The nurse manager is conducting an in-service education session on catheter associated urinary tract infection (CAUTI). Which instruction will the nurse provide to the staff? Select all that apply.

The nurse administers an inhaled corticosteroid to a client with COPD. What is the most important intervention for the nurse to implement to prevent a common adverse effect of this drug?

The nurse in the ED calls to report to the maternal-child unit for a client who is 34 weeks pregnant and being admitted with a diagnosis of placenta previa. As the nurse plans for the client's arrival on the unit, what is important to include in the plan of care?

Nurses on the unit are completing an annual satisfaction survey. On the survey, they all indicate that their nurse manager is a transformational leader. What behavior by the nurse manager led the nurses to this conclusion?

A nurse in the obstetrician's office receives a call from a client who gave birth 8 days ago. The client says, "I thought they said that my bleeding would become pinkish brown, then yellow, and eventually fade away. I still have bright red bleeding." The nurse tells the client to come in immediately. In planning for the client's care upon arrival, what is most important for the nurse to include in the plan?

There has been an outbreak of influenza and the community health nurse plans a presentation at the community center for older adults on ways to prevent the spread of influenza. What should the nurse include in the presentation? Select all that apply.

The nurse working in a telehealth center speaks with an older adult client reporting “heartburn”. The nurse suspects the client is experiencing gastroesophageal reflux disease (GERD). To determine if the client is experiencing GERD, what important question should the nurse ask the client?

A client with a history of bipolar disorder called the provider office to report a new onset of symptoms. “I’ve had nausea and vomiting since yesterday, and I’m so sleepy, it seems like I just can’t get enough sleep. My hands are shaky too.” For the following nursing responses, which one is appropriate to say?

The nurse cares for a client who lost 7 year old twins in a house fire 8 months ago. The client was admitted today for major depression. The client says to the nurse, “they took my 2 babies away from me, so what is the point of living. They were all I had”. What is the most important thing for the nurse to include in the client’s care plan?

A 10-year-old client with sickle cell disease is experiencing a vaso-occlusive episode. The client’s respiratory rate is 26 and oxygen saturation is 95%. Along with prescribed medication management, which intervention is most important for the nurse to implement?

The home health nurse visits a client who was recently discharged from the hospital for treatment of a blood glucose of 380 mg/dL and a diabetic foot ulcer. The nurse will be performing a dressing change to the foot ulcer today and providing diabetic education. The nurse weighs the client and calculates a BMI of 34.7. The client’s lunch is seen on the table and includes a double hamburger, large fries, bowl of potato chips. A salad, 2 doughnuts, and 2 pieces of chocolate pie. What is the most important for the nurse to place in the teaching plan for this client?

The nurse cares for a client who was in a motor vehicle accident and lost significant blood volume. The healthcare provider has ordered a blood transfusion for the client, but the client is conflicted and experiencing spiritual distress. What is the likely source of the client’s spiritual distress that the nurse should be aware of when planning care?

The nurse cares for a client with a terminal illness. The client starts everyday with a spiritual ritual of burning candles and praying. To maintain safe care while still recognizing the client’s spirituality, what nursing action is most appropriate?

The local hospital receives word that there is a bombing at a local mall and many injured victims are being transported to the hospital. What is the most important for the hospital to include in its immediate disaster response?

A client is admitted to the neuro unit from ED with a new diagnosis of seizures. Client is quiet and makes very little eye contact with the healthcare provider. Health history is completed, no seizure activity since admission. Several family members at bedside. It is observed that the client is sitting up at the bedside being fed hot liquids from two different flasks. Nurse inquires about the contents of flasks and they are teas prepared by the family herbalist to heal seizures. The nurse cares for a 22 year old patient with a new onset of seizures. Based on the information, what is the initial nursing action? Select all that apply

A young client is brought to the ED by the school coach who reports a patient fell and hurt their left ankle while playing soccer on the school campus an hour ago. Observation reveals the ankle is edematous. What is the priority nursing action?

The school nurse plans to implement primary prevention in the school regarding TB. What actions should be included in the nurse’s plan? Select all that apply.

At 20:00, Client was admitted to the ortho unit with fracture and soft tissue injury to the left lower extremity, sustained in an accident on a construction site where the client works. An external fixator is in place on the affected extremity. Pin sites are clean without signs of infection. Neuro assessment completed, client able to wiggle toes, toes warm to touch, no reports of numbness and pedal pulses present. At 22:15, client reports pain 8/10 to affected extremity, oxycodone 10mg administered as prescribed. At 23:00, client states pain has decreased to 4/10 and is tolerable. Next day at 08:15, client reports pain 10/10 to extremity, oxycodone 10mg administered orally. At 09:45, client states pain decreased to 8/10, pin site care performed, no signs of infection or loose pins noted. At 11:40, client reports stabbing pain to affected extremity 10/10, states pain is worse than before. Assessment is done and pulses diminished and extremity cooler than normal to touch. Client reports slight numbness and tingling in toes. What should be in the immediate plan of care for this client based on assessments?

