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WorksheetsNursing Clinical Scenarios Worksheet
Total questions: 86
Worksheet time: 43mins
A client with a 20-year history of schizophrenia is hospitalized. The client appears visibly upset, approaches the nurse, and says in a shaky voice, "I can’t find my headband. I can’t find my headband. The oil is going to leak out of the crack in my head." What is the best response by the nurse?
"How long has the oil been leaking from your head?"
"Let’s go back to your room and look for your headband together."
"There is no oil coming out of your head."
"You are going to miss breakfast if you do not go into the dining room."
A nurse is caring for a 1-month-old client who is being evaluated for congenital hypothyroidism. Which of the following are clinical manifestations of hypothyroidism in infants? Select all that apply.
Difficult to awaken
Dry skin
Frequent, loose stools
Hoarse cry
Tachycardia
The nurse is monitoring a client who is 6 cm dilated with recurrent variable decelerations on the fetal heart rate monitor. The health care provider places an intrauterine pressure catheter and prescribes an amnioinfusion. After the amnioinfusion bolus is complete, which assessment finding should the nurse report immediately?
Cervix is 8 cm dilated and 100% effaced, with fetal presenting part at +1 station
Contractions are every 3 minutes and 60–80 seconds each
Fetal heart rate baseline is 155/min with early decelerations and moderate variability
Uterine resting tone baseline has increased to 45 mm Hg and perineal pads are dry
The nurse is caring for a client with surgical complications who requires continuous total parenteral nutrition (TPN). A subclavian triple-lumen central venous access device is inserted. What is the priority action before initiating the TPN infusion?
Attach a filter to the IV tubing
Check baseline fingerstick glucose levels
Check the results of the portable chest x-ray
Program the electronic infusion pump
The emergency department nurse prepares a male client for surgery. The client was admitted with a traumatic open fracture of the femur, hematocrit of 36%, and hemoglobin of 12 g/dL. Which prescription should the nurse validate with the health care provider before administration?
Cefazolin
Enoxaparin
Morphine
Tetanus toxoid
The nurse is preparing to defibrillate a client who suddenly went into ventricular fibrillation. Which steps are essential prior to delivering a shock? Select all that apply.
Apply defibrillator pads
Call out and visually confirm that everyone is "all clear"
Continue chest compressions until ready to deliver the shock
Ensure adequate IV sedation has been given
Ensure the synchronization button is turned on
The home health nurse assesses a child and suspects child abuse. Which questions are appropriate for the nurse to ask the caregiver? Select all that apply.
"How would you describe your child’s usual behavior at home?"
"These bruises seem excessive and suspicious. How did they happen?"
"What forms of discipline do you use with your child?"
"When you are stressed, what coping mechanisms do you use?"
"Who watches your child when you are at work?"
A client is receiving lithium carbonate 900 mg/day for schizoaffective disorder. The lithium level is 1.0 mEq/L. Which prescription does the nurse anticipate receiving?
Continue at the current dosage
Decrease the dosage
Discontinue the medication
Increase the dosage
A nurse auscultates a loud cardiac murmur in a newborn with suspected trisomy 21. Vital signs are stable and oxygen saturation is 98% on room air. What is the most appropriate next action?
Call the health care provider immediately
Document the assessment finding
Place the neonate in a knee-chest position
Provide oxygen to the neonate
A nurse is participating in an obstetrical emergency simulation when the provider announces shoulder dystocia. Which interventions should the assisting nurse implement? Select all that apply.
Assist maternal pushing efforts by applying fundal pressure
Document the time the fetal head was born
Flex the client’s legs back against the abdomen and apply suprapubic pressure
Prepare for a forceps-assisted birth
Request additional assistance from other nurses immediately
A client with schizophrenia is hospitalized. After 2 weeks of treatment, the frequency of the client's hallucinations seems to be diminishing. When first hospitalized, the client refused to leave the room. Now the client spends time in the dayroom, sitting in a corner watching television, but does not initiate conversation or social interaction with other clients or staff. What is the most appropriate activity for the client?
A board game with a staff member
Participation in a group songfest
Planning a unit picnic
Playing Bingo with other clients
A client with hypothermia has just arrived in the emergency department via ambulance. The client is being rewarmed with blankets, and IV fluids are being changed over to warmed fluids. What additional intervention is a priority?
Attaching the cardiac monitor
Covering the client’s head
Drawing blood for electrolytes and glucose
Placing an additional large-bore IV catheter
The nurse is documenting assessments of pregnant clients in the antepartum unit. Which client’s assessment findings are most important to report to the health care provider?
Client at 28 weeks gestation with an asymptomatic systolic murmur
Client at 34 weeks gestation with 1+ edema of bilateral lower extremities
Client at 35 weeks gestation with painful genital lesions
Client at 39 weeks gestation with brownish, mucoid vaginal discharge
Which assessment findings should the nurse anticipate in a child with suspected acute otitis media (AOM)? Select all that apply.
