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? - ANS-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? - ANS-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? - ANS-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? - ANS-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? - ANS-"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? -
ANS-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) - ANS-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? - ANS-"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? - ANS-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? - ANS-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? - ANS-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? - ANS-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? - ANS-"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? -
ANS-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? -
ANS-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? - ANS-"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? - ANS-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? - ANS-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? -
ANS-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? - ANS-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? - ANS-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? - ANS-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? - ANS-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? - ANS-"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? - ANS-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? - ANS-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? - ANS-Skin rash with fever
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