NR 449 EVIDENCE BASED PRACTICE Questions and answers
1. A nurse is caring for a client who is wearing antiembolic stockings. Which of the following interventions should the nurse include in the plan of care? Fold the top of the stocking over neatly Apply the stockings after the client is in a chair Massage the client's legs once every 8 hr while the stockings are in place Determine if the stockings are binding 2. A nurse on a medical surgical is performing medication reconciliation for a newly admitted client. Which of the flollowing should the nurse take? Compare the prescription to the allergy history of the client Compare the medication label to the provider's prescription on three occasions before administration Compare a list of common medications to treat a condition to the actual prescriptions Compare for client's list of home medications to the admission prescriptions written for the client 3. A community health nurse is receiving laboratory reports for a group of clients. The nurse should identity that which of the following disorders is on the CDCs Nationally Notifiable Conditions list? Pediculosis capitis bacterial vaginosis respiratory syncytial virus Lyme disease 4. A nurse is caring a client following application of a cast. Which of the following actions should the nurse take first? Place an ice pack over the cast Position the casted extremity on a pillow Palpate the pulse distal to the cast Teach the client to keep the cast clean and dry 5. A staff nurse is observing a newly licensed nurse suction a client's tracheostomy. Which of the following actions by the newly licenses nurse requires interventions by the staff nurse? Applies suction for 15 seconds Encourages the client to cough during suctioning Wait for 2 min between suctions Inserts the catheter without applying suction 6. A nurse is working with a client who has an anxiety disorder and is in in the orientation phase of the therapeutic relationship. Which of the following statements should the nurse make during this phase? Let's talk about how you can change your response to stress Let me show you simple relation exercise to manage stress We should establish our roles in the initial session We should discuss resource to implement in your daily life 7. A nurse is caring for a client who is at 11 weeks of gestation. Which of the following immunization should the nurse recommend? a. influenza b. human Papillomavirus C. Measles, mumps, and rubella d. varicella 8. A home health nurse is preparing to make a initial visit to a family following a referral from a local provider. Identify the sequence of step the nurse should take when conducting a home visit. Placing them in the order of performance. Use all steps Discus plans for future visits with the family Clarify the reason for the referral with the provider's office Record information about the home visit according to agency policy Identify family needs and interventions using the nursing process Contact the family to determine availability and readness to make an appointment A. 9. A nurse is planning care for a client who has an L4 spinal cord injury. Which of the following interventions to prevent skin breakdown should the nurse include in the plan of care? Massage reddened area over bony prominences Provide a hight fiber diet for the client Ask the client to shift his weight every 20 min while sitting in a chair Maintain the head of bed at 45 degree angle 10. A nurse is preparing to administer vancomycin IV to an adult client. The client asks the nurse if the medication can be given 2 hr earlier. Which of the following statements should the nurse makes? I have up to 2 hours after usual schedule time to give you this medication I can start the medication 30 min earlier I can infuse the medication as a faster rate I can adjust the time and schedule for when it's convenient for you 11. A nurse is planning care for a client who sustained a major burn over 20% of the body. Which of the following interventions should the nurse include is important to support the client's nutritional requirements? Schedule meals at 6hr Keep a calories amount for foods and beverages Amount of protein, high carbohydrates diet Maintain the calories intake as 1,500 per day 12. A sure at a mental health unit is planning room assignments for four clients. Which of the following client should the nurse assign to a room near the nurse station A client who has bipolar disorder and impaired social interactions A client who has a source symptom disorder and reports chronic pain A client who has a depressive disorder and reports feeling hopeless A client who has an anxiety disorder and is experiencing moderate anxiety 13. A nurse is preparing discharge information for a client who has type 2 diabetes mellitus. Which of the following information resources should the nurse provide to the client? 