requested consultation

4.     A nurse is caring for a client who has Clostridium difficile. When applying a cover gown, which of the following techniques should the nurse use?

·        Tuck the glove cuffs under the gown sleeves.

·        Push the gown sleeves up to the elbows

·        Apply the gown before the gloves

·        Tie the gown with the gloves on.

5.     A nurse is collecting data from a 10-month-old infant during a well-child visit. Which of the following findings should the nurse identify as a manifestation of torticollis?

·        Feet turn inward

·        Neck is in a flexed position

·        Frenulum connected to the tip of the tongue

·        Asymmetry of gluteal folds

6.     A nurse is collecting data from a client about risk factors for cardiovascular disease. The nurse should identify that which of the following findings is a modifiable risk factor?

·        Age 65

·        Cholesterol 240 mg/dL

·        Sex

·        Family history of cardiovascular disease

7.     A nurse is reinforcing teaching with a client who has a new prescription for warfarin. The nurse should identify which of the following over-the counter medications as safe for use with warfarin?

·        Aspirin

·        Omeprazole

·        Ibuprofen

·        Docusate

8.     A nurse is reinforcing teaching about palliative care to a client who has cancer. Which of the following statements should the nurse make?

·        "It includes restriction of nutritional support."

·        "It enhances quality of life by promoting comfort"

·        It is for clients who have a terminal illness

·        "It is for clients who are given 6 months or less to live."

9.     A nurse is completing documentation in the medical record about a client who fell on the floor. Which of the following statements should the nurse include in the documentation?

·        An incident report has been completed and sent to risk management

·        "The client does not appear to have any injuries resulting from the fall.

·        "Client stated, "I lost my balance and fell when I got out of bed to go to the bathroom

·        The client fell because the assistive personnel did not place nonskid slippers on the client.

10. A nurse is reinforcing teaching with the parents of a child who has a new diagnosis of Wilms tumor. Which of the following information should the nurse include in the teaching?

·        "You should give your child captopril 200 mg PO daily."

·        Your child will not require further treatment after removal of the tumor.

·        "Your child should have surgery in 7 to 10 days to remove the tutor

·        you should not palpate your child's abdomen prior to surgery.

11. A nurse is assisting in the care of a client who is in active labor and is to undergo an amniotomy. Which of the following actions should the nurse take? (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)

·        Position the client with a rolled towel under her hips.

·        Obtain a baseline reading of the FHR and contraction pattern.

·        Document the procedure in the electronic medical record.

·        Pass the sterile hook to the provider.

·        Check the fluid for color, odor, and consistency.

12. 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?

·        "What makes you think the staff is following you?"

·        "This must be very frightening for you. Let's talk more about it."

·        "The psychiatric staff is not FBI. They are here to help you."

·        "Why do you feel the staff is the FBI?"

13. A nurse is reinforcing teaching with a client who has primary open-angle glaucoma and a new prescription for timolol eye drops. Which of the following statements indicates an understanding of the teaching?

·        "I should take a zinc supplement while taking this medication,

·        "I should check my heart rate while taking this medication."

·        "This medication will darken the color of my eyes."

·        "This medication will dilate my eyes."

14. A nurse is caring for a client who is taking multiple medications and asks about possible interactions. To which of the following members of the interdisciplinary team should the nurse make a referral?

·        Social worker

·        Psychologist

·        Patient care technician

·        Advanced practice nurse

15. A nurse is caring for a client who is in bed and begins experiencing a tonic-clonic seizure. Which of the following actions should the nurse take?

·        Measure the duration of the seizure.

·        Restrain the client's arms and legs to prevent injury.

·        Lower the side rails of the bed when the seizure begins.

·        Insert an oral airway into the client's mouth.

16. A nurse is assisting in the care of a client who is 48 hr postpartum. The client states, "My baby won't stop crying even though I've changed her diaper and breastfed her." Which of the following statements should the nurse make?

·        "Breastfed babies are usually fussy from swallowing too much air during feedings."

·        "Your baby needs to suck on a pacifier."

·        "Swaddling your baby snugly in a blanket might help soothe her."

·        "Breastfed babies often need to be supplemented with formula."