A client is diagnosed with MRSA in the urine. Client does not have an indwelling urinary catheter. What assessment finding is most important when determining the client’s compliance with isolation precautions?

The nurse cares for a client with AIDS and reviews the client's lab results. The client’s CD4+ T cell count is 150 cells/uL. What is the priority nursing intervention?

The nurse plans preoperative teaching for the parents of a 3 month old child scheduled for cleft lip surgery in the morning. What is important for the nurse to tell the parents now to prepare them for their child’s care postoperatively?

A client in the ED is to have realignment of a dislocated elbow. This will be performed with the use of conscious (moderate to deep) sedation. What is the priority nursing action?

A mass shooting disaster occurred at the local school and many students and staff including the shooter have been hurt. The school nurse was not hurt and is instrumental in trying to implement the school’s emergency preparedness plan in the best way possible. Place these 5 clients in the order they should receive treatment first to last.

The nurse cares for a client admitted 6 hours ago with a fracture to the hip due to fall sustained while intoxicated. Nurse places a call to the healthcare provider to report the client is experiencing early alcohol withdrawal symptoms. What assessment finding led the nurse to make this call?

The UAP in the nursing home reports to the nurse that a client is “grumpy” and refuses to take a bath. The client is incontinent and needs a bath daily. When the nurse speaks to the client to assess the situation, the client states “I need more sleep, I don’t want a bath now”. What is the most appropriate response by the nurse?

A young client is brought to the ED by a parent who reports that the client fell and they hurt the left ankle while playing at home. X-ray reveals a sprained ankle, what interventions are important for the nurse to include in the plan of care for this client? Select all that apply.

The nurse cares for a client on the unit with frequent family visitors. The UAP is upset and complains to the nurse that the patient always has too many visitors that must be asked to move out of the way when providing care. In planning future care for this patient, how can the UAP be culturally sensitive while still ensuring appropriate care for the client?

A client admitted with exacerbation of hypertension is being discharged. When assessing the client’s understanding of managing high blood pressure upon discharge, what statement indicates the client needs more education?

A nurse in the oncology unit has identified a gap in the written procedure for administration of chemotherapy and has asked for the procedure to be taken to the shared governance council for discussion. The nurses on the unit are proud of her actions as in the past this nurse was shy and afraid to speak up about anything. How has participating in the shared governance council impacted the nurse’s leadership skills?

A client with preeclampsia is monitored on the maternal-child unit. What assessment findings indicate the client’s condition is declining? Select all that apply. Think HELLP (Hemolysis, Elevated Liver Enzymes, Low Platelets)

The nurse just admitted a client to the unit who is in preterm labor. The client is prescribed magnesium sulfate and the nurse starts the infusion. What is important to include in this client’s plan of care. Select all that apply.

Client presents to ED with complaints of chest pain and SOB. States had a baby 2 weeks ago at the age of 45. Client was doing housework when symptoms started. Excessive perspiration present, alert and oriented x 4, does complain of dizziness. Lung sounds clear. Labored breathing, S1/S2 heard on auscultation. Muscles tense throughout the body. Lab included Troponin at 0.01 and D-Dimer at 0.1 Vitals include 134/82 BP, HR 122, RR 24, Temp 98.6, SPO2 97% on RA. What are 2 actions to take?

Client presents to ED with complaints of chest pain and SOB. States had a baby 2 weeks ago at the age of 45. Client was doing housework when symptoms started. Excessive perspiration present, alert and oriented x 4, does complain of dizziness. Lung sounds clear. Labored breathing, S1/S2 heard on auscultation. Muscles tense throughout the body. Lab included Troponin at 0.01 and D-Dimer at 0.1 Vitals include 134/82 BP, HR 122, RR 24, Temp 98.6, SPO2 97% on RA. Condition Most likely experiencing

2 Parameters to Monitor? - Compliance with peak flow meter - aPTT levels - ECG changes

Clients on 5/1 are seen for fussiness and ear pain. Client has acute otitis media in the left ear, and will be treated with amoxicillin. On 6/24, client has ear pain and fever, left ear once again infected, will treat with clindamycin. 8/5, client has left ear otitis media, will discuss treatment options for chronic otitis media with parent. The nurse cares for a 3 year old, for each nursing action say if it is appropriate or not for the nurse to complete. Which of the following actions are appropriate for the nurse to complete?

