Nursing Multiple Choice Questions

Questions and Answers

The child is at risk for developing which of the following? (Select all that apply)

Aspiration (correct)

Delayed bowel training

Dehydration (correct)

Skin breakdown (correct)

An infection (correct)

What should you set your hot water heater temperature at or below?

120 degrees F (correct)

130 degrees F

100 degrees F

110 degrees F

Which laboratory value indicates cellular injury of myocardial tissue?

Troponin T (correct)

Homocysteine

Amylase

Low-density lipoprotein (LDL)

What should the newborn receive vitamin K to prevent?

Bleeding Signup and view all the answers

What instruction should a nurse give to a postpartum client to help prevent engorgement discomfort?

Place ice packs on the breasts for 15 min several times per day Signup and view all the answers

What action should the nurse take for a child experiencing a tonic-clonic seizure?

Place the child in a side-lying position Signup and view all the answers

What is the most likely condition the child is experiencing?

Epiglottitis Signup and view all the answers

What parameter should be monitored for the child?

Temperature Signup and view all the answers

What causes constipation in a client who is 28 weeks pregnant?

The enlarged uterus compresses the intestines and causes constipation Signup and view all the answers

The client is at highest risk for developing _______

Pyelonephritis Signup and view all the answers

As evidenced by the client's __________

Urinalysis results Signup and view all the answers

Which of the following instructions should the nurse plan to include for preventing further UTIs?

Gently cleanse the perineum before intercourse Signup and view all the answers

Which of the following assessment findings should the nurse report to the provider as unexpected?

Temp Signup and view all the answers

Select the two findings that require immediate follow-up:

Platelet count Signup and view all the answers

What should the nurse plan to first assess the newborn's _______

Respiratory rate Signup and view all the answers

What should the nurse plan to assess the newborn's _______

Heart rate Signup and view all the answers

Which of the following may be a common adverse effect of methadone?

Sedation is a common adverse effect of this medication Signup and view all the answers

Which findings require follow-up?

Weight 2,545 g (5 lb 9 oz); 12% weight loss Signup and view all the answers

Which action should the nurse take when preparing to administer insulin?

Inject 20 units of air into the NPH insulin vial Signup and view all the answers

To facilitate the staff's acceptance of the scheduling system change, which action should the nurse manager take first?

Provide information about scheduling issues to the staff Signup and view all the answers

Which of the following indicates a manifestation of vaso-occlusive crisis in sickle cell anemia?

Hematuria Signup and view all the answers

Which statement about car seat safety should the nurse include in teaching?

Secure the retainer clip at the level of your baby's armpits Signup and view all the answers

Which catheter should a nurse use for intermittent urinary catheterization?

Straight urinary catheter Signup and view all the answers

Which action requires a nurse manager to intervene?

Tells the hospital chaplain a client's diagnosis Signup and view all the answers

What should the nurse do for a client presenting with alcohol withdrawal symptoms?

Maintain a low-stimulation environment Signup and view all the answers

Which actions should be taken for a client with major depressive disorder?

Observe the client swallow all prescribed medications Signup and view all the answers

Which method should the nurse manager use to evaluate the nurse's time management skills?

Maintain regular notes about the nurse's time management skills Signup and view all the answers

Which of the following actions should the nurse plan to take first?

Fetal heart rate variability Signup and view all the answers

Which of the following findings requires immediate intervention by the nurse?

Boggy uterus Signup and view all the answers

The nurse should recognize the client is demonstrating which defense mechanism?

Sublimation Signup and view all the answers

Which of the following findings is the priority for the nurse to report to the provider?

Temp 39.4 C (102.9 F) Signup and view all the answers

Which finding should the nurse identify as a contraindication for the client to receive clozapine?

WBC: 2,800 Signup and view all the answers

Which of the following actions should the nurse plan to take first?

Identify health-related issues within the community Signup and view all the answers

Which of the following statements by the client indicates an understanding of the infection prevention teaching?

I will walk for short distances throughout the day Signup and view all the answers

Which of the following actions should the nurse recommend first when implementing an emergency preparedness plan?

Notify the incident commander Signup and view all the answers

Which actions should the nurse take after reviewing assessment findings?