17. A nurse is reviewing the medical record of a client who is at 37 weeks of gestation and has HELLP syndrome. Which of the following laboratory findings should the nurse expect?

·        Platelet count 77,000/mm³

·        Hemoglobin 12 g/dL

·        BUN 20 mg/dL

·        WBC count 18.000/mm³

18. A nurse is reinforcing teaching with a client who has an ankle injury and requires crutches. Which of the following instructions should the nurse provide?

·        "Keep your elbows flexed at a 35 angle when using the crutches."

·        "Maintain your head and neck erect when walking with crutches."

·        "Wash the tips of your crutches daily.

·        "Support your body weight by leaning on the crutches."

19. 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?

·        Define the problem.

·        Review the facility's policy and procedure manual.

·        Identify data collection methods

·        Perform chart audits.

20. A nurse is caring for a client who has AIDS. Which of the following solutions should the nurse use to disinfect the client's overbed table following a blood spill?

·        Isopropyl alcohol

·        Bleach

·        Chlorhexidine

·        Hydrogen peroxide

21.  A nurse is collecting data from a client who is 8 hr postoperative following an appendectomy. Which of the following manifestations is the best indication that the client needs a PRN analgesic?

·        The client grimaces when changing positions.

·        The client's heart rate has increased to 110/min.

·        The client reports pain as 7 on a scale of 0 to 10:

·        The client demonstrates a decreased attention span.

22.  A nurse overhears two assistive personnel (AP) in the nurses' station discussing a client who was recently admitted. Which of the following actions should the nurse take?

·        Tell the APs to stop the conversation.

·        Submit an incident report to the risk manager.

·        Inform the client of the APs actions.

·        Document the event in the client's progress notes.

23.  A nurse is administering a client's morning oral medications. Which of the following actions should the nurse take?

·        Verify the medication three times with the medication administration record.

·        Administer time-critical medication 60 min before or after the scheduled time.

·        Identify the client by using one identifier before giving the medication.

·        Document medication administration prior to administering medication.

24.  A nurse is reinforcing teaching with a client who has diabetes mellitus and is taking insulin lispro and insulin glargine. Which of the following instructions should the nurse include in the teaching?

·        "Anticipate that the insulin glargine will peak in 3 hours."

·        "Take an extra dose of insulin lispro prior to aerobic exercise."

·        "Draw up the insulin lispro and insulin giargine in separate syringes

·        "Expect insulin glargine to be cloudy.

25.  A nurse is contributing to the plan of care for a client who is pregnant and reports having trouble sleeping. Which of the following instructions should the nurse include in the plan of care?

·        Obtain a prescription for pramipexole.

·        "Lie on your left side with your top leg forward."

·        "Use a transcutaneous electrical nerve stimulator."

·        "Soak in a bathtub of hot water each night."

26.  A nurse working in a rehabilitation unit is administering medications to two clients who have the same name. Which of the following identifiers should the nurse use to verify the identities of each client?

·        The telephone numbers of the clients

·        The diagnoses of the clients

·        The names of the clients nearest relatives

·        The room numbers of the clients

27.  A nurse is collecting data from a client who has left sided heart failure. For which of the following findings should the nurse notify the provider?

·        Productive cough with pink frothy sputum

·        Pale, clammy skin

·        Weight loss of 1 kg (2.2 lb) in the past 24 hr

·        Fatigue when ambulating 152 m (500 ft)

28.  A nurse is reinforcing discharge teaching with a client who has tuberculosis. Which of the following statements by the client indicates an understanding of the teaching?

·        "I should throw away my used tissues in a closed plastic bag."

·        "I will no longer be infectious after 30 days of treatment.

·        "I will need to take medication for this condition for the rest of my life."

·        My family will need to wear a mask when around me at home.

29.  A nurse is caring for a client who recently gave birth to her first child. The newborn is crying and the client states, "I can't seem to do anything right. What should I do?" Which of the following responses should the nurse make?

·        Babies need to cry soon after they are born to develop their lungs

·        "I'll take him back to the nursery, so you can get some rest

·        "Let me show you how to swaddle and cuddle him, then you try"

·        "If I turn him on his side, maybe he'll go back to sleep.