14. A nurse is caring for a 1 day old newborn who has jaundice and is receiving phototherapy. Which of the following actions should the nurse take? Apply lotion to the newborn every 4 hr Ensure that the newborn wears a diaper Give the infant 30 ml( 1oz) or glucose water every 2 hr Keep the infant's head covered with a cap 15.. A charge nurse on a medical surgical unit is planning assignments for a licensed practical nurse (LPN) who has been sent from the postpartum unit due to a staffing shortage for the shift. Which of the following client assignments should the nurse delegate to the LPN? A client who is post following a bowel resection with an NG tube set to continuous suction A client who orientation a conversation and has unequal pupils A client who fractured a fetter yesterday and is experiencing shortness of breath A client who has an high of 6.3gdl and a prescription for packed of RBCs 16. A sure at a mental health unit is planning room assignments for four clients. Which of the following client should the nurse assign to a room near the nurse station A client who has bipolar disorder and impaired social interactions A client who has a source symptom disorder and reports chronic pain A client who has a depressive disorder and reports feeling hopeless A client who has an anxiety disorder and is experiencing moderate anxiety 17.. A nurse is caring for a client who has increased intracranial pressure following a traumatic brain injury. Which of the following actions should the nurse take? (select all that apply) Encourage the client to cough and deep breathe Provide a quiet environment for the client Obtain client vital signs every 8 hr Maintain the head of the bed at 30 degree angle Administer stool softeners to the client 18. A nurse is providing discharge instructions about newborn safety to a client wo is 2 days postpartum. Which of the following instructions should the nurse includes? Change smoke detector batteries every other year Place a plastic waterproof sheet over the crib bedding Lay the baby on his stomach to nap during the daytime Use a car seat when traveling by airplane 19. A nurse has identified tasks to delegate to a group of assistive personal (AP) after receiving change-off-shift reports. Identify the sequence of step the nurse should follow when delegating tasks to the APs. Placing then in the selected order of the following Review the skill level and qualification of each AP Communities appropriate tasks to the APs with specific expectations 20. A home health nurse is preparing to make a initial visit to a family following a referral from a local provider. Identify the sequence of step the nurse should take when conducting a home visit. Placing them in the order of performance. Use all steps Discus plans for future visits with the family Clarify the reason for the referral with the provider's office Record information about the home visit according to agency policy Identify family needs and interventions using the nursing process Contact the family to determine availability and readness to make an appointment 21. A nurse is teaching participants at a community center about advance directives. Which of the following informations should the nurse include in the teaching? Advance directives cannot be changed one implemented A client must have do-not- resuscitation order when completing advance directives A health care surrogate makes health care decisions when the client is no longer able Assigning a health care surrogate requires legal consultation 22. A nurse is caring for a client who has cancer of the throat and is receiving radiation therapy. The nurse should monitor for which of the following? Elevated platelet count Altered taste sensation Insomnia Excessive salvation 23.. A nurse is providing discharge teaching to a client who is postoperative following surgery for carpal tunnel syndrome. Which of the following statements by the client indicates an understanding of the teaching? a. I should expect numbness and tingling in my hand b. I can apply heat for the first 24 hours to minimize the pain in my hand c. I will need to keep my hand elevated above my heart for several days d. I should not use my effected hand for 4 to 6 weeks 24. A nurse is teaching a client who is pregnant and has prescription for an iron supplement. Which of the following statement should the nurse include? You should take this medication with a source of protein You should notify the provider of your stools turn black You might become constipated while taking this medication Your urine will be an organ color while on this medication 25. A nurse is an intensive care unit is assessing a client who has heart failure and has been receiving metoprolol for 3 days. Which of the following findings indicates the treatment has been effective? Decrease urinary output Increase heart rate Decreased edema Increased blood pressure 26. A nurse is assessing a client who is receiving daily aspirin therapy. The nurse should identify that which of the following findings might indicates an allergic reaction to this medication? Blurred vision Difficulty swallowing Weight gain Hight blood pressure 27. A nurse is providing discharge instructions about newborn safety to a client who is 2 days postpartum. Which of the following instructions should the nurse includes? Change smoke detector batteries every other year Place a plastic waterproof sheet over the crib bedding Lay the baby on his stomach to nap during the daytime Use a car seat when traveling by airplane 28 A nurse is caring for a client who is 4 hr postpartum. The client reports an urge to void but is unable to void. Which of the following action should the nurse take? Instruct the client to place her hands in cold water while attempting to void Massage the client fundus Administer a diuretic the the client Encourage the client to attempt to void while using a sitz bath 29. A nurse is caring for a client who has respiratory depression from an opioid administration. After administering naloxone to the client, which of the following finding should the nurse expect Somnolence Hyperglycemia Increase pain Hypoventilation 30. A nurse is caring for a 1 day old newborn who has jaundice and is receiving phototherapy. Which of the following actions should the nurse take? Apply lotion to the newborn every 4 hr Ensure that the newborn wears a diaper Give the infant 30 ml( 1oz) or glucose water every 2 hr Keep the infant's head covered with a cap 31. A nurse manager is updating protocols for the use of belt