Monitor vital signs frequently Signup and view all the answers

Which information should the nurse report to the provider?

Neurologic status Signup and view all the answers

Which action should the nurse take first for a client refusing to ambulate post-surgery?

Ask the client to rate their pain level Signup and view all the answers

Which statement indicates that the therapy of using acupressure bands is having the desired effect?

I have not vomited as much recently Signup and view all the answers

Which of the following actions should the nurse take regarding a reusable BP cuff?

Place the BP cuff in a labeled bag and send it for decontamination Signup and view all the answers

Which findings require immediate follow-up by the nurse?

Casual Blood Glucose Signup and view all the answers

Which intervention should the nurse include in the plan of care for a child with acute lymphoid leukemia?

Withhold administering the varicella vaccine to the child Signup and view all the answers

Which task should the RN delegate to the LPN?

Insertion of a nasogastric tube Signup and view all the answers

Which action should the charge nurse take first after observing a staff nurse document a dressing change that was not performed?

Gather more information about the staff nurse's actions Signup and view all the answers

Which client should the nurse identify as having a nationally notifiable infectious condition?

An adolescent client who has foodborne botulism Signup and view all the answers

Which of the following instructions should the nurse include for a client who has hepatitis A?

Use hydrogen peroxide to clean kitchen surfaces Signup and view all the answers

Which action should the nurse take regarding reporting STI information?

Explain to the client why this information will be shared Signup and view all the answers

Which of the following should the nurse include in the toddler's plan of care?

Encourage the parents to bring toys from home Signup and view all the answers

Which medication should the nurse anticipate administering after a client develops a respiratory rate of 6/min?

Flumazenil Signup and view all the answers

Which assessment findings should the nurse report to the provider?

Dysuria Signup and view all the answers

Which provider prescriptions should the nurse anticipate for this client?

Educate the client on new prescription for sulfamethoxazole/trimethoprim Signup and view all the answers

The client is at highest risk for developing ____

pyelonephritis Signup and view all the answers

Which actions should the charge nurse take first to provide teaching about chest tubes?

Ask the nurse about their knowledge of the procedure Signup and view all the answers

What should the nurse do while waiting for the new infusion pump?

Administer the TPN solution at the same rate using manual drip tubing. Signup and view all the answers

Which action should the nurse take first for a client who is immediately postoperative following a total vaginal hysterectomy?

Measure the client's vital signs Signup and view all the answers

The nurse should first address the client's _______

electrolyte imbalance Signup and view all the answers

Followed by the client's __________

fear of weight gain Signup and view all the answers

Which action should the nurse take when providing colostomy care?

Place the skin barrier over the stoma and hold it for 30 seconds Signup and view all the answers

What information is the priority for the nurse to communicate to the oncoming nurse about a client preparing for discharge?

The client needs assistance when transferring from the bed to the wheelchair Signup and view all the answers

Which statement by the parents indicates an understanding of sleep promotion for their preschooler?

We should read a story together every night before bedtime Signup and view all the answers

What action should the nurse take when conducting a root cause analysis for increased client falls?

Investigate environmental factors that might be contributing to client injury during these hours Signup and view all the answers

For which of the following manifestations should the nurse monitor a client with a potassium level of 3 mEq/L?

Decreased deep tendon reflexes Signup and view all the answers

What should the nurse document when a mental health client refuses medication?

Document the client's refusal of the medication Signup and view all the answers

Which physiological change should the nurse recognize as related to aging in an older adult client?

Decreased lung expansion Signup and view all the answers

Which actions should the nurse take for a client with colorectal cancer and a new colostomy?

Refer the client to a community-based social worker Signup and view all the answers

How many mL should the nurse administer for a toddler weighing 22lb who needs diazepam 0.3mg/kg IV bolus?

0.6mL Signup and view all the answers

Match the following conditions and actions the nurse must take.

1.) Action 1 = Monitor the client's physical manifestations 2.) Action 2 = Assess the client for a secondary gain from illness 3.) Condition most likely = Somatic symptom disorder 4.) Parameter 1 to monitor = Pain 5.) Parameter 2 to monitor = Vital signs Signup and view all the answers

What intervention should a home health nurse include in the care plan for an older adult client with impaired vision?