30.  A nurse is collecting data from a client who has a sodium level of 156 mEq/L. Which of the following findings should the nurse expect?

·        Nausea and vomiting

·        Hypothermia

·        Dysthythmias

·        Altered mental status

31.  A nurse is assisting with developing a plan of care for a client who is immobilized. Which of the following interventions should the nurse recommend to reduce the development of pressure ulcers?

·        Turn the client every 3 hr.

·        Place a donut-shaped cushion under the client.

·        Place the client in a 30 lateral position.

·        Check the client's skin every 4 hr.

32.  A nurse is collecting data from a client who has a urinary tract infection and is taking ciprofloxacin. The client reports pain in her calf muscle. Which of the following statements should the nurse make?

·        "This is an allergic reaction. Take the medication with an antihistamine.

·        "Continue to take the medication. Calf pain is a minor reaction that will resolve itself.

·        "Discontinue the medication. I will ask your provider for another antibiotic"

·        "That reaction means your dose is too high. Cut the pill in half.

33.  A nurse is caring for a client who has a new prescription for a fentanyl transdermal patch. Which of the following actions should the nurse take when administering a transdermal patch? (Select all that apply.)

·        Apply the patch to a clean, hairless area of the client's skin.

·        Dispose of old transdermal patches in a childproof container

·        Apply the transdermal patch to either of the client's forearms.

·        Use sterile gloves to apply and remove transdermal patches.

·        Remove the old transdermal patch before applying a new one.

34.  A nurse is assisting in providing postmortem care for a client who was a devout follower of Hinduism. Which of the following requests should the nurse anticipate from the client's family?

·        To prohibit medical personnel from touching the client's body

·        To bury the client's body within 24 hr of their death

·        To cremate the client's body

·        To stay with the client's body for 8 hr following their death

35.  A nurse is collecting data from a client who is receiving IV therapy. The nurse suspects fluid infiltration. Which of the following findings should the nurse expect at the insertion site?

·        Erythema

·        Pruritus

·        Blood

·        Edema

36.  A nurse is assisting with the care of a preschooler who has manifestations that suggest epiglottitis. Which of the following actions should the nurse take?

·        Determine the preschooler's oxygen saturation level.

·        Collect a sputum sample.

·        Obtain a specimen for throat culture.

·        Inspect the preschooler's tonsils for edema.

37.  A nurse is contributing to the plan of care for a client who has COPD. Which of the following interventions should the nurse include in the plan?

·        Provide the client with three large meals each day.

·        Place the client in an orthopneic position.

·        Encourage the client to cough and deep breathe once every 8 hr.

·        Limit fluid intake to 1.000 mL daily.

38.  A nurse is reinforcing teaching with a client who is scheduled for an intravenous pyelogram. Which of the following statements by the client indicates an understanding of the teaching?

·        "I will feel a warming sensation after the injection of the dye.

·        "I should limit my fluid intake for 2 days after the procedure."

·        "I do not need to sign a consent form before this procedure.

·        "I can have a meal up to 2 hours before the procedure."

39.  A nurse is preparing a sterile field to perform a dressing change of a client's leg wound. Which of the following actions should the nurse take?

·        Place sterile objects at least 2.5 cm (1 in) from the edge of the sterile field.

·        Place the irrigation solution bottle cap on the sterile field.

·        Hold the irrigation solution bottle 5 cm (2 in) above the sterile container.

·        Open the outer wrapper of the sterile package toward her body.

40.  A nurse is reinforcing teaching with a client who is scheduled to have a colonoscopy in 1 week. Which of the following client statements indicates an understanding of the teaching?

·        "This procedure will take place while I'm under general anesthesia."

·        "I'll have my friend drive me home after the procedure."

·        I follow ull-liquid diet the day before the procedure."

·        "I can expect rectal bleeding for a week after the procedure."

41.  A nurse is reinforcing discharge teaching with a client who has COPD and reports problems with maintaining adequate nutrition. Which of the following instructions should the nurse include?

·        "Perform pulmonary hygiene 1 hour before meals."

·        "Lie down for 30 minutes after eating."

·        "Self-administer oxygen through your nasal cannula at 6 milliliters per minute during meals."

