An RN is making assignments for client care to an LPN at the beginning of the shift. Which of

An RN is making assignments for client care to an LPN at the beginning of the shift. Which of the following assignments should the LPN question?

• Assisting a client who is 24 hr postop to use an incentive spirometer
• Collecting a clean catch urine specimen from a client who was admitted on the previous shift
• providing nasopharyngeal suctioning for a client who has pneumonia
• Replacing the cartridge and tubing on a PCA pump

A nurse is preparing an inservice program about delegation. Which of the following elements should she

identify when presenting the 5 rights of delegation. Select all:

• Right client
• Right supervision/evaluation
• Right direction/communication
• Right time
• Right circumstances

A nurse offers pain meds to a client who is postop prior to ambulation. The nurse understands that this aspect of care delivery is an example of which of the following ethical principles?

• Fidelity
• Autonomy
• Justice
• Beneficience

An RN is making assignments for client care to an LPN at the beginning of the shift.Which of the following assignments should the LPN question?

• Assisting a client who is 24 hr postop to use an incentive spirometer
• Collecting a clean catch urine specimen from a client who was admitted on the

previous shift

• providing nasopharyngeal suctioning for a client who has pneumonia
• Replacing the cartridge and tubing on a PCA pump

A four-month-old infant is admitted to the pediatric intensive care unit with a temperature of 105°F (40.5 °C). The infant is irritable, and the nurse observes nuchal rigidity. Which assessment finding would indicate an increase in intracranial pressure?

• Positive Babinski.
• High-pitched cry.
• Bulging posterior fontanelle.
• Pinpoint pupils.

A client is receiving total parenteral nutrition (TPN). To determine the client's tolerance of this treatment, the nurse should assess for which of the following?

• A significant increase in pulse rate.
• A decrease in diastolic blood pressure.
• Temperature in excess of 98.6°F (37°C).
• Urine output of at least 30 cc per hour.

The client is exhibiting symptoms of myxedema. The nursing assessment should reveal

• increased pulse rate.
• decreased temperature.
• fine tremors.
• increased radioactive iodine uptake level.

2 A nonstress test is scheduled for a client at 34-weeks gestation who developed hypertension, periorbital edema, and proteinuria. Which of the following nursing actions should be included in the care plan in order to BEST prepare the client for the diagnostic test?

• Start an intravenous line for an oxytocin infusion.
• Obtain a signed consent prior to the procedure.
• Instruct client to push a button when she feels fetal movement.
• Attach a spiral electrode to the fetal head.

3 Which of the following nursing interventions is MOST important for a 45-year-old woman with rheumatoid arthritis?

• Provide support to flexed joints with pillows and pads.
• Position her on her abdomen several times a day.
• Massage the inflamed joints with creams and oils.
• Assist her with heat application and ROM exercises.

the nurse is caring for a young adult admitted to the hospital with a severe head injury. The nurse should position the patient

• with his neck in a midline position and the head of the bed elevated 30°.
• side-lying with his head extended and the bed flat.
• in high Fowler's position with his head maintained in a neutral position.
• in semi-Fowler's position with his head turned to the side.

The nurse is teaching a 40-year-old man diagnosed with a lower motor neuron disorder to perform intermittent self-catheterization at home. The nurse should instruct the client to

• use a new sterile catheter each time he performs a catheterization.
• perform the Valsalva maneuver(holding breath and bearing down) before doing the

catheterization.

• perform the catheterization procedure every 8 hours.
• limit his fluid intake to reduce the number of times a catheterization is needed.

A client is being discharged with sublingual nitroglycerin (Nitrostat).The client should be cautioned by the nurse to

• take the medication five minutes after the pain has started.
• stop taking the medication if a stinging sensation is absent.
• take the medication on an empty stomach.
• avoid abrupt changes in posture.

A 38-year-old woman is returned to her room after a subtotal thyroidectomy for treatment of hyperthyroidism. Which of the following, if found by the nurse at the patient's bedside, is nonessential?

• Potassium chloride for IV administration.
• Calcium gluconate for IV administration.
• Tracheostomy set-up.
• Suction equipment.

A nurse recognizes that an initial positive outcome of treatment for a victim of sexual abuse by one parent would be that the client

• acknowledges willing participation in an incestuous relationship.
• reestablishes a trusting relationship with his/her other parent.
• verbalizes that s/he is not responsible for the sexual abuse.
• describes feelings of anxiety when speaking about sexual abuse.

An adolescent client is ordered to take tetracycline HCL (Achromycin) 250 mg PO bid. Which of the following instructions should be given to this client by the nurse?

• "Take the medication on a full stomach, or with a glass of milk."
• "Wear sunscreen and a hat when outdoors."
• "Continue taking the medication until you feel better."
• "Avoid the use of soaps or detergents for two weeks."

After a client develops left-sided hemiparesis from a cerebral vascular accident (CVA), there is a decrease in muscle tone. Which of the following nursing diagnoses would be a priority to include in his care plan?

• Alteration in mobility related to paralysis.
• Alteration in skin integrity related to decrease in tissue oxygenation.
• Alteration in skin integrity related to immobility.
• Alteration in communication related to decrease in thought processes

history of oliguria, hypertension, and peripheral edema. Current lab values are: BUN -25, K+ -4.0 mEq/L.Which nutrient should be restricted in the client's diet?

• Protein.
• Fats.
• Carbohydrates.
• Magnesium

An extremely agitated client is receiving haloperidol (Haldol) IM every 30 minutes while in the psychiatric emergency room. The MOST importantnursing intervention is to

• monitor vital signs, especially blood pressure, every 30 minutes.
• remain at the client's side to provide reassurance.
• tell the client the name of the medication and its effects.
• monitor the anticholinergic effects of the medication.

The nurse is caring for clients in the skilled nursing facility. Which of the following clients require the nurse's IMMEDIATE attention?

• A client admitted for a cerebral vascular accident (CVA) whose prescription for

warfarin (Coumadin) expired two days ago.

• A client in pain who was receiving morphine in an acute care institution and was

transferred with a prescription for acetaminophen with codeine.

• A client who has dysuria and foul-smelling, cloudy, dark amber urine.
• An immunosuppressed client who has not received an influenza immunization.

The nurse is observing care given to a client experiencing severe to panic levels of anxiety. The nurse would intervene in which of the following situations?

• The staff maintains a calm manner when interacting with the client.
• The staff attends to client's physical needs as necessary.
• The staff helps the client identify thoughts or feelings that occurred prior to the

onset of the anxiety.

• The staff assesses the client's need for medication or seclusion if other

interventions have failed to reduce anxiety.A 69-year-old client is undergoing his second exchange of intermittent peritoneal dialysis (IPD). Which of the following would require an intervention by the nurse?

• The client complains of pain during the inflow of the dialysate.
• The client complains of constipation.
• The dialysate outflow is cloudy.
• There is blood-tinged fluid around the intra-abdominal catheter.

The clinic nurse is performing diet teaching with a 67-year-old client with acute gout. The nurse should teach the client to limit his intake of