Frequent pulling on the affected ear
Refusal to eat
Restlessness and irritability
Retracted tympanic membranes
Severe pain with pressure on the tragus
The nurse reinforces medication teaching to a client prescribed metronidazole. Which client statement indicates a need for further education?
I might have a metallic taste in my mouth when I’m taking this medicine.
I need to decrease the amount of alcohol I drink while taking this medicine.
I should not worry if my urine turns a dark color while taking this medication.
I will immediately call the clinic if I get a new rash or have skin peeling.
A 3‑month‑old infant has irritability, facial edema, a 1‑day history of diarrhea with adequate oral intake, and seizure activity. The parents report that they have recently been diluting formula to save money. What is the most likely cause of the infant’s symptoms?
Hypernatremia due to diarrhea
Hypoglycemia due to dilute formula intake
Hypokalemia due to excess gastrointestinal output
Hyponatremia due to water intoxication
The nurse develops a teaching plan for a client prescribed isoniazid, rifampin, ethambutol, and pyrazinamide to treat active tuberculosis (TB). Which instruction regarding the adverse effects of rifampin is most important to include?
Notify the health care provider if your urine is red
Take acetaminophen every 6 hours for drug‑associated joint pain
Wear eyeglasses instead of soft contact lenses while taking this medication
You can stop taking the medications as soon as one sputum culture comes back normal
A client with schizophrenia says, “The world turns as the world turns on a ball at the beach. But all the world’s a stagecoach and I took the bus home.” The nurse recognizes this statement as an example of:
Concrete thinking
Loose associations
Tangentiality
Word salad
The nurse is reviewing several fetal heart rate (FHR) tracings for laboring clients at term gestation. Based on the FHR tracings, which client requires priority assessment?
Client with minimal variability and early decelerations
Client with a normal frequency of contractions and FHR pattern
Client experiencing uterine tachysystole (>5 contractions in 10 minutes)
Client with a category 1 FHR tracing
The emergency department nurse receives a client with extensive injuries to the head and upper back. The nurse will perform what action to allow the best visualization of the airway?
Head‑tilt chin‑lift in the supine position on a backboard
Head‑tilt chin‑lift in the Trendelenburg position
Jaw‑thrust maneuver in semi‑Fowler’s position
Jaw‑thrust maneuver in the supine position on a backboard
The nurse is caring for a client with a history of heart failure and atrial fibrillation. The client’s current medications include digoxin and furosemide. Which assessment finding is most important to report to the health care provider?
Apical pulse of 62 beats/min
Digoxin level of 1.2 ng/mL
Potassium level of 3.2 mEq/L
Serum creatinine of 0.9 mg/dL
A nurse is caring for a client being treated for a deep vein thrombosis (DVT) with a continuous heparin infusion. Which laboratory result should the nurse monitor to evaluate the effectiveness of heparin?
Activated partial thromboplastin time (aPTT)
International normalized ratio (INR)
Platelet count
Prothrombin time (PT)
The nurse is assessing a client with a diagnosis of pleural effusion. Which physical assessment findings should the nurse expect? Select all that apply.
Decreased breath sounds
Dullness on percussion
Hyperresonance on percussion
Increased tactile fremitus
Sharp pleuritic chest pain
The nurse is reviewing arterial blood gas results for a client with an exacerbation of chronic obstructive pulmonary disease (COPD): pH 7.30, PaCO2 52 mm Hg, HCO3 28 mEq/L, PaO2 60 mm Hg. How should the nurse interpret these results?
Metabolic acidosis
Metabolic alkalosis
Respiratory acidosis
Respiratory alkalosis
The nurse is teaching a client newly diagnosed with type 1 diabetes mellitus about foot care. Which instruction should the nurse include?
Apply moisturizing lotion between the toes
Cut toenails in a rounded shape to follow the toe’s curve
Soak feet in warm water for 20 minutes daily
Wear well‑fitting, closed‑toe shoes
A client with chronic kidney disease (CKD) has a serum potassium level of 6.8 mEq/L. Which intervention should the nurse prioritize?
Administering a dose of sodium polystyrene sulfonate
Placing the client on a cardiac monitor
Preparing the client for emergency hemodialysis
Restricting dietary potassium intake
The nurse is caring for a client with a permanent pacemaker. Which instruction should be included in discharge teaching?
Avoid using a microwave oven
Do not travel by airplane
Notify airport security of the pacemaker before a search
Refrain from using a cellular phone
The nurse is caring for a client scheduled for a colonoscopy. Which action should the nurse perform as part of pre‑procedure care?
Administer a clear liquid diet the day before the procedure
Maintain the client on NPO status for 24 hours
Provide a high‑fiber meal the evening before
Withhold all medications on the morning of the procedure
The nurse is assessing a client with a history of cirrhosis who is scheduled for a paracentesis. Which action is a priority to perform before the procedure?
Ask the client to empty the bladder
Obtain a baseline weight
Place the client in a Trendelenburg position
Record the client’s abdominal girth
The office nurse instructs a client newly diagnosed with asthma about using a peak flow meter to evaluate airflow. Which statement indicates an understanding of the teaching?
I will exhale as quickly and forcibly as possible through the mouthpiece of the device to obtain a peak flow reading.
