A nurse receives report on a group of clients. which client should the nurse assess first

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A nurse is setting up a sterile field prior to performing a dressing change. Which of the following actions should the nurse take?

Open the outermost flap of the wrapper toward the body

A nurse is caring for a school-age child whose family adheres to a vegan diet in the home. The nurse should recognize the child is at risk for deficiency of which of the following?

A nurse in long-term care facility has received change-of-shift report about four clients. Which of the following clients should the nurse attend to first?

A client who has COPD and dementia and was agitated during the night shift

A nurse in a urgent care clinic is collecting data from a client who reports having diarrhea for the past 3 days. Which of the following findings indicates hypokalemia?

A nurse in a providers office is talking on the phone with the parent of a school-age child who has varicella.

All vesicles have crusted over

A nurse is administering a cleansing enema to a client who reports mild cramping during instillation of the solution. Which of the following actions should the nurse take?

Slow the rate of instillation

A nurse receives report on four clients. The nurse should first collect data about the client who has which of the following?

A decreased level of consciousness and vomiting

A nurse who orienting to a medical-surgical unit is having difficulty finishing client care tasks during his shift. Which of the following suggestions should the nurse's preceptor make to help the nurse with time management?

A nurse working in an inpatient mental health facility is assisting with the plan of care for a client who has anorexia nervosa. Which of the following should the nurse recommend to include in the plan of care?

Maintain continuity of staff members.

A nurse is speaking to a client who called the provider's office to report chest pain and requests clarification on how to take his sublingual nitroglycerin tablets. Which of the following instructions should the nurse give the client?

Wait 5 min between doses.

A nurse on a medical-surgical unit is planning care for a group of clients. Which of the following tasks is appropriate to delegate to an assistive personnel?

Administer a large-volume enema to a client.

A nurse is reviewing the medical record of a client who has sustained a full-thickness burn and is in the emergent phase of the burn. Which of the following findings should the nurse expect?

A nurse delegates a task to an assistive personnel (AP) and the AP refuses the assigned task. Which of the following actions should the nurse take first?

A nurse on a medical unit is observing an assistive personnel (AP) delivering food trays. Which of the following actions by the AP requires intervention?

Providing a ham and cheese sandwich to a client who follows a kosher diet

A nurse is working in an urgent care clinic when a client who does not speak the same language arrives with a laceration that will require suturing. Which of the following actions appropriate for the nurse to take?

Ask an assistive personnel who speaks the same language as the client to assist in obtaining informed consent.

A nurse is removing a female client's indwelling urinary catheter. Which of the following actions should the nurse take?

Withdraw the fluid from the catheter's balloon.

A home health nurse is reinforcing teaching with a client about kitchen safety. Which of the following instructions should the nurse reinforce about using a fire extinguisher?

Sweep the extinguisher from side to side to put out the fire.

A nurse is reviewing the medical record of a client who is requesting an oral contraceptive. Which of the following findings should the nurse identify as a contraindication to the use of oral contraceptives?

A nurse is escorting a client to his car following discharge from an acute mental health facility. The client states intentions to harm a friend when he leaves the facility. Which of the following actions should the nurse take?

Prevent the client from leaving the facility.

A nurse receives a verbal order for a client to receive a stat dose of meperidine 100 mg PO. She administers the medication, charts the administration, and then realizes she has administered phenytoin 100 mg PO. Which of the following actions should the nurse take first?

Check the client's vital signs.

A nurse is observing the mother of a 12-hr-old newborn. Which of the following actions by the mother requires intervention by the nurse?

The mother places the newborn in prone position.

A nurse in a mental health facility is reviewing the laboratory reports for four clients. Which of the following results should the nurse report to the provider immediately?

Sodium level of 130 mEg/L for a client who has bipolar disorder and takes lithium

After receiving change-of-shift report, which of the following clients should the nurse collect data from first?

A client who has heart failure and reports severe dyspnea

A nurse is evaluating a client who just attended a breastfeeding class. Which of the following statements by the client demonstrates that she has understood the teaching?

"I will feed my baby each time he cries."

A nurse in a pediatric clinic is reviewing the urine laboratory results for an adolescent. For which of the following results should the nurse notify the provider?

A nurse is admitting a client who has active tuberculosis. Which of the following nursing interventions is appropriate?

Place the client in a room that is ventilated to the outside.

A nurse in the newborn nursery is planning to obtain blood from a newborn by a heel stick. Which of the following actions should the nurse plan to take?

Apply a heat pack 5 to 10 min prior to the procedure.

A nurse from a medical-surgical unit is floating to a postpartum unit. Which of the appropriate assignment for the nurse to accept?

A client who had a cesarean delivery 24 hr ago

A client's daughter calls the nurse requesting information about her mother's condition. The client's chart does not specify that information can be released to the daughter. Which of the following is an appropriate response by the nurse?

"You will need to contact your mother directly about her condition."

