The nurse cares for a client diagnosed with superficial partial thickness burn. The nurse should assign the client to a room with which client? - ANSWER A client diagnosed with Cushing's Syndrome. The nurse observes client care on a geriatric unit. The nurse should intervene in which situation? - ANSWER A student nurse assists the client to stand from a sitting position by grasping the client's elbows. The nurse evaluates the results of the client's purified protein derivative (PPD) 2 1⁄2 days after the injection. The nurse noted the induration is 4 mm. which action by the nurse is most appropriate? - ANSWER Inform the client the results are negative The nurse cores for the client with a history of schizophrenia. The nurse expects to note which speech pattern? - ANSWER Repetition of the words used by the nurse. The nurse cares for a 6-month-old infant. The parents report that the infant had severe diarrhea for twelve hours. The nurse anticipates which finding? - ANSWER Depresses anterior fontanel. The nurse cares for a client receiving hydrocodone every 6 hours prn for pain. The client reports pain at 1600. The nurse notes that the hydrocodone was last administered at 1200, and the nurse proceeds to administer hydromorphone at 1615. After discovering the error, how should the nurse record the occurrence? - ANSWER Hydromorphone given at 1615; health care provider notified. B/P 122/80, RR 16." The male client asks the nurse, "Why am I experiencing erectile dysfunction (ED)?" The nurse reviews the client's medications. The nurse recognizes that which classification increases the risk for ED? - ANSWER Antihypertensive medications. The nurse in the hospital cafeteria overhears two nursing assistive personnel (NAP) discuss the client's condition. What is the PRIORITY action for the nurse to take? - ANSWER Inform the employees about patient confidentiality and the client's right to privacy. The nurse cares for a client diagnosed with dehydration. The plan of care indicates the client is to drink two ounces of fluid every hour. The nurse determines the goal is met if which is recorded on the intake and output (I&O) sheet for an eight-hour shift? - ANSWER 480 ml The nurse and LPN/LVN care for clients on a medical-surgical unit. The RN should delegate which activity to the LPN/LVN? - ANSWER Take the blood pressure and heart rate before administration of enalapril. The nurses care for the client diagnosed with tuberculosis. Before discontinuing airborne precautions, the nurse must confirm which? - ANSWER No acid-fast bacteria are in the sputum. The nurse cares for the client at 28 weeks gestation diagnosed with a complete placenta previa. The nurse determines discharge teaching is effective if the client makes which statement to her husband? - ANSWER I'm sorry to tell you we can't have sexual relations The nurse prepares the client diagnosed with myxedema for discharge. Which action should the nurse teach related to body temperature? - ANSWER "Put on multiple layers of clothes until you fell comfortably warm." The nurse cares for clients in the labor and delivery unit. The nurse anticipates which client is a candidate for induction of labor? - ANSWER The client diagnosed with preeclampsia. The nurse cares for the client diagnosed with HIV. The nurse determines which goal is MOST important? - ANSWER Prevent infections. The nurse educator presents an in-service on acyanotic heart disease. Which is the most common symptom of this disorder that the nurse educator should include? - ANSWER Presence of an audible heart murmur. The nurse provides care for the client diagnosed with pneumonia who has postural drainage twice a day. Which client response indicates to the nurse that treatment is effective? - ANSWER "I am coughing up more sputum." The risk management department plans a program to reduce errors. Which is the most common cause of errors in medication administration? - ANSWER Failure to follow routine policy and procedures. The nurse cares for the school-aged child newly diagnosed with type 1 diabetes. The nurse instructs the family that the child's insulin needs will decrease during which situation? - ANSWER Active exercise The nurse cares for the client receiving lactulose. The nurse determines the medication is effective if which is observed? - ANSWER The client is alert and oriented to person, place and time. The nurse cares for the three-year-old prior to a surgical procedure. Which behavior indicates that the child is coping with preoperative preparation? - ANSWER The child talks about the picture of a nurse and client while coloring the picture using a number of bright colored crayons. The nurse instructs the client after a total hip arthroplasty. The client will utilize which assistive devices in the home? - ANSWER SATA: A long-handled shoehorn. A reaching device. A raised toilet seat. A shower bench. The client reports vomiting and diarrhea for three days. Which assessment finding does the nurse anticipate? - ANSWER Decreased blood pressure. The nurse cares for the client in active labor. The health care provider orders an oxytocin infusion. Which action should the nurse take FIRST after initiating the infusion? - ANSWER Time and record the length and strength of the contractions. The intensive care nurse cares for the client two hours after a myocardial infarction is diagnosed. The nurse's PRIORITY is to focus on which action? - ANSWER Relieve pain. The home health nurse instructs the family how to "allergy-proof" their preschooler's bedroom. The nurse determines teaching is successful if which of the following is observed? - ANSWER There are no pictures hung on the walls. The nurse cares for infants in the newborn nursery. Which observation requires the nurse to contact the physician? - ANSWER Uneven skin folds are noted on a the upper legs of a Mexican-American female born 6 hours ago. The nurse cares for the client diagnosed with partial thickness burns to the entirety of both arms. Using the Rule-of-Nines, the nurse estimates the injury is which percentage? - ANSWER 18% The home care nurse visits the client diagnosed with late stage Parkinson's disease. The client sits in a wheelchair. Which statement, if made by the caretaker, indicates to the home care nurse teaching is effective? - ANSWER "My Client should push the hips up from the wheelchair for about 10 seconds every hour or so." The home care nurse makes a visit to the client diagnosed with heart failure. The client reports having difficulty sleeping at times. The nurse should take which action FIRST? - ANSWER Obtain a thorough sleep assessment history. The nurse cares for the client admitted to the critical care unit. The nurse observes splinter hemorrhages in the nails, painful nodules on the fingertips and splenomegaly. It is MOST important for the nurse to take which action? - ANSWER Auscultate the precordium for murmurs. (ENDOCARDITIS) The nurse instructs the client about stable angina. The nurse determines teaching is effective if the client makes which statement? - ANSWER My chest pain can occur if I overexert myself. The nurse cares for the client in pain. Which factor is MOST important to determine if the client is a candidate for patient controlled analgesia? - ANSWER The client is mentally alert. The nurse received report from the previous shift. Which client should the nurse see FIRST? - ANSWER The client scheduled for discharge later in the day and is reporting increased shortness of breath. The nurse reviews the arterial blood gas

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