The nurse reviews lab results for patients with cancer receiving chemo and radiation. Client white blood cells, neutrophils, reticulocytes, and platelets are all low. What is the most important for the nurse to include in the self-care education of this client? Select all that apply.

The nurse participates in a psychotherapy session for 3 clients with OCD who are scheduled to be discharged from the treatment program tomorrow. What statement by one client indicates the plan for that client’s discharge may need to be changed?

The nurse examines a pregnant client who came to the obstetrician's office today after noticing bleeding from the vagina. What additional assessments findings lead the nurse to conclude that the client is experiencing abruptio placenta and immediate intervention is needed? Select all that apply.

The public health nurse cares for a 70 year old client who presents to the clinic for medication refills accompanied by a caregiver. The client seems anxious and is not making eye contact and has different color bruises to exposed arms. The nurse suspects the client is being abused, which actions does the nurse take? Select all that apply.

An attendee at a community health fair approaches the nurse and reports a 3-day history of nausea, vomiting and just feeling “bad”. The client is rubbing the back of the neck and reporting stiffness to the neck and a bad headache. The nurse places the client in a quiet, secluded room and calls 911 immediately. What health risk prompted the nurse’s quick action?

A client with pneumonia is being treated with Levofloxacin and takes antacids daily for heartburn. After 5 days of taking the antibiotic, the nurse observes that the client’s pneumonia is not resolving. What is an appropriate nursing action?

The charge nurse assigns care of clients on the day shift and has delegated care of 5 clients to a registered nurse. Which client should the nurse see first?

The nurse is precepting a student nurse in the ED, which action by the student nurse requires further teaching from the preceptor?

The nurse provides discharge teaching to an older adult client but the client seems disinterested, bored, and confused at times. What communication factors may have impacted the client’s response to the nurse’s teaching? Select all that apply.

The hospice nurse cares for a client with late stage breast cancer. Yesterday, the client was tearful and said to the nurse, “I am so scared to be alone when the time comes, I have no family members in this country”. As the nurse plans for the client’s remaining days, what is most important for the nurse to include in the client’s plan of care?

The charge nurse of a medical-surgical unit is planning assignments for the shift, which task can be safely assigned to the LPN/LVN?

A client presents to the ED accompanied by their spouse. The client reports feeling very lightheaded and dizzy while walking from the bedroom to the bathroom and had to sit down to prevent falling. Blood pressure is 86/50, HR 110, temperature 98.4F, RR 20, and O2 saturation at 97%. The nurse takes the client’s health history and the spouse whispers to the nurse that they had just finished having sexual intercourse and that the client had taken one sildenafil tablet. What finding in the client’s health history may have contributed to the client’s condition?

A 34 year old client presents to ED with reports of severe headache with sudden onset. Client reports using cocaine regularly. Left pupil is dilated, rates pain 10/10, says it is the worst headache ever had, reports the pain is mainly behind one eye. Client reports dizziness and the room is spinning. Nuchal rigidity upon assessment, lung sounds clear, S1/S2 heard, normal sinus rhythm on ECG. Which of the following actions should be taken?

A 34 year old client presents to ED with reports of severe headache with sudden onset. Client reports using cocaine regularly. Left pupil is dilated, rates pain 10/10, says it is the worst headache ever had, reports the pain is mainly behind one eye. Client reports dizziness and the room is spinning. Nuchal rigidity upon assessment, lung sounds clear, S1/S2 heard, normal sinus rhythm on ECG. The client is most likely experiencing which of the following conditions?

A 34 year old client presents to ED with reports of severe headache with sudden onset. Client reports using cocaine regularly. Left pupil is dilated, rates pain 10/10, says it is the worst headache ever had, reports the pain is mainly behind one eye. Client reports dizziness and the room is spinning. Nuchal rigidity upon assessment, lung sounds clear, S1/S2 heard, normal sinus rhythm on ECG. Which parameter should be most closely monitored?

A patient has an emergency cholecystectomy. At 17:45, all preoperative assessments completed and consents signed. Client is lying in supine position, sterile drapes covering client with surgical area exposed and prepped with antiseptic solution. Anesthesiologist successfully administers gas anesthesia followed by intubation. At 17:50, the client experienced generalized muscle rigidity including tetanus like rigidity to jaw. Which of the following actions should be taken?