A nurse in a mental health unit asks a client who has schizophrenia, "How are you?" Which of the following responses should the nurse identify as the speech alteration of echolalia?

A nurse in an acute mental health facility observes a client having a panic attack. Which of the following interventions should the nurse implement first?

Instruct the client to use abdominal breathing.

A nurse is expressing concern about his assignment with the charge nurse. The nurse states that he has more work to do than anyone else. Which of the following statements by the charge nurse demonstrates the conflict resolution strategy of competing?

"We will take a look at the assignments together and attempt to modify the workload you are concerned about."

A nurse working on a mental health unit is meeting with a client who has been on the unit for 2 days. The nurse greets the client and asks, "What has been happening with you today?" Which of the following therapeutic techniques is the nurse using?

A nurse discovers a fire in a trash can in a client's room. Which of the following actions should the nurse take first?

Walk the client to the waiting room.

A client who has inoperable cancer tells the nurse that she does not want to pursue the recommended treatment. She asks if the provider can force her to have the treatment. Which of the following is an appropriate response by the nurse?

"You have the right to refuse the recommended treatment plan."

A nurse and an assistive personnel (AP) are caring for a client who requests a PRN pain medication. After the nurse administers the medication, which of the following tasks should the nurse assign to the AP?

Document the client's respiratory rate in 1 hr.

A nurse is discussing incident reports with a group of newly licensed nurses. The nurse should include that which of the following situations requires completion of an incident report?

A nurse collects data from a client who reports severe pain and finds a dose of hydromorphone in the client's bed.

A nurse is orienting a newly licensed nurse to a medical-surgical unit. Which of the following actions should the nurse take to verify that the newly licensed nurse understands the procedure for measuring a client's blood glucose level?

Have the nurse perform a return demonstration.

A nurse is receiving change-of-shift report on a group of clients. Which of the following clients should the nurse see first?

A client who is exhibiting flight of ideas

A nurse in the newborn nursery is collecting data about a newborn's Moro reflex. Which of the following actions should the nurse take to elicit this reflex?

Strike the crib surface on which the newborn is lying.

A nurse is applying a condom catheter to a male client who is incontinent. Which of the following is an appropriate technique to use?

A nurse in a long-term care facility is observing an assistive personnel (AP) who is performing hand hygiene. Which of the following actions by the AP requires intervention?

Holding his hands up and elbows down while washing his hands

A nurse is establishing a baseline postoperative assessment for a client who is recovering from a right femoropopliteal bypass graft. Which of the following findings in the assessment of the client's right leg should be of the most concern to the nurse?

The client's pedal pulse in the right foot is not palpable.

A nurse is reviewing standard precautions with an assistive personnel (AP) who is new to the newborn nursery. For which of the following newborn care procedures should the nurse remind the AP to wear clean gloves?

Applying an identification bracelet

A nurse is checking the home environment of a client for safety hazards. Which of the following items require intervention by the nurse?

The television set is turned to a loud volume.

A nurse in a prenatal clinic is reinforcing teaching with a client about a nonstress test. Which of the following statements should the nurse include?

"You will be asked to press a button when you feel your baby move."

A charge nurse in a long-term care unit is planning care for a group of clients. Which of the following care tasks should the nurse plan to delegate to an assistive personnel?

Measuring urine output every 2 hr for a client recently diagnosed with a urinary tract infection

A nurse in a provider's office is reinforcing teaching with the parents of a school-age child who has an active case of Pediculosis humanus capitis. Which of the following should the nurse include in the teaching?

Wash the bed linens in hot water.

A nurse in an inpatient mental health facility is caring for a client who has bipolar disorder and is in an acute manic episode. Which of the following activities should the nurse suggest for the client?

Take a walk with a staff member

A nurse in a provider's office is collecting data from a client who was discharged from the hospital 7 days ago following treatment for deep-vein thrombosis. Which of the following findings is the nurse's priority? (Click on the "Exhibit" button for additional information about the client. There are three tabs that contain separate categories of data.)

The client takes ibuprofen daily to treat musculoskeletal pain.

A nurse is reviewing the laboratory results for a client who is at 32 weeks of gestation. For which following results should the nurse notify the provider?

Platelet count 90,000/mm3

A nurse in a clinic is reinforcing teaching with a client who has a new prescription for a combination contraceptive transdermal patch. Which of the following should the nurse include in the teaching?

Apply the patch to the lower abdomen,"

A nurse working in a long-term care facility is assisting with the plan of care for a client who has Alzheimer's disease. The nurse notes that the client wanders the halls at night and says she is looking for the bathroom. Which of the following interventions should the nurse recommend to include in the plan of care?

Label the client's bathroom door.

A client who is prescribed metoprolol for hypertension tells the nurse, "I don't want to take this medication because makes me tired all the time." Which of the following is the appropriate response?

"Let's talk with your doctor about other options."

A nurse on a mental health unit is discussing client rights with a group of coworkers. Which of the following statements should the nurse include?

"A client must withdraw consent for treatment in writing if he is competent to do so."