·        "Drink at least 240 milliliters of water during each meal."

42.  A nurse is verifying informed consent for a client who is preoperative for a vaginal hysterectomy. Which of the following statements should the nurse identify as an indication that the client has given informed consent?

·        "I should expect my periods to resume in 1 month."

·        "I am thankful I am done having children."

·        "I will no longer need a regular gynecological examination

·        "I will have a large scar on my stomach after this procedure."

43.  A nurse working on a medical-surgical unit is notified about a mass casualty event that recently took place in the community. Which of the following assignments should the nurse anticipate?

·        Assist in discharging stable clients to home.

·        Determine the acuity and number of casualties arriving at the facility.

·        Provide informational updates to members of the media

·        Delegate tasks to emergency health care specialists

44.  A nurse in a mental health facility is caring for a client who reports palpitations and a sense of impending doom. Which of the following actions should the nurse take first?

·        Explain to the client that anxiety causes physical manifestations.

·        Minimize environmental stimuli in the client's surroundings.

·        Administer an anti-anxiety medication.

·        Explore behaviors that have helped to reduce the client's anxiety in the past.

45.  A nurse is assisting with the admission of an older adult client who has impaired mobility and is at risk for falls. Which of the following fall precautions should the nurse plan to implement first?

·        Determine the client's ability to use the call light.

·        Move the bedside table with the client's personal items close to the bed.

·        Create a schedule with an assistive personnel to do hourly rounding for the chent

·        Apply rubber-soled slippers before ambulation.

46.  A nurse is administering an intermittent enteral feeding through a client's NG tube. During the instillation, the client reports abdominal cramping and nausea. Which of the following actions should the nurse take?

·        Lower the head of the bed to 15%.

·        Replace the NG tube.

·        Chill and readminister the formula.

·        Slow the rate of formula instillation.

47.  A client who has type 1 diabetes mellitus asks a nurse about beginning an exercise regimen. Which of the following instructions should the nurse include?

·        Inject additional insulin before exercising

·        Eat a piece of fruit before exercising.

·        Exercise when insulin is at its peak action.

·        Avoid protein before exercising

48.  A charge nurse in a long-term care facility notices the smell of alcohol on a nurse's breath. Which of the following actions should the nurse take first?

·        Remove the nurse from the client care area.

·        Document objective findings about the situation.

·        Call the supervisor to ask for another nurse.

·        Assign clients to the remaining staff.

49.  A nurse is reinforcing teaching with the family of a client who is terminally ill about the grief process. Which of the following information should the nurse include in the teaching?

·        The grieving process should be complete within 1 year."

·        "Anticipatory grieving prolongs the grief process."

·        "Anger toward the health care staff is expected."

·        The stages of grief occur in sequential order."

50.  A nurse is administering pancrelipase to a child who has cystic fibrosis. Which of the following outcomes should the nurse expect as a therapeutic effect of the treatment?

·        Improved respiratory function

·        Reduced fat in the stools

·        Decreased sodium excretion

·        Improved absorption of vitamins B and C

51.  A nurse at a long-term care facility is part of a risk management team that is creating a plan to lower infection rates in the facility. Which of the following instructions regarding hand hygiene should the nurse include?

·        Clean hands with alcohol-based hand gel for 15 seconds.

·        Hold the hands slightly higher than the elbows when using running water.

·        Wash hands under running water for at least 10 seconds.

·        Dry hands thoroughly from fingers to wrist

52.  A nurse is reviewing the plan of care for a group of clients. The nurse should identify that informed consent is required for which of the following procedures?

·        Administration of an iron injection using Z-track technique

·        Placement of a central venous catheter

·        Irrigation of a wound with antibiotic solution

·        Insertion of a nasogastric tube

53.  A nurse is caring for a client who has Graves' disease. Which of the following findings should indicate to the nurse that the client is developing a thyroid storm?

·        Respiratory depression

·        Neck pain

·        Tachycardia

·        Hypotension

54.  A nurse in an acute care facility is assisting with the development of an in-service about reducing environmental stressors to improve clients sleep. Which of the following instructions should the nurse include?

·        Wear shoes with rubber soles.

·        Conduct change of shift report near the clients rooms.

