A nurse is teaching a client who has a new prescription for metformin extended release
tablets.
Which of the following statements by the client indicates an understanding of the
teaching?
a. I will avoid crushing this medication
A nurse is assessing a client who is receiving enteral feeding via an NG tube.
The client has developed hyperosmolar dehydration. Which of the following
actions should the nurse take when administering the client\u2019s findings?
Switch to a lactose-free formula.
A nurse is providing discharge teaching to a client who has a new ostomy.
Which of the following instructions should the nurse include?
Empty your ostomy pouch when it is half full
A nurse is teaching the parents of a school-age child who has sickle cell anemia
about managing the disease at home which of the following instructions should
the nurse include?
a. Apply cold compresses too painful areas
A nurse is teaching about Safe Handling of formula to a client who is postpartum
and chooses to bottle feed her newborn. Which of the following statements by the
client indicates an understanding of the teaching?
I should boil tap water for 2 minutes and call it before I mix it with powdered
formula
A nurse is assessing a child who is post-operative following a tonsillectomy.
Which of the following findings should the nurse identify as the priority?
Frequent swallowing
A nurse is teaching a client who is pregnant about non-stress testing. Which of
the following statements by the client indicates an understanding of the
teaching?
During this test, I will punch a button if the baby moves
A nurse is monitoring a client who is receiving a transfusion of packed RBC’s. The
1 \/ 4
client reports chills, headaches, low back pain, and a feeling of tightness in his
chest. The nurse should identify that the client has developed which of the
following types of transfusion reactions?
a. Acute hemolytic
2 \/ 4
A nurse is caring for a client who is in the latent phase of Labor and reports severe
back pain. The vaginal examination reveals that the cervix is dilated two
centimeters, 25% effaced and -2 station. Which of the following interventions
should the nurse implement?
Request the provider prescribe a pudendal nerve block
A nurse is teaching about how to suppress lactation with a client who is
postpartum and bottle feeding her newborn. Which of the following instructions
should the nurse include in the teaching?
You should wear a snug fitting bra continuously for 72 hours
A nurse is preparing to administer medication to a client. What are the
following identifiers should the nurse use to identify the client?
Room number
A nurse is caring for a client who is taking antihypertensive medication and is
moving from a supine to a seated position. Which of the following findings should
indicate to the nurse that the client is experiencing orthostatic hypotension?
The clients systolic blood pressure decreases by 25 mmHg
While a nurse is caring for a client who is receiving mechanical ventilation via an
endotracheal tube, the high-pressure alarm of the ventilator sounds. Which of the
following actions should the nurse take?
Look for a leak in the tubes
cuff A nurse is preparing to insert an indwelling urinary catheter for a client. Which of
the following actions should the nurse take first?
Position the sterile drape leaving the perineum exposed
A nurse is planning to administer packed RBC’s to an older adult client who
has a low hemoglobin level. Which of the following actions should the nurse
plan to take?
Monitor Vital Signs every hour throughout the transfusion
A new nurse in an acute mental health facility is teaching a client about potential
adverse effects of transcranial magnetic stimulation. The nurse tells the client that
he might not feel light-headed but that it should not affect his memory. The nurse is
demonstrating which of the following ethical principles?
Beneficence
A nurse is teaching a class about providing care within the legal scope of practice
to a group of nurses. The nurse should include that which of the following
procedures is outside the legal scope of practice for an RN?
Irrigation of the external ear canal
3 \/ 4
A nurse in an acute care facility is caring for a client who has anorexia nervosa.
During the first week of care, which of the following actions should the nurse take?
Observe the client for 1 hour after meals
A nurse is planning care for a client who has sciatica and a prescription for a
transcutaneous electrical nerve stimulation (TENS) unit. Which of the following
referral should the nurse anticipate for the client?
Physical therapist
A nurse is teaching a client who has generalized anxiety disorder about ways to
help manage stress. Which of the following instructions should the nurse give the
client about using Progressive relaxation?
Tighten the muscle group, then release tension and move to the next one
A nurse is assessing a client who is at 37 weeks of gestation and reports sudden,
severe abdominal pain with moderate vaginal bleeding and persistent uterine
contraction. The client’s blood pressure is 88 over 50 mmhg and her abdomen is
rigid. The nurse should identify these findings as indicating which of the following
complications?
Placenta abruption
A home health nurse is planning care for an older adult client who has a vision
loss and takes medication throughout the day. Which of the following actions
should the nurse include in the plan?
Use container Lids of different shapes to indicate times of Administration
A nurse is planning care for a client who has a history of urinary tract infections
UTIs and requires placement of an indwelling catheter. Which of the following
actions should the nurse take to help minimize the client’s risk of acquiring a
UTI?
a. Whoop the tubing so that is lower than the collection bag
b. keep urine a bag at bladder level when ambulating
c. secure the catheter to the client\u2019s thigh
d. obtain urinary samples by disconnecting the tubing connections
A nurse at an acute care facility is teaching a client about fall risk prevention
strategies for use during their stay at the facility. Which of the following
statements by the client indicates an understanding of the teaching?
I will wear a yellow wristband, so everyone knows I’m at risk for falling
A nurse is caring for a client who is taking disulfiram for alcohol-use disorder
and reports ingestion of alcohol. For which of the following adverse effects
should the nurse monitor?<\/p>\n","protected":false},"excerpt":{"rendered":"
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