A patient has an emergency cholecystectomy. At 17:45, all preoperative assessments completed and consents signed. Client is lying in supine position, sterile drapes covering client with surgical area exposed and prepped with antiseptic solution. Anesthesiologist successfully administers gas anesthesia followed by intubation. At 17:50, the client experienced generalized muscle rigidity including tetanus like rigidity to jaw. The condition most likely being experienced is:

A patient has an emergency cholecystectomy. At 17:45, all preoperative assessments completed and consents signed. Client is lying in supine position, sterile drapes covering client with surgical area exposed and prepped with antiseptic solution. Anesthesiologist successfully administers gas anesthesia followed by intubation. At 17:50, the client experienced generalized muscle rigidity including tetanus like rigidity to jaw. Which parameter should be most closely monitored?

The nurse speaks with a client scheduled for surgery later today and the client says “the doctor came in here speaking nonsense. I don’t understand a word they said about the surgery, can you go over it with me? What is the most appropriate response by the nurse?

The nurse cares for a client who is transgender and having breast augmentation surgery. While performing the client's preoperative preparation, the client says I’m getting cold feet. I don’t know if this is the right thing to do, my partner is the one who really wants me to do this. What responses by the nurse are most appropriate?

The charge nurse is making assignments for the day for the unit consisting of 2 RNs, 2 LPNs, and 1 UAP. Which clients should be assigned to the registered nurse? Select all that apply.

A client with colostomy is being discharged in a few days and the nurse begins to teach the client how to care for the stoma and device. Every time the nurse asks the client to attempt self-care, the client turns the head away and starts to cry. What is an appropriate intervention by the nurse?

For each finding in the following scenario, state if it is relevant or not relevant to the client’s current primary issue. The findings are subjective statements, menstruation, collapse, vital signs, weight change. Scenario: On 2/6 at 15:00, a 16-year-old female admitted from the ED following a collapse during physical education at school, client states I do not have any friends and even if I did they would all say I was fat. Client admits to having lost 35 pounds in about 2 months and her last menstrual period was three weeks ago. Current BMI is 19.8. Vitals include BP 80/50, HR 64, RR 12, Temperature 96.9F, SPO2 98%. For each finding, state if it is relevant or not relevant to the client’s current primary issue:

The client is most likely experiencing ____ as evidenced by _____ .

For the same patient what laboratory result is most concerning to be reported to HCP immediately?

Client arrived on medical surgical unit after RN received report from ED RN. Client resting in bed with parent at bedside. Parent approaches the RN and asks I know you can fix her medical problems here, but what about her eating disorder? How is that treated?

For each discharge education point, specify to include or do not include: - Don’t pay attention to what foods you eat, just make sure to eat 4-6 times per day - need structured meals

For each discharge education point, specify to include or do not include: - A referral has been made with a dietitian, the dietitian will help determine a nutrition plan for regular weight gain

For each discharge education point, specify to include or do not include: - Eat your meals in private so you do not feel extra pressure or judgement while you are eating - no should be supervised

For each discharge education point, specify to include or do not include: - You need to weigh yourself daily, your parent can record the number if you do not want to see- can trigger anxiety

For each discharge education point, specify to include or do not include: - Work with your psychologist to explore the emotional issues contributing to your eating habits

For each finding click to spicy if finding indicated improvement, no change, or decline in client's condition (select one only for each): - Weight - Self-Esteem - Eating Behaviors - Hydration Assessment - Self-Harm

A 3-year-old client with cystic fibrosis is admitted to the unit to receive IV antibiotics for a respiratory infection. What other intervention is most important for the nurse to include in the client's plan of care?

A client with hypertension and diabetes developed kidney disease and the healthcare team is monitoring the client's kidney function closely. Today the nurse reviews the client's kidney function tests and notes a GFR of 13 mL/min/1.73m2. As the nurse develops a plan of care for the client, what intervention is likely to be part of the plan?

The registered nurse assigns tasks to the LPN/LVN and UAP on the shift. Which tasks should be assigned to the UAP? Select all that apply.

The nurse works as a volunteer providing care to clients in a homeless shelter. One client sitting in a corner with a blanket over their head is heard coughing profusely. Understanding health conditions that are prevalent among the people experiencing homelessness, what assessment is priority for the nurse?

A nurse in the pediatrician's office has several children in the waiting area who are there for immunizations. The next client to be seen is a 2 month old who already received 2 doses of Hep B vaccine. Which vaccine should the nurse prepare for this client?

The nurse receives a prescription for insertion of a nasogastric (NG) tube on a client. The nurse has not completed the procedure in a while. In planning for completion of the procedure, what are the most important decisions for the nurse to make? Select all that apply.