Mark the edges of stairs for contrast Signup and view all the answers

What statement should the nurse make to a client with a terminal illness requesting no lifesaving measures?

I will provide you with information about medical treatment to include in your living will Signup and view all the answers

Which findings require immediate follow-up for a client with schizophrenia?

Client has involuntary tongue movement and foot tremor. Signup and view all the answers

What manifestation should the nurse expect in a client with delirium?

Rapid speech Signup and view all the answers

What manifestation should the nurse expect in a client in the manic phase of bipolar disorder?

Grandiose delusions Signup and view all the answers

Which action should the nurse take when performing gastric lavage for a client with gastrointestinal bleeding?

Use 0.9% sodium chloride for irrigation of the NG tube Signup and view all the answers

What action should the nurse take first when interviewing a client who is now without a home due to a natural disaster?

Determine the client's perception of the personal impact of the crisis Signup and view all the answers

Which response should a nurse make to a family member of a client with end-stage Alzheimer's disease who expresses doubt about visiting?

It seems like you feel your visits are a waste of time Signup and view all the answers

What is the first action the nurse should take when preparing to discharge a client who has experienced intimate partner violence?

Develop a safety plan with the client Signup and view all the answers

The child is at risk for developing _ and _.

an infection, skin breakdown Signup and view all the answers

Which of the following actions should the nurse take when receiving a call from someone claiming to be the client's parent?

Ask the Caller for verification of their identity Signup and view all the answers

Which of the following assessment findings should the nurse identify as the priority for a client with a fractured femur and fiberglass cast?

The client's heel is reddened and tender Signup and view all the answers

What information should the nurse provide a client who is to start taking misoprostol?

Complete a serum pregnancy test before taking the medication Signup and view all the answers

Which manifestation should the nurse include when teaching about digoxin toxicity?

Nausea Signup and view all the answers

For which complication should the nurse monitor a client with obstructive sleep apnea?

Hypertension Signup and view all the answers

Identify the proper sequence of steps for performing tracheostomy care.

1 = Clean the stoma with 0.9% sodium chloride irrigation 2 = Remove the inner cannula 3 = Change the tracheostomy collar 4 = Remove soiled dressing Signup and view all the answers

What should the nurse ensure when observing a newly licensed nurse administer enteral feedings?

Keep the head of the bed elevated to 45 degrees for 1 hour after feedings Signup and view all the answers

Which medication should the nurse expect to administer for a client with a closed-head injury to reduce intracranial pressure?

Mannitol Signup and view all the answers

Which action by the assistive personnel (AP) requires the nurse to intervene while turning a client onto the right side?

Places a pillow under the client's right arm Signup and view all the answers

Which of the following instructions should the nurse include to improve nutrition for a client with multiple sclerosis?

Thicken your beverages before drinking Signup and view all the answers

The infant is at highest risk of developing as evidenced by .

dehydration, vomiting Signup and view all the answers

Which action should the nurse take first for a client who is 4 hours postpartum and has a boggy uterus with heavy lochia?

Massage the uterus to expel clots Signup and view all the answers

Which of the following events should the nurse complete an incident report for?

A client's IV pump delivers an inadequate dose of medication Signup and view all the answers

What action should the nurse take to prevent clogging of a client's percutaneous gastrostomy tube?

Flush the client's gastrostomy tube with 30mL of water before administering the medication Signup and view all the answers

Which task should the nurse delegate to an assistive personnel (AP) for a client with hypertension taking captopril?

Obtain the client's blood pressure before the nurse administers medication Signup and view all the answers

The client is most likely experiencing manifestations of and .

Autonomic dysreflexia, Pneumonia Signup and view all the answers

Which findings should the nurse expect when assessing a client who is experiencing autonomic dysreflexia?

Facial flushing Signup and view all the answers

Which intervention should a charge nurse include in the care plan for a client in mechanical restraints?

Provide a staff member to stay with the client continuously Signup and view all the answers

Which strategy incorporates visualization techniques to help decrease a child's discomfort?

Blowing bubbles with liquid soap to 'blow the hurt away' Signup and view all the answers

Which assessment finding should the nurse expect for a client admitted with cardiac tamponade?

