An assistive personnel tells the charge nurse that her assignment is too demanding. She angrily
tells the nurse to reassign one of her tasks to another AP. Which of the following actions should
the nurse take to resolve the conflict? - correct answer Ask the AP to discuss the issue in a
private area
A nurse is supervising an assistive personnel (AP) obtain supplies for a client who is on seizure
precautions. Which of the following materials should the AP place in the client's room? -
correct answer Oral Suction Equipment
A charge nurse on a mental health unit is supervising a newly licensed nurse. For which of the
following actions by the newly licensed nurse should the supervising nurse intervene? - correct
answer Tells a client he will lose his phone privileges if he does not take his medication
A nurse is caring for a client who follows a kosher diet. Which of the following menu items
should the nurse include in the meal tray? - correct answer Roasted Salmon
A nurse is reviewing information about advance directives with a newly admitted client. Which
of the following statements by the client indicates an understanding of the information? -
correct answer "Advance directives include a living will"
A nurse is collecting data from the caregiver of a client who has Alzheimer's disease. The
caregiver reports the client has difficulty sleeping at night and wanders throughout the house.
Which of the following interventions should the nurse recommend? - correct answer
Encourage the client to take frequent walks during the day
A nurse is assisting in the care of a client who is 8hr postpartum and has uterine atony with
increased bleeding. Which of the following actions should the nurse take? (Select all that apply)
- correct answer Assist the client to empty her bladder
A nurse is reinforcing teaching with the support person of a client who is in the first stage of
labor. Which of the following instructions should the nurse include regarding effleurage? -
correct answer "Gently stroke her abdomen during contractions"
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? - correct answer Use a moisture barrier on the client's skin
A nurse is caring for a client who has terminal cancer. Which of the following actions should the
nurse take to promote the client's autonomy? - correct answer Allow the client to choose
treatment times
A nurse in a clinic is caring for a client who is at 40 weeks of gestation and experiences a sudden
gush of vaginal fluids. Which of the following findings is evidence of an obstetric complication? -
correct answer Appears greenish-brown in color
A nurse is assisting with the care of an adolescent client immediately following a lumbar
puncture. Which of the following actions should the nurse take? - correct answer Inform the
adolescent that he might experience a headache
A nurse is reinforcing teaching about advance directives with a client who has end-stage heart
failure. Which of the following statements by the client indicates an understanding of the
teaching? - correct answer "I should discuss this document with my family after I sign it"
A nurse is caring for a client who has continuous bladder irrigation following a transurethral
resection of the prostate. The nurse notices clots and dark red blood in the catheter collection
bag. Which of the following actions should the nurse take? - correct answer Irrigate the
bladder with 20 to 30 mL of 0.9% sodium chloride
A nurse is planning to obtain a 12-lead ECG for a client who has a history of cardiac
dysrhythmias. Which of the following actions should the nurse plan to take? - correct answer
Instruct the client to remain as still as possible during the recording
A nurse is reinforcing teaching with a client who has genital herpes. Which of the following
information should the nurse include in the teaching? - correct answer "You should increase
fluid intake to relieve dysuria"
A nurse is preparing to empty a postoperative client's closed-wound drainage system. Which of
the following actions should the nurse plan to take? - correct answer Compress the container
before replacing the drainage plug
A nurse is reinforcing teaching with the parents of a toddler who has a new diagnosis of asthma
and a prescription for montelukast. Which of the following instructions should the nurse
include in the teaching? - correct answer Administer the medication to the toddler each
evening
A nurse in an acute mental health facility is caring for a newly admitted client. Which of the
following should occur during the orientation phase of the nurse-client relationship? - correct
answer Defining responsibilities
A nurse is caring for a client who reports having a decrease in fetal movement following an
external cephalic version 6 hr ago. The nurse identifies the fetus is in the right occiput anterior
position. The nurse should place the fetal heart monitor on which of the following sites to
auscultate the fetal heart rate? - correct answer Lower left
A charge nurse is observing a newly licensed nurse perform suctioning for a client who has a
tracheostomy. For which of the following actions by the newly licensed nurse should the charge
nurse intervene? - correct answer Suction for 30 seconds
A nurse is reviewing the medication administration record of a client who takes atenolol PO and
supplies a nitroglycerin transdermal patch daily. Which of the following interactions should the
nurse monitor with this client? - correct answer Hypotension
A nurse in an acute care setting is preparing to administer medications to a client. Which of the
following actions should the nurse verify the client's identity? - correct answer Verify the
client's identity using a photograph
A nurse in a provider's office is collecting data from a client who has psoriasis. Which of the
following statements made by the client should she report to the provider? - correct answer "I
try not to look at the scales on my body"
A nurse is completing chart reviews in a long-term care facility in response to an increase in
falls. Which of the following responses in the chart should the nurse use to determine the
potential causes of falls? - correct answer Medication record
A nurse is making client care assignments for an assistive personnel (AP). Which of the
following tasks should the nurse assign to the AP? - correct answer Complete post mortem
care for a client who has died
A nurse is reinforcing teaching with a client who is taking allopurinol about the risk for
developing Stevens-Johnsons syndrome. For which of the following manifestations should the
nurse instruct the client to monitor and report? - correct answer Skin rash with fever
A charge nurse in a long-term care facility is reinforcing teaching with a group of nurses about
fall precautions. Which of the following statements made by the nurse indicates an
understanding of the teaching? - correct answer "I will instruct the client to sit when putting
on a pair of pants"
A nurse is recommending clients for discharge to allow for admission of clients following a
tornado disaster. Which of the following clients should the nurse recommend for discharge? -
correct answer A client who has a sodium level of 140 mEq/L after one episode of diarrhea
A nurse is assisting with the plan of care for a newly admitted client who has anorexia nervosa.
Which of the following interventions should the nurse include in the plan? - correct answer
Administer liquid supplements
A charge nurse is reinforcing teaching with a newly licensed nurse about floating to a different
unit. Which of the following statements by the newly licensed nurse indicates an understanding
of the teaching? - correct answer "I will document in the medical record the support nurse
who assists with planning care for my clients"
A nurse is caring for a client who has dehydration due to diarrhea. Which of the following
findings should the nurse report to the provider? - correct answer Urine output 12 mL/hr
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