·        Turn on overhead lights briefly when checking IV lines

·        Open curtains between clients in semi private rooms.

55.  A community health nurse is assisting with the development of a pamphlet regarding choking hazards for toddlers. Which of the following foods should the nurse include?

·        Grapes

·        Potatoes

·        Oranges

·        Corn

56.  A home health nurse is caring for an older adult client who lives with a family caregiver and has urinary incontinence. The client states, I guess will be locked in my room again for wetting the bed." Which of the following actions should the nurse take?

·        Restrict family members from visiting with the client.

·        Report the suspected abuse to the nurse manager.

·        Review the medical record to see if the client has reported abuse in the past.

·        Contact the client's caregiver to discuss the client's comment.

57.  A nurse is reinforcing discharge teaching with a client who states, "I don't feel confident driving to my follow-up appointments." The nurse should obtain a referral for which of the following members of the health care team?

·        Physical therapist

·        Primary care provider

·        Social worker

·        Occupational therapist

58.  A nurse enters the room of a school-age child and finds them on the floor experiencing a tonic-clonic seizure. Which of the following actions should the nurse take?

·        Place a padded tongue blade in the child's mouth.

·        Place a pillow under the child's head.

·        Restrain the child's upper extremities.

·        Turn the child onto their back.

59.  A nurse has assigned an assistive personnel (AP) to perform a gastrostomy feeding for a client who has been receiving feedings at home. Which of the following actions should the nurse take to monitor the AP's performance of the task?

·        Instruct the AP to report back once the task is complete.

·        Request the AP to provide a return demonstration of the task.

·        Ask the family if the AP performed the task correctly.

·        Tell the AP to list the steps of the task

60.  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?

·        Have visitors remain at least 0.91 m (3 feet) away from the client.

·        Assign the client to a negative pressure airflow room.

·        Administer aspirin if the client develops a fever.

·        Initiate contact precautions for the client.

61.  A nurse is obtaining a capillary blood specimen to measure a client's blood glucose. Which of the following actions should the nurse take?

·        Allow the antiseptic to dry before puncturing

·        Massage the client's finger away from the puncture site.

·        Hold the lancet at a 45° angle.

·        Apply sterile gloves.

62.  A nurse is caring for a client who is unable to perform ADLS and wears dentures. Which of the following actions should the nurse take when providing denture care?

·        Place a towel in the sink when cleaning the dentures.

·        Use a circular motion to cleanse the biting surface of the dentures.

·        Store the dentures in a dry denture cup on the bedside table after cleaning.

·        Remove the lower dentures before the upper dentures

63.  A nurse is caring for a client who is 1 day postoperative following a total hip arthroplasty and is receiving heparin subcutaneously. Which of the following adverse effects of the medication should the nurse report to the provider?

·        Epistaxis

·        Anorexia

·        Weight gain

·        Bradycardia

64.  A nurse is caring for an older adult client who is postoperative following a total hip arthroplasty. The client is incontinent of stool and urine. Which of the following actions should the nurse take to prevent skin breakdown?

·        Use a moisture barrier on the client's skin.

·        Clean the client's skin with soap and hot water.

·        Massage the area around the client's coccyx

·         Limit the client's fluid intake.

65.  A nurse is reinforcing teaching with a client's family about home oxygen use via nasal cannula. Which of the following statements by a family member indicates an understanding of the teaching?

·        "We will need to remove the nasal cannula when he is eating

·        "We can use petroleum jelly to keep his nares moist."

·        "We can turn the oxygen up to 10 when he has trouble breathing"

·        "We will frequently check the top of his ears for sores.

66.  A nurse is assisting with the care of a client who is at 37 weeks of gestation and is undergoing a nonstress test. Which of the following actions should the nurse take?

·        Assist the client into a supine position

·        Tell the client the test should take about 10 min.

·        Remind the client to press the button when she feels fetal movement!

·        Explain that nonreactivity might require immediate medication administration

67.  A nurse is discussing risk factors for child abuse with members of a parenting group. The nurse should identify which of the following findings as characteristic of perpetrators of child abuse?

