A nurse is collecting data from a client who has substance use disorder and reports recently taking
opioids. Which of the following findings should the nurse identify as a manifestation of opioid
intoxication?
Pinpoint pupils
A nurse is contributing to the discharge plans for four clients. The nurse should identify that which of the
following clients requires an interdisciplinary care conference?
A client who has hemiparesis and lives alone
A nurse is reinforcing teaching with an adolescent who has a new prescription for cefazolin. For which of
the following findings should the nurse instruct the adolescent to monitor and report to the provider?
Depression
A nurse is reinforcing teaching with a group of expectant parents regarding the proper use of a car seat.
Which of the following statements by a parent indicates an understanding of the teaching?
I can place a rolled towel on each side of my newborns head until he can hold his head up
A nurse is caring for a school-age child who has epistaxis. Which of them following actions should the
nurse take?
Apply pressure at the bridge of the child's nose
A nurse is caring for four clients. Which of the following clients statements should the nurse attend to
first?
My heartburn pain is going into my jaw now
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 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 client who has bipolar disorder and is experiencing mania. Which of the following
actions should the nurse take?
Frequently remind the client of the expectations for her behavior
A nurse is caring for a client who has viral pneumonia. Which of the following actions should the nurse
take?
Administer Azithromycin
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?
Try to complete a task before moving on to the next.
A nurse is caring for an older adult client who is postoperative following a total hip arthroplasty. The
nurse is preparing to change the client's dressing. Which of the following actions should the nurse take
to demonstrate sensitivity to age-related changes?
Use paper tape for securing the new dressing.
, 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 reinforcing teaching with a postpartum client about bathing her newborn. Which of the
following statements should the nurse include?
"Wash your newborn's head under a stream of running water."
A nurse is caring for a client who has heart failure and reports difficulty limiting sodium in his diet. Which
of the following recommendations should the nurse provide?
Replace bottled salad dressing with homemade vinegar and oil dressing.
A nurse is reinforcing teaching about nonpharmacological pain relief with a client who is 6 hr postpartum
following a vaginal delivery. The client has an episiotomy and swelling of the labia. Which of the
following instructions should the nurse include?
Sit on soft pillows throughout the day.
A nurse is caring for a client who has a new colostomy. He voices a reluctance about resuming sexual
relations. Which of the following is an appropriate response by the nurse?
"I'm available if you'd like to talk about your concerns."
A nurse is reinforcing discharge teaching about transmission precautions with a client who has hepatitis
C. Which of the following information should the nurse include?
Avoid sharing razors with other family members.
A nurse is contributing to the plan of care for a client who has bulimia nervosa. Which of the following
interventions should the nurse recommend?
Observe the client for 1 hr after meals.
A nurse is assisting with the discharge planning for a client following a myocardial infarction. Which of
the following is an appropriate referral for this client?
Respiratory therapist for breathing exercises
A nurse is reinforcing teaching with a client who plans to bottle feed her newborn. Which of the