Pulsus paradoxus Signup and view all the answers

Which assessment findings should the nurse suspect a transfusion reaction based on?

Anxiety Signup and view all the answers

Which action should the nurse take first when preparing to administer long-acting insulin?

Check the insulin dose with another licensed nurse Signup and view all the answers

Which finding indicates a priority in assessing the client in skeletal traction for a femur fracture?

Upper chest petechia Signup and view all the answers

Which complementary therapy should the nurse recommend to alleviate distress for a client with PTSD?

Guided imagery Signup and view all the answers

Which intervention should the nurse include in the plan of care for a client receiving heparin to treat deep-vein thrombosis?

Elevate the affected leg Signup and view all the answers

The client is at risk for due to .

Thrombocytopenia, Petechiae Signup and view all the answers

Which finding should the nurse identify as the priority for a client taking lithium carbonate?

Confusion Signup and view all the answers

Which staff member should the nurse assign to collect vital signs for a postoperative client requiring a blood pressure check?

An assistive personnel (AP) who is assisting a client to return to bed Signup and view all the answers

Study Notes

Communication and Client Privacy

Nurses must verify the caller's identity before disclosing client information, especially when family members inquire about the client's status.

Pediatric Nursing Considerations

Redness and tenderness of the heel in a child with a leg cast may indicate potential complications and should be prioritized in assessments.

Medication Guidelines

Before starting misoprostol, a serum pregnancy test is essential for clients on long-term NSAID therapy to prevent complications.

Digoxin Toxicity Awareness

Nausea is a common manifestation of digoxin toxicity, which nurses should educate clients about when prescribing this medication.

Obstructive Sleep Apnea Complications

Hypertension is a significant complication to monitor in clients diagnosed with obstructive sleep apnea.

Tracheostomy Care

The correct sequence for tracheostomy care includes cleaning the stoma, removing the inner cannula, changing the collar, and removing soiled dressings.

Enteral Feeding Practices

Keeping the head of the bed elevated to 45 degrees for one hour post-NG tube feeding is vital to reduce aspiration risk.

Intracranial Pressure Management

Mannitol is expected to be administered to reduce intracranial pressure in clients with closed-head injuries.

Patient Safety in Positioning

During patient repositioning, unapproved actions like placing a pillow under the right arm during lateral turns require intervention by the supervising nurse.

Nutrition for Neurological Conditions

Providing appropriate guidance for clients with multiple sclerosis includes suggesting speech pathologist evaluations and encouraging rest before meals.

Pediatric Risk Assessment

Infants who exhibit projectile vomiting may be at higher risk for dehydration, as highlighted by crying and other symptoms indicative of pyloric stenosis.

Postpartum Assessment

For a boggy uterus and heavy lochia in a postpartum client, the immediate action should focus on fundal massage to expel clots.

Incident Reporting

Nurse should complete an incident report for medication errors, such as inadequate IV pump doses, to ensure proper documentation and follow-up.

Medication Administration Techniques

Flushing a gastrostomy tube with water before medication administration is a crucial practice to prevent clogging.

Hypertension Management and Delegation

Obtaining a blood pressure reading is an essential task that should be delegated to assistive personnel in managing a client on captopril.

Spinal Cord Injury Observations

In clients with spinal cord injuries, autonomic dysreflexia and pneumonia are critical complications to monitor due to changes in vital signs and symptoms.

Autonomic Dysreflexia Symptoms

Common symptoms include facial flushing, nasal congestion, and headaches, which nurses should identify and manage promptly.

Care for Clients with Restraints

Ongoing supervision, including continuous staff presence with restrained clients, is an essential safety measure in care plans.

Pain Management for Children

Visualization techniques, like blowing bubbles, can effectively complement pain medication for children, helping to reduce discomfort.

Cardiac Tamponade Indicators

Pulsus paradoxus is an expected clinical finding in clients presenting with cardiac tamponade.

Transfusion Reaction Monitoring

Symptoms of transfusion reactions can include back pain, headache, and anxiety, which should be carefully monitored during blood transfusion.

Insulin Administration Protocol

Checking the insulin dosage with another nurse is a critical safety step in administering long-acting insulin for diabetic clients.