·        Rigid expectations of behavior

·        Laissez-faire leadership style

·        High self-esteem

·        Self-blame for financial problems

68.  A nurse is reinforcing discharge teaching with the caregiver of a client who has dependent personality disorder. Which of the following instructions should the nurse include in the teaching?

·        Encourage the client to be assertive.

·        Assume responsibility for making the client's decisions.

·        Maintain a verbal no-harm contract with the client.

·        Limit the client's social interactions.

69.  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 is able to complete his homework on time.

·        "Our child has increased his daily caloric intake."

·        "Our child has a better grasp of reality."

·        "Our child has lost some weight since his last appointment."

70.  A nurse is caring for an older adult client who wears hearing aids with detachable ear molds. Which of the following actions should the nurse take when caring for the hearing aids?

·        Change the battery once per month.

·        Disinfect the hearing aid with isopropyl alcohol.

·        Clean the hearing aid with a soft cloth.

·        Replace the ear molds once per year.

71.  A nurse is preparing to ibuprofen solution 60mg orally to a 3-month-old infant who is febrile. Available is ibuprofen 50 mg/1.25 ml. How many ml should the nurse administer? (Round the answer to the nearest tenth. U se a leading zero if it applies. Do not use a trailing zero)

72.  A nurse is collecting data from a client who is taking tranylcypromine and reports ingestion of tyramine-rich foods. The nurse should monitor the client for which of the following findings as an adverse effect of this medication?

·        Hypertension

·        Hyperglycemia

·        Hematuria

·        Tinnitus

73.  A nurse is caring for a client who has chronic diarrhea. Which of the following findings should the nurse expect?

·        Hypertension

·        Hypokalemia

·        Hypermagnesemia

·        Respiratory acidosis

74.  A nurse is caring for a client who is confused and is trying to pull out their IV catheter. After attempting other measures to prevent the client from self-harm, the nurse places wrist restraints on the client. Which of the following actions should the nurse take?

·        Remove the restraints from the client's wrists every 2 hr

·        Fasten the restraints ties to the bed's side rails.

·        Check that one finger will fit between the client's wrists and the restraints.

·        Contact the provider within 48 hr to obtain a prescription for the restraints

75.  A nurse is contributing to the plan of care for a client who has a potassium level of 2.9 mEq/L. Which of the following actions should the nurse plan to take?

·        Administer furosemide.

·        Monitor for Chvostek's sign.

·        Apply a cardiac monitor.

·        Give a dose of alendronate

76.  A nurse is caring for a client who has an indwelling catheter with a urinary drainage system. Which of the following actions should the nurse take?

·        Instruct the client to hold the drainage bag at waist height when ambulating.

·        Collect a sterile specimen from the urinary drainage bag.

·        Secure the tubing with adhesive tape to the lower abdomen.

·        Coil the tubing on the bed above the collection bag

77.  A nurse is reinforcing teaching with a client about advance directives and a health care proxy. Which of the following client statements indicates an understanding of the teaching?

·        "My health care proxy designee is not able to sign a consent form on my behalf.

·        If I have a health care proxy, then I do not need to have a living will

·        "Once my health care proxy is in place, I relinquish my right to make my own decisions.

·        I do not need to name a relative as my designee in my health care proxy

78.  A nurse is assisting with the care of a group of clients. Which of the following actions should the nurse take to manage her time effectively (Select all that apply.)

·        Keep track of how long it takes to complete certain tasks.

·        Make a priority to-do list at the beginning of the shift.

·        Delegate collection of vital signs to the assistive personnel on the team.

·        Plan a time at the end of the shift to document nursing interventions.

·        Complete activities with one client before moving to another client.

79.  A nurse is caring for a client who delivered a newborn by cesarean birth 1 day ago. The client requests nonpharmacological interventions to manage pain when changing positions. Which of the following responses should the nurse make?

·        "You should use patterned-paced breathing when changing positions

·        "You should change positions as little as possible.

·        "You can splint the incision with a pillow when changing positions

·        "You can apply counterpressure to your back with each position change."

80.  A nurse is talking with a client who refuses a blood transfusion for religious reasons. Which of the following responses should the nurse make?

·        "I'm sure that everything will be all right, regardless of your decision."

·        "You have a right to change your mind."