restraints. Which of the the following guidelines should the nurse manager include? Request a PRN restraint prescription for clients who are aggressive Attach the restraint to the bed's side rails Remove the client's restraint every 4 hr Document the client's condition every 15 min 32. A nurse is caring for a client who has a new prescription for warfarin. When reviewing the client's current medications, which of the following medications would the nurse identify as contraindicated for use with warfarin? (select all apply) Ibuprofen Aspirin Ginkgo biloba Magnesium sulfate Cetirizine 33. A nurse is providing dietary teaching to a client who has a new diagnosis of irritable bowel syndrome. Which of the following recommendations should the nurse include? Sweeten food with fructose corn syrup increase intake of food high in gluten consume foods high in bran fiber increase in take of milk products 34. A nurse is caring for a client who experienced a stroke 4 days ago and has dysphagia. Which of the following actions should the nurse take to assist the client during meals? Place a small bites of food on the unaffected side of the clients mouth Have the client sit in a semi-fowlers position during meal Intrust the client to extent the head back when swallowing Provide the client with clear liquids for assist with swallowing 35. A nurse is reading a tuberculin skin test for a client who received a purified protein derivative test 72 hr ago. Which of the following finding indicates a positive test? An induration measuring 5 mm A reddened are measuring 10 mm A reddened area measuring 5 mm An induration measuring 10mm 36. A nurse is teaching a client who has heart failure about engaging in an exercise program. Which of the following statements by the client indicates an understating of the teaching? I will. Make sure I can still talk while exercising? I will slow my walking pace if I experience chest pain I will work to achieve 60 minutes of exercise each day? I will wait 30 minutes after eating before exercising 37. A nurse is providing teaching to an older adult client about methods to promote nighttime sleep. Which of the following instructions should the nurse include? Perform exercises prior to bedtime Stay in the bed at least 1 hr if unable to fall asleep Take a 1-hr nap during the day Eat a high snack before bedtime 38. A nurse is teaching a newly licensed nurse about postpartum hemorrhage. Which of the following statement by the new licensed nurse indicate an understanding of the teaching? Postpartum hemorrhage from a cervical laceration is treat with terbutaline 0.25 milligrams subcutaneous A woman is at highest risk for postpartum hemorrhage during her first delivery postpartum hemorrhage can occur within the first 6 weeks after delivery Inversion of the uterus in the leading cause of postpartum hemorrhage 39. A nurse is preparing to administer a NG tube feeding to a school-age-child. Which of the following actions should the nurse plan to take? Complete the feeding in 5 min Warm the formula in the microwave Postion the child at a 10 degree to 20 degree angle after feeding Measure the tubing from the nose to the distal port 40. The nurse is preparing discharge teaching to the patient who chronic kidney disease receiving hemodialysis. Which of the following instruction should the nurse include in teaching? Take magnesium hydroxide for ingestion Drink at least 3 L of fluid daily Consume foods high in potassium Eat 1 g/kg of protein per day 41. A nurse is preparing educational material for a client. Which of the following techniques should the nurse use to creating the material? Write information at a seventh-grade reading level Use words with three or four syllables Emphasize importance information using bold lettering Avoid using cartoons in the teaching material 42. A charge nurse is teaching a group of newly licensed nurses about the correct use of restraints. Which of the following examples should the charge nurse include in the reaching? Applying elbow immobilizers on an infant recovering from cleft lip surgery Placing a belt restraint on a school age child who has seizure Securing wist restraints to the bed rails for an adolescent Keeping the side-rails of a toddler's crib elevated 43. A nurse is caring for a 1-month old infant who has manifestations of severe dehydration and a prescription for parental fluid therapy. The guardian asks, " what are the indications that my baby needs an IV" which of the following responses should the nurse make? Your baby needs an IV because she is breathing slower than normal Your baby needs an IV because her heart rate is decreased Your baby needs an IV because her fontanels are bulging Your baby needs an IV because she is not producing tears 44. A nurse is caring for an infant who has coarctation of the aorta. Which of the following should the nurse identify as an expect findings? Weak femoral pulses Upper extremity hypotension increased intracranial pressure 45. A nurse is receiving assessment data from several clients. For which of the following clients should the nurse recommend referral to dietitian A client who has a nonhealing leg ulcer An older client who has presbyopia An older adult client who has a BMI of 24 A client who has an albumin level of 3.7 g/dL 46. A nurse is caring for a client who has increased intracranial pressure following a traumatic brain injury. Which of the following actions should the nurse take? (select all that apply) Encourage the client to cough and deep breathe Provide a quiet environment for the client Obtain client vital signs every 8 hr Maintain the head of the bed at 30 degree angle Administer stool softeners to the client 47. A