Fat Embolism Signs

Upper chest petechiae is a significant sign of a fat embolism, requiring immediate medical attention in clients with skeletal traction.

Mental Health Complementary Therapies

Guided imagery is an effective non-pharmacological therapy that can help alleviate distress in clients with post-traumatic stress disorder.

Deep Vein Thrombosis Management

Elevating the affected leg is a critical intervention for clients being treated with heparin for deep vein thrombosis management.

Thrombocytopenia Risk

Clients with petechiae and a low platelet count may be at risk for thrombocytopenia, which necessitates ongoing monitoring and intervention.

Lithium Toxicity Awareness

Confusion is an early warning sign of lithium toxicity in bipolar disorder treatment, signaling the need for immediate assessment.

Postoperative Care Responsibilities

Assigning an assistive personnel to check the blood pressure of a postoperative client is an appropriate task in nursing delegation.

Prenatal Assessment Priorities

In pregnant clients experiencing changes in responsiveness, immediate concern should focus first on respiratory rate, followed by level of consciousness.

Postpartum Assessment Indicator

A boggy uterus in the postpartum assessment is a crucial sign that the nurse must address for the health of the client.### Immediate Interventions
Boggy uterus indicates potential uterine atony; requires immediate intervention to prevent hemorrhage.
Temperature of 39.4 C (102.9 F): High fever in a client on chlorpromazine may suggest infection or neuroleptic malignant syndrome; priority to report.
WBC count of 2,800 indicates leukopenia, contraindicating clozapine initiation due to increased risk of infection.

Nursing Priorities in Community Health

First step in health education for a rural community: Identify health-related issues to tailor the program effectively.

Client Education for Infection Prevention

Walking for short distances during chemotherapy reflects understanding of maintaining mobility while avoiding fatigue.

Emergency Preparedness

The first action in an emergency preparedness plan should be to notify the incident commander to initiate response protocols.

Pediatric Nursing Response

In the case of a preschooler exhibiting signs of allergic reaction (swollen lips, hives), actions include discontinuing IV medication, monitoring vital signs, administering epinephrine IM, and starting IV fluids.

Postoperative Neurological Assessment

Neurologic status is critical to report after cardiac catheterization, especially if there are signs of impairment such as slurred speech or unequal hand grasp.

Postoperative Pain Management

Instructing the client to rate their pain level provides necessary information for effective pain management and appropriate interventions.

Client Self-Report and Understanding

A statement such as "I have not vomited as much recently" indicates effective symptom management using acupressure bands during pregnancy.

Infection Control Measures

For cleaning a reusable BP cuff after contamination, it should be placed in a labeled bag for decontamination to ensure proper sanitation.

Emergency Assessment Focus

In an adolescent with fever, decreased appetite, and leg injury, immediate follow-up should focus on skin assessment, temperature, WBC count, and casual blood glucose.

Pediatric Immunization Planning

In children with low neutrophil counts, withholding vaccines like varicella is essential to avoid complications from infection.

Delegation of Nursing Tasks

In a care team, insertion of a nasogastric tube can be delegated to an LPN, demonstrating appropriate task delegation based on scope of practice.

Reporting Inaccurate Documentation

Observations of incorrect documentation by a nurse should prompt the charge nurse to gather more information about the incident.

Notifiable Infectious Diseases

Foodborne botulism is a nationally notifiable infectious condition, warranting reporting for public health tracking.

Client Education for Hepatitis A

Instructing a client with hepatitis A to use hydrogen peroxide for kitchen surface cleanliness helps prevent virus transmission.

STI Reporting Protocol

Explaining to the client why their STI information needs to be shared is crucial for transparency and adherence to public health policies.

Comfort Measures in Pediatrics

Encouraging parents to bring familiar toys for the hospitalized toddler can help ease anxiety and provide comfort during hospitalization.

Medication Administration for Overdose

For a client experiencing respiratory depression while on lorazepam, administration of flumazenil is indicated to reverse the effects.

Assessing Urinary Symptoms

Report significant symptoms such as dysuria, frequency, and urgency in an assessment, as they suggest possible urinary tract issues that need evaluation.