·        "If I were you would contact your spiritual director."

·        "Making this decision is wrong.

81.  A nurse is preparing to give change-of-shift report on a client who is 2 days postoperative following a total knee arthroscopy. Which of the following information should the nurse include in the report?

·        Steps required for dressing change

·        Admission vital signs

·        Time of last pain medication

·        Preferred bath time

82.  A nurse is monitoring a client's lower extremity following the placement of a cast earlier in the day. Which of the following findings should the nurse identify as manifestations of compartment syndrome? (Select all that apply.)

·        Pain relieved by analgesia

·        Decreased skin turgor

·        Pale colored toes

·        Diminished capillary refill

·        Sensation of tingling

83.  A nurse is caring for a client who has a prescription for NPH insulin 10 units and regular insulin 15 units subcutaneously. After injecting 10 units of air into the NPH insulin vial, which of the following actions should the nurse take next?

·        Verify the dosage with another nurse.

·        Inject 15 units of air into the regular insulin vial.

·        Place the cap over the needle

·        Withdraw 10 units of NPH insulin

Answered by mabieposh on coursehero.com

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Nam risus ante, dapibus a molestie consequat, ultrices ac magna. Fusce dui lectus, congue vel laoreet ac, dictum vitae odio. Donec aliquet. Lorem ipsum dolor sit amet, consectetur adipiscing elit. Nam lacinia pulvinar tortor nec facilisis. Pellentesque dapibus efficitur laoreet. Nam risus ante, dapibus a molestie consequat, ultrices ac magna. Fusce dui lectus, congue vel laoreet ac, dictum vitae odio. Donec aliquet. Lorem ipsum dolor sit amet, consectetur adipiscing elit. Nam lacinia pulvinar tortor nec facilisis. Pellentesque dapibus efficitur laoreet. Nam risus ante, dapibus a molestie consequat, ultrices ac magna. Fusce dui lectus, congue vel laoreet ac, dictum vitae odio. Donec aliquet. Lorem ipsum dolor sit amet, consectetur adipiscing elit. Nam lacinia pulvinar tortor nec facilisis. Pellentesque dapibus efficitur laoreet. Nam risus ante, dapibus a molestie consequat, ultrices ac magna. Fusce dui lectus, congue vel laoreet ac, dictum vitae odio. Donec aliquet. Lorem ipsum dolor sit amet, consectetur adipiscing elit. Nam lacinia pulvinar tortor nec facilisis. Pellentesque dapibus efficitur laoreet. Nam risus ante, dapibus a molestie consequat, ultrices ac magna. Fusce dui lectus, congue vel laoreet ac, dictum vitae odio. Donec aliquet. Lorem ipsum dolor sit amet, consectetur adipiscing elit. Nam lacinia pulvinar tortor nec facilisis. Pellentesque dapibus efficitur laoreet. Nam risus ante, dapibus a molestie consequat, ultrices ac magna. Fusce dui lectus, congue vel laoreet ac, dictum vitae odio. Donec aliquet. Lorem ipsum dolor sit amet, consectetur adipiscing elit. Nam lacinia pulvinar tortor nec facilisis. Pellentesque dapibus efficitur laoreet. Nam risus ante, dapibus a molestie consequat, ultrices ac magna. Fusce dui lectus, congue vel laoreet ac, dictum vitae odio. Donec aliquet. Lorem ipsum dolor sit amet, consectetur adipiscing elit. Nam lacinia pulvinar tortor nec facilisis. Pellentesque dapibus efficitur laoreet. Nam risus ante, dapibus a molestie consequat, ultrices ac magna. Fusce dui lectus, congue vel laoreet ac, dictum vitae odio. Donec aliquet. Lorem ipsum dolor sit amet, consectetur adipiscing elit. Nam lacinia pulvinar tortor nec facilisis. Pellentesque dapibus efficitur laoreet. Nam