A client with a known cardiac valve disease is admitted to the cardiac floor with a diagnosis of acute pericarditis. The client has become increasingly restless and confused. HR is 108, Temp 98.2 F, RR 26, with a change in systolic blood pressure from 116 to 96 mmHg when the client inhales. What is a priority action by the nurse?

The nurse facilitates a healthy heart support group in which 4 clients were recently prescribed antihypertensive medications. The clients each completes a daily log for 5 days of BP readings and shared results. The nurse recognizes that only one client has shared results indicating treatment in therapy.

A client was admitted to the medical floor from the ICU and is being treated for C.Diff positive diarrhea. When the nurse evaluates the client’s treatment, what finding indicates the treatment is effective?

A group of nurses travels to a rural area to provide healthcare to farm workers. During client assessments, several were found to have respiratory distress. Based on this assessment finding, what should be included in the nurses education to the workers and their bosses?

The charge nurse on the psych unit makes assignments for the oncoming shift. What action is most important when assigning staff to a client with paranoid personality disorder?

Client helped into the chair and set up for morning hygiene. Client ate 50% of breakfast. Client back in bed per request to rest before morning session of PT. Client vital signs at 8/12 07:30 were 134/79, HR 74, RR 14, Temp 98.7, SPO2 98%. Vitals at 10:55 were 115/72, HR 82, RR 16, Temp 98.7, SPO2 98%. MAR includes Quinapril, Levothyroxine, Aspirin, Loratadine. Which information is most concerning to the nurse?

Client on 8/30 at 14:30 was brought to the urgent care clinic by a neighbor who reported the client was seen sitting on the front porch for a long time and appeared disoriented. The neighbor reports the client lives alone and has been experiencing hard times. Neighbor has been helping clients with food and water lately but cannot afford to be consistent with the help. Nursing assessment of client reveals poor skin turgor, shrunken eyes, and dry oral mucous membranes. Client is able to urinate 25 mL of very dark concentrated urine for a urinalysis specimen. Client reports lightheadedness and dizziness when standing. Vitals include 88/62, HR 102, RR 22, 97.6 F, 96% SPO2. What is the priority action by the nurse?

Client on 10/5 at 09:55, a 68-year-old arrives in ED accompanied by an adult daughter. Client has a history of COPD currently with a productive cough with dark yellow sputum. Daughter reports the client has allergies to eggs and nuts. Client has been increasingly out of breath after a cold she had last week and has not had an appetite for the past few days. She was feeling a little better until today when she was exposed to a lot of dust. She had a 20 pack year smoking history and stopped smoking when diagnosed with COPD at age 50. Client is sitting in a tripod position on a stretcher and leaning over the bedside table. She appears anxious and becomes breathless when speaking. Client is using pursed lip breathing and reports using her “puffer” but it did not help. The clients lips and tip of her ears have bluish tint and clubbing of her fingers is noted. Crackles and wheezing heard on auscultation. Oral mucous membranes and tongue are dry.

What 2 factors are most likely contributing to the client’s current exacerbation?

During chest x-ray lungs appear hyperinflated, flattening of the diaphragm, no filtrations or foreign objects. For each client finding, specify if finding is most consistent with Acute COPD exacerbation, respiratory infection, or both:

Same patient at 10:15, oxygen applied at 5L per nasal cannula. Peripheral IV started in the left forearm and normal saline started 100mL/hr. Respiratory therapy consulted and labs drawn. ABG results are pH 7.21, pCO2 75, PO2 55, HCO3 32. What is her ABG results respiratory/metabolic, alkalosis/acidosis, compensated/partially compensated/uncompensated?

What pharmacological treatments does the nurse anticipate the provider may order for this client's acute condition? Other labs that came in were WBC at 12000, Hgb at 17.

Same patient at 10:40, medication administered. Client respiratory status deteriorating, client restless in bed and placed on non-invasive ventilation via BIPAP at the bedside after respiratory therapy. At 12:00, client resting in bed with HOB elevated, BIPAP remains, ABGs redrawn. Respirations even with mild-labored breathing. Client pale without cyanosis. Crackles to bilateral lung fields on auscultation. S1/S2 heard, moderate productive cough noted. New ABG is pH 7.35, pCO2 68, PO2 70, pHCO3 28. Indicate the findings improvement or no change.

The nurse in the health ministry at the local church provides stroke education and checks blood pressure measurements after church for members of the congregation. One congregant who has never taken blood pressure medications, reports a headache that has been persisting for a few hours. The congregant's BP is 198/108. What are the priority nursing actions? Select all that apply.

The nurse is working on the correctional health unit of a facility that cares for five clients from state prison. Client X committed a heinous crime of which the entire community is aware because it was in the news media. What action by the nurse while caring for Client X is a breach of justice?