nurse is preparing to obtain a client's signature on an informed consent form. Which of the following actions should the nurse take first? a. Witness the client signing the inform consent form b. Inform the client of his right to change his mind c. Ask the client to explain his understanding of the procedure d. Notify the provider if the client has questions about the procedure 48.A nurse in an emergency department is caring for a child who reports being sexually abused by a family member. Which of the following action should the nurse take? Reassure a child that no one will be told about the abuse Explain to the child what will happens when the abuse is reported Ensure that multiple nurses are present for the physical examination Use leading statements to obtain information from the child 49. A nurse is teaching a wellness class about depression for a group of older adult clients. Which of the following information should the nurse include in teaching? Depression can be misdiagnoses as a neurocognitive disorder in older adult clients Treatment options for depression are different for older adult clients than for clients in other age groups Changes in sleep patterns are not a manifestation of depression in order adult client Higher dosages of antidepressants are required to achieve therapeutic effects in older adult clients 50. A nurse manager is developing a protocol for staff discipline. Which of the following actions should the nurse manager take when implementing this new protocol? Take individual circumstances into account when determining consequences Promote staff adherence to new processes using strong consequences Schedule disciplinary meetings at a time convenient for all parties Inform staff about the purpose of the unit's new process. 51. A nurse is caring for a client who has preeclampsia receiving magnesium sulfate. The nurse should identify that which of the following preeclampsia receiving magnesium sulfate which of the following is manifestation of magnesium toxicity? Blurred vision Hyperventilation tachycardia hyperreflexia 52. A nurse is receiving the medication administration record of a client. Which of the following prescriptions should the nurse clarify? Digoxin 250 PO daily cetirizine 1 g IV Q 24 hours acetaminophen 650 mg PO Q 6 hours levothyroxine 25 mcg PO daily at 0600 53. A nurse is providing teaching to the parents of a newborn who has been circumcised. Which of the following instructions should the nurse include? remove yellow exudate around the wrap sterilize gauze around the if bleeding occurs apply petroleum jelly to the glans with diaper changes use soap to clean the side 54. A nurse is reviewing the laboratory results of a client who is taking cyclosporine following a kidney transplant. Which of the following findings should the nurse report to the provider? Urine specific gravity 1.023 BUN 18 mg/dL Serum creatinine 1.6 mg/dL Urine PH 6.2 55. A nurse is teaching a group of newly licensed nurses about client advocacy. Which of the following statements by the newly licenses nurse indicates an understanding of the teaching? I will inform the client that his family should help make his health care decision I should advise a client about what I feel to be his best health care decision I will intervene if there is a conflict between a client and his provider I should not advocate for a client unless he is able to ask the himself 56. A nurse is assessing a client to determine the need for physical restraints. The nurse should identify which of the following as an acceptable reason to apply physical restraints? to maintain the patency of the IV line To keep the client from sliding down while in bed To achieve to the family's request for restraints To protect client injury due to staffing limitations 57. A nurse is teaching a client who is receiving radiations therapy about skin protection. Which of the following client statements indicates an understanding of teaching? I will apply my favors lotion to the radiation area of skin twice each day I will use my hand instead of a washcloth to wash the radiated area of the skin I will expose the radiated area of skin to the sun for no more than 30 minutes per day I will make sure I have sterile water to wash the radiated area of skin 58. A charge nurse on a medical surgical unit is planning assignments for a licensed practical nurse (LPN) who has been sent from the postpartum unit due to a staffing shortage for the shift. Which of the following client assignments should the nurse delegate to the LPN? A client who is post following a bowel resection with an NG tube set to continuous suction A client who orientation a conversation and has unequal pupils A client who fractured a fetter yesterday and is experiencing shortness of breath A client who has an high of 6.3gdl and a prescription for packed of RBCs 59. A nurse is caring for a client who has depression and reports taking St.John's wort along with citalopram. The nurse should monitor the client for which of the following conditions as a result of an interaction between these substances? Acute dystonia Serotonin syndrome Tardive dyskinesia Pseudoparkinsonism 60. Nurse is caring for an infant who has respiratory syncytial virus. Which of the following interventions should the nurse take? Initiate isolation precaution Suction nares prior to feeding Request a prescription for guardians
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a nurse is caring for a client who is wearing antiembolic stockings which of the following interventions should the nurse include in the plan of care
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a nurse on a medical surgical is performing medi