risus ante, dapibus a molestie consequat, ultrices ac magna. Fusce dui lectus, congue vel laoreet ac, dictum vitae odio. Donec aliquet. Lorem ipsum dolor sit amet, consectetur adipiscing elit. Nam lacinia pulvinar tortor nec facilisis. Pellentesque dapibus efficitur laoreet. Nam risus ante, dapibus a molestie consequat, ultrices ac magna. Fusce dui lectus, congue vel laoreet ac, dictum vitae odio. Donec aliquet. Lorem ipsum dolor sit amet, consectetur adipiscing elit. Nam lacinia pulvinar tortor nec facilisis. Pellentesque dapibus efficitur laoreet. Nam risus ante, dapibus a molestie consequat, ultrices ac magna. Fusce dui lectus, congue vel laoreet ac, dictum vitae odio. Donec aliquet. Lorem ipsum dolor sit amet, consectetur adipiscing elit. Nam lacinia pulvinar tortor nec facilisis. Pellentesque dapibus efficitur laoreet. Nam risus ante, dapibus a molestie consequat, ultrices ac magna. Fusce dui lectus, congue vel laoreet ac, dictum vitae odio. Donec aliquet. Lorem ipsum dolor sit amet, consectetur adipiscing elit. Nam lacinia pulvinar tortor nec facilisis. Pellentesque dapibus efficitur laoreet. Nam risus ante, dapibus a molestie consequat, ultrices ac magna. Fusce dui lectus, congue vel laoreet ac, dictum vitae odio. Donec aliquet. Lorem ipsum dolor sit amet, consectetur adipiscing elit. Nam lacinia pulvinar tortor nec facilisis. Pellentesque dapibus efficitur laoreet. Nam risus ante, dapibus a molestie consequat, ultrices ac magna. Fusce dui lectus, congue vel laoreet ac, dictum vitae odio. Donec aliquet. Lorem ipsum dolor sit amet, consectetur adipiscing elit. Nam lacinia pulvinar tortor nec facilisis. Pellentesque dapibus efficitur laoreet. Nam risus ante, dapibus a molestie consequat, ultrices ac magna. Fusce dui lectus, congue vel laoreet ac, dictum vitae odio. Donec aliquet. Lorem ipsum dolor sit amet, consectetur adipiscing elit. Nam lacinia pulvinar tortor nec facilisis. Pellentesque dapibus efficitur laoreet. Nam risus ante, dapibus a molestie consequat, ultrices ac magna. Fusce dui lectus, congue vel laoreet ac, dictum vitae odio. Donec aliquet. Lorem ipsum dolor sit amet, consectetur adipiscing elit. Nam lacinia pulvinar tortor nec facilisis. Pellentesque dapibus efficitur laoreet. Nam risus ante, dapibus a molestie consequat, ultrices ac magna. Fusce dui lectus, congue vel laoreet ac, dictum vitae odio. Donec aliquet. Lorem ipsum dolor sit amet, consectetur adipiscing elit. Nam lacinia pulvinar tortor nec facilisis. Pellentesque dapibus efficitur laoreet. Nam risus ante, dapibus a molestie consequat, ultrices ac magna. Fusce dui lectus, congue vel laoreet ac, dictum vitae odio. Donec aliquet. Lorem ipsum dolor sit amet, consectetur adipiscing elit. Nam lacinia pulvinar tortor nec facilisis. Pellentesque dapibus efficitur laoreet. Nam risus ante, dapibus a molestie consequat, ultrices ac magna. Fusce dui lectus, congue vel laoreet ac, dictum vitae odio. Donec aliquet. Lorem ipsum dolor sit amet, consectetur adipiscing elit. Nam lacinia pulvinar tortor nec facilisis. Pellentesque dapibus efficitur laoreet. Nam risus ante, dapibus a molestie consequat, ultrices ac magna. Fusce dui lectus, congue vel laoreet ac, dictum vitae odio. Donec aliquet. Lorem ipsum dolor sit amet, consectetur adipiscing elit. Nam lacinia pulvinar tortor nec facilisis. Pellentesque dapibus efficitur laoreet. Nam risus ante, dapibus a molestie consequat, ultrices ac magna. Fusce dui lectus, congue vel laoreet ac, dictum vitae odio. Donec aliquet. Lorem ipsum dolor sit amet, consectetur adipiscing elit. Nam lacinia pulvinar tortor nec facilisis. Pellentesque dapibus efficitur laoreet. Nam ri