Anticipated Nursing Actions

Anticipated prescriptions for a client with urinary symptoms include educating on sulfamethoxazole/trimethoprim, collecting urine for culture, and prescribing phenazopyridine for symptomatic relief.

Risk Assessment for Pyelonephritis

A client with a positive nitrite and leukocyte esterase in urinalysis is at high risk for developing pyelonephritis, necessitating prompt medical attention.

Preventive Steps for UTIs

Teaching the client to gently cleanse the perineum before intercourse is a key preventive measure against urinary tract infections.

Reportable Lab Findings

Unexpected findings in a returning client may include temperature changes reflecting infection risk and unanticipated bowel elimination, which could indicate further complications to discuss with healthcare providers.### Client Assessment and Findings
Client has difficulty reaching the bathroom on time and experiences night-time urination.
Vital signs indicate slight elevation in blood pressure; lower extremity edema is present; S3 heart sound auscultated.
Urinalysis shows orange-colored urine, and the presence of nitrites and leukocyte esterase suggests a possible urinary tract infection.
Client reports a fluid intake of 3L daily but is increasingly concerned about bruising.

Laboratory Results

Initial urinalysis indicates amber, cloudy urine with a specific gravity of 1.04 and pH of 9.
Notable findings include positive nitrite and leukocyte esterase.
Three days later, urine analysis shows orange color, normal specific gravity, and a return to neutral pH.
New findings include trace glucose in urine.

Vital Signs Tracking

Temperatures: 37.2°C (99°F) to 37.7°C (100.9°F); blood pressure increased from 142/88 to 144/90.
Heart rates are stable but slightly elevated to 88 and 87 bpm.
Oxygen saturation varies between 92% and 93% on room air.

Medication Administration Protocols

NPH and regular insulin administration requires injecting air into the NPH vial before drawing insulin to prevent vacuum formation.
Methadone education for patients with opioid use disorder should include information about common side effects, particularly sedation.
Immediate nursing interventions for alcohol withdrawal may include CIWA-Ar assessments, seizure precautions, and medication administration (e.g., chlordiazepoxide).

Newborn Assessment Insights

Vital signs and assessments are crucial in newborn care, particularly after birth complications such as meconium-stained amniotic fluid.
The newborn's respiratory rate and heart rate should be monitored first in any assessment.
Detailed observations such as abnormal skin color or breastfeeding patterns necessitate further follow-up.

Patient Safety and Care Guidelines

Discharge teaching for new parents about car seat safety should emphasize the proper placement of the retainer clip at the baby's armpits.
Conduct regular assessments of clients for signs of suicidal ideation, ensuring safety measures are in place.
Interventions for psychiatric patients include monitoring their access to harmful objects and evaluating their mental state.

Monitoring Electrolyte Levels

For patients diagnosed with anorexia nervosa, addressing electrolyte imbalances is paramount before tackling psychological concerns like fear of weight gain.
Regular tracking of vitals, weight changes, and specific lab values is essential for assessing a patient's health status during treatment.

Nursing Management Strategies

Investigating environmental factors contributing to client falls assists in improving patient safety within care settings.
Establish clear communication regarding any patient's need for assistance in daily activities during shift changes to ensure continuity of care.

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Nursing Multiple Choice Questions

Questions and Answers

The child is at risk for developing which of the following? (Select all that apply)

What should you set your hot water heater temperature at or below?

Which laboratory value indicates cellular injury of myocardial tissue?

What should the newborn receive vitamin K to prevent?

What instruction should a nurse give to a postpartum client to help prevent engorgement discomfort?

What action should the nurse take for a child experiencing a tonic-clonic seizure?

What is the most likely condition the child is experiencing?

What parameter should be monitored for the child?

What causes constipation in a client who is 28 weeks pregnant?

The client is at highest risk for developing _______

As evidenced by the client's __________

Which of the following instructions should the nurse plan to include for preventing further UTIs?

Which of the following assessment findings should the nurse report to the provider as unexpected?

Select the two findings that require immediate follow-up:

What should the nurse plan to first assess the newborn's _______

What should the nurse plan to assess the newborn's _______

Which of the following may be a common adverse effect of methadone?

