An unlicensed assistive personnel (UAP) is assigned to feed a client who has received a prescription to institute droplet precautions for a bacterial meningitis infection. The UAP requests a change in assignment, reporting having not yet been fitted for a particulate filter mask. Which action should the nurse take?

 Which assessment data reflects the need for the nurse to include the problem, “Risk for falls” in a clients plan of care? 

Reference range: Hemoglobin (14 to 18)

The nurse plans to encourage a group of young adult clients to engage in problem-solving strategies. Which of the following is most useful for the nurse to include?

The nurse notices a client grimacing while moving from the bed to the chair, but when asked about the pain the client denies any pain. Which intervention should the nurse implement first?

A male client has right-sided hemiplegia following a left cerebrovascular accident (CVA). His sitting balance has improved, and he is now able to sit in a wheelchair. To assist the client in transferring from the bed to a wheelchair, which action should the nurse take?

A patient with fluid volume overload is admitted to the hospital for diuresis. Which assessment should the nurse perform to evaluate the patient’s fluid balance?

surgical incision that is healing by secondary intention develops a thick tan exudate. Which action should the nurse take first?

A 45 year-old client has breast cancer that has metastasized is receiving hospice care. The client is at home, and the family is concerned about their loved one. The nurse assesses the client. Which of the following signs indicate that the client is near death?

SELECT ALL THAT APPLY

The nurse is initiating a 24 hour urine collection for a client with an indwelling urinary catheter. After emptying all the urine from the collection bag, which action is most important for the nurse to implement?

While preparing to obtain a stool specimen for occult blood, the nurse observes that the client’s feces is soft, solid, and light brown. Which action should the nurse implement?

While measuring vital signs, the nurse observes that a client is using accessory neck muscles during respirations. Which follow-up action should the nurse take first?

The nurse assesses a client’s dorsalis pedis pulse, the nurse applies firm pressure over the top of the foot between the extension tendons of the great and first toes but does not feel pulsation. Which action should the nurse take next?

When entering a client’s room, the nurse observes the client holding up an arm and coughing non-productively into the upper sleeve. Which action should the nurse take?

The nurse identifies several problems for an older adult client experiencing diarrhea and fecal incontinence who is confined to bed and being cared for by a primary caregiver. In planning care, the nurse should determine which nursing problem is the highest priority?

 A client diagnosed with primary open-angle glaucoma received a prescription for miotic eye drops. Which instruction should the nurse plan to include in the client's teaching? Select all that apply

The nurse is interviewing a client with lower abdominal pain and dysuria, and needs to question the client about sexual activity. Which approach is best for the nurse to use?

When assessing a client with a serum potassium level of 2.5 mEq/L, which intervention is most important for the nurse to implement?

Reference range: Potassium (K+) 3.5 to 5 mEq/L

The nurse is using guided imagery with a client who is experiencing chronic pain. What should the nurse direct the client’s attention on during the session?

 A client is admitted with pneumonia and has a recent history of methicillin-resistant staphylococcus aureus (MRSA). The client is placed in isolation. While caring for the client, which item should the nurse place in a designated biohazard bag before it is removed from the room?

The nurse is documenting wound care in a client's electronic medical records (EMR) when the computer system shuts down. Which action should the nurse implement first?

A client with a sprained ankle is seen at the clinic and given a pair of crutches. When the client stands with the aid of the crutches, the nurse notes a space of three finger widths between the top of the crutch and the client’s axilla. Which action should the nurse take?

A clear liquid breakfast is prescribed for a client who is scheduled for surgery later today. The client asks the nurse for a small cup of chocolate ice cream. Which action should the nurse take?

A clear liquid breakfast is prescribed for a client who is scheduled for surgery later today. The client asks the nurse for a small cup of chocolate ice cream. Which action should the nurse take?

The charge nurse is observing a new nurse administering care during new hire orientation at the hospital. Which activity by the new nurse indicates correct body movement and posture to reduce the risk for injury?

A client who is admitted for malnutrition and severe dehydration receives a prescription for liquid feedings through a feeding tube. After the feeding tube is inserted and placement confirmed, which assessment is most important for the nurse to complete before starting the feeding?

A client who speaks another language is admitted. The sister offers to translate and asks for an update of the client's information. What to do?

A nurse is caring for an alert and oriented 68 year old patient with a terminal illness. The patient has a signed advance directive that clearly states they do not want to be intubated or resuscitated. The patient’s physician, however, believes that all possible measures should be taken to prolong life. The patient’s family is in disagreement about the wishes. What is the most appropriate action for the nurse to take?

A nurse is providing discharge teaching to a client who is recovering from pneumonia. The nurse notices the client looks anxious while being given instruction on her new medication and follow-up care. What is the most appropriate initial action for the nurse to take?

You went on break at 1845. The covering nurse gave your client their second dose of insulin and decided to write on paper that the dose was given. You were unaware and gave the client another dose on your return. Which error prevention techniques would have helped avoid this. SATA

 A nurse is observing a new nursing student perform hand hygiene. Which action by the student best demonstrates an understanding of the proper technique for handwashing when preparing for a procedure?

A nurse is caring for a client with a history of severe blood loss from a traumatic injury. The nurse's priority is to assess the client for signs of hypovolemic shock. Which of the following assessment findings is the most indicative of poor peripheral perfusion?

The nurse receives a new Rx to administer  O2 at 3L/min via nasal cannula to maintain O2 stat 90-100% for an adult client. The nurse obtains an O2 saturation reading of 85% and after repositioning to a different finger, obtains a second reading of 87%, which action should the nurse take next?

When evaluating the effectiveness of a client's nursing care, the nurse first reviews the expected outcomes identified in the plan of care. What action should the nurse do next? 

A client is getting ready to have a procedure. The doctor educates the client on the benefits and risks of the procedure. When the nurse goes to have the client sign for informed consent, the client asks about details about how the procedure is performed. What should the nurse do?

The nurse is reviewing the personal care needs of an older adult client who lives alone. What client assessment findings indicate the need to assign an UAP to provide routine foot care and file the clients toenails? (SATA)

When initiating O2 per mask to a client who is SOB, the nurse hears a loud hissing sound after inserting the flowmeter into the wall outlet. Which should the nurse do next?

After a week of bedrest, a client is being assisted to the chair for the first time. The nurse raises the head of the bed and moves the client to a sitting position. Which action should the nurse implement next?

A nurse enters the room of a client who has a productive cough. The nurse observes the client coughing into the front of their hospital gown. What is the nurse's most appropriate action

A nurse is caring for a client who has been placed in bilateral soft mitten restraints to prevent them from pulling at their nasogastric tube. What is nursing priority?

What is the best method to provide oral care to an unconscious client?

A nurse is assessing a client who reports a pain level of 6 out of 0-10 pain scale. Which of the following is the most appropriate initial action for the nurse to take to get more information about the quality of pain?

A nurse is providing dedication to a client on healthy lifestyle habits. The client reports that they have started an exercise regimen but that it is keeping them awake at night. What is the nurse's most appropriate initial action?

A nurse is receiving a patient from the emergency department who has been placed in a soft wrist and ankle restraints on all four extremities. What is the priority assessment the nurse must perform upon receiving the patient?

The nurse walks in and notices a UAP providing peri care to a client with Cdiff. The UAP is wearing gloves and tells you the client has diarrhea. What should you do?

 What is the best indication that a client is at risk for pressure ulcer formation?

The palliative care nurse receives a consult for a terminally ill client in the intensives care unit. The client is weak, mouth breathing, and refusing anything to eat or drink. Which intervention should the nurse include in the plan of care?