Which findings require follow-up?

Which action should the nurse take when preparing to administer insulin?

To facilitate the staff's acceptance of the scheduling system change, which action should the nurse manager take first?

Which of the following indicates a manifestation of vaso-occlusive crisis in sickle cell anemia?

Which statement about car seat safety should the nurse include in teaching?

Which catheter should a nurse use for intermittent urinary catheterization?

Which action requires a nurse manager to intervene?

What should the nurse do for a client presenting with alcohol withdrawal symptoms?

Which actions should be taken for a client with major depressive disorder?

Which method should the nurse manager use to evaluate the nurse's time management skills?

Which of the following actions should the nurse plan to take first?

Which of the following findings requires immediate intervention by the nurse?

The nurse should recognize the client is demonstrating which defense mechanism?

Which of the following findings is the priority for the nurse to report to the provider?

Which finding should the nurse identify as a contraindication for the client to receive clozapine?

Which of the following actions should the nurse plan to take first?

Which of the following statements by the client indicates an understanding of the infection prevention teaching?

Which of the following actions should the nurse recommend first when implementing an emergency preparedness plan?

Which actions should the nurse take after reviewing assessment findings?

Which information should the nurse report to the provider?

Which action should the nurse take first for a client refusing to ambulate post-surgery?

Which statement indicates that the therapy of using acupressure bands is having the desired effect?

Which of the following actions should the nurse take regarding a reusable BP cuff?

Which findings require immediate follow-up by the nurse?

Which intervention should the nurse include in the plan of care for a child with acute lymphoid leukemia?

Which task should the RN delegate to the LPN?

Which action should the charge nurse take first after observing a staff nurse document a dressing change that was not performed?

Which client should the nurse identify as having a nationally notifiable infectious condition?

Which of the following instructions should the nurse include for a client who has hepatitis A?

Which action should the nurse take regarding reporting STI information?

Which of the following should the nurse include in the toddler's plan of care?

Which medication should the nurse anticipate administering after a client develops a respiratory rate of 6/min?

Which assessment findings should the nurse report to the provider?

Which provider prescriptions should the nurse anticipate for this client?

The client is at highest risk for developing ____

Which actions should the charge nurse take first to provide teaching about chest tubes?

What should the nurse do while waiting for the new infusion pump?

Which action should the nurse take first for a client who is immediately postoperative following a total vaginal hysterectomy?

The nurse should first address the client's _______

Followed by the client's __________

Which action should the nurse take when providing colostomy care?

What information is the priority for the nurse to communicate to the oncoming nurse about a client preparing for discharge?

Which statement by the parents indicates an understanding of sleep promotion for their preschooler?

What action should the nurse take when conducting a root cause analysis for increased client falls?

For which of the following manifestations should the nurse monitor a client with a potassium level of 3 mEq/L?

What should the nurse document when a mental health client refuses medication?

Which physiological change should the nurse recognize as related to aging in an older adult client?

Which actions should the nurse take for a client with colorectal cancer and a new colostomy?

How many mL should the nurse administer for a toddler weighing 22lb who needs diazepam 0.3mg/kg IV bolus?

Match the following conditions and actions the nurse must take.

What intervention should a home health nurse include in the care plan for an older adult client with impaired vision?

What statement should the nurse make to a client with a terminal illness requesting no lifesaving measures?

Which findings require immediate follow-up for a client with schizophrenia?

What manifestation should the nurse expect in a client with delirium?

What manifestation should the nurse expect in a client in the manic phase of bipolar disorder?

Which action should the nurse take when performing gastric lavage for a client with gastrointestinal bleeding?

What action should the nurse take first when interviewing a client who is now without a home due to a natural disaster?

Which response should a nurse make to a family member of a client with end-stage Alzheimer's disease who expresses doubt about visiting?

What is the first action the nurse should take when preparing to discharge a client who has experienced intimate partner violence?

The child is at risk for developing _______ and _______.

Which of the following actions should the nurse take when receiving a call from someone claiming to be the client's parent?

The child is at risk for developing _ and _.

The infant is at highest risk of developing as evidenced by .

The client is most likely experiencing manifestations of and .

The client is at risk for due to .