I will move the indicator to the desired reading on the numbered scale before using the device.
I will record my personal best reading, which is the average of three consecutive peak flow readings.
I will remember to use the device after taking my fluticasone metered-dose inhaler.
A client has just returned from the cardiac catheterization laboratory for a permanent pacemaker placement. How should the nurse document the rhythm on the client's cardiac monitor?
Atrial paced rhythm
Atrioventricular paced rhythm
Biventricular paced rhythm
Ventricular paced rhythm
A client in the postoperative period after an open reduction and internal fixation of a left wrist fracture reports constant, severe arm pain unrelieved by morphine administered 30 minutes ago. The client's nail beds appear dusky. What are the nurse’s appropriate actions? Select all that apply.
Apply a heating pad and encourage range-of-motion exercises
Assess the temperature and movement of the fingers
Elevate the arm on pillows above the level of the heart
Notify the health care provider
Reassure the client, document findings, and reassess in 1 hour
The nurse is teaching about the importance of dietary fiber at a community health fair. Which health benefits of consuming a fiber-rich diet should the nurse include? Select all that apply.
Helps prevent colorectal cancer
Improves glycemic control
Promotes weight loss
Reduces risk of vascular disease
Regulates bowel movements
A home health nurse is assessing a client who has been using crutches for 2 weeks. Assessing for which finding is most important?
Biceps muscle spasm
Forearm swelling
Hand and wrist weakness
Shoulder range of motion
A client with myocardial infarction (MI) underwent successful revascularization with stent placement and is now chest pain free. The client is embarrassed to talk about resuming sexual activity. What teaching should the nurse initiate?
If the client is able to climb two flights of stairs without symptoms, the client may be ready for sexual activity if approved by the health care provider.
Inform the client that medications such as sildenafil or tadalafil are available as prescriptions from the health care provider.
It will be six months before the heart is healthy enough for sexual activity.
The client will be ready for sexual activity after completion of cardiac rehabilitation.
The camp nurse conducts a class for incoming summer counselors on prevention of tick bites and Lyme disease. Which instructions should the nurse include? Select all that apply.
Apply a tick repellent spray before outdoor activities
Avoid hiking through areas of tall grass and thick underbrush
Cover ticks found on skin with petroleum jelly
Report bull's-eye rash or flulike symptoms to a health care provider
Wear a long-sleeved shirt tucked into pants and closed-toe shoes while hiking
A cardiac catheterization was performed on a client 2 hours ago. The catheter was inserted into the left femoral artery. What signs of potential complications should the nurse report immediately? Select all that apply.
Bleeding at the catheterization site
Client lying down and quietly watching television
Client taking only sips of fluids
Left foot remarkably cooler than right foot
Urine output of 100 mL since the procedure
The nurse has provided education for a client with newly diagnosed ankylosing spondylitis. Which statements indicate a correct understanding of teaching? Select all that apply.
I should continue strenuous exercise during flare-ups.
I should include spine-stretching activities such as swimming.
I should quit smoking and perform breathing exercises.
I will sleep on a soft mattress to decrease my morning stiffness.
I will take the prescribed ibuprofen on an empty stomach.
During assessment of a client who had major abdominal surgery a week ago, the nurse notes dehiscence and evisceration of the incision. How should the nurse position the client while waiting to cover the wound?
Low Fowler's position with knees bent
Prone to prevent further evisceration
Side-lying lateral position
Supine with head of the bed flat
If a client reports muscle weakness or sensory symptoms in the forearm, wrist, and hand after using crutches, what is the most likely cause?
Biceps muscle spasm
Damage to the radial nerve
Restricted shoulder range of motion
Triceps muscle fatigue
The nurse plans teaching for an adolescent client being discharged home with a Boston brace for treatment of scoliosis. Which instruction should the nurse include in the discharge teaching plan?
Apply body lotion or powder under the brace to prevent skin irritation
Avoid any exercises that require the use of spinal muscles
Keep the brace on for all activities, including showering
Wear a cotton T-shirt under the brace at all times
A client with type 1 diabetes mellitus is prescribed an insulin pump. Which statement indicates that the teaching has been effective?
I will check my blood glucose levels at least four times a day.
I will still need to give myself a shot of long-acting insulin every night.
I won't have to worry about what I eat anymore because the pump does all the work.
The pump will automatically adjust my insulin based on my glucose levels.
The nurse is caring for a 4-year-old child in the emergency department who has a high fever, is drooling, and is making a high-pitched noise when breathing. What action should the nurse take first?
Assess the child's throat with a tongue blade
Obtain a STAT throat culture
Place the child in a high Fowler's position
Prepare for immediate endotracheal intubation
The nurse is preparing to administer an intramuscular injection to a 6-month-old infant. Which is the most appropriate site?
Deltoid muscle
Dorsogluteal muscle
Ventrogluteal muscle
Vastus lateralis muscle
A client is admitted with a diagnosis of acute pancreatitis. Which nursing intervention should the nurse prioritize?
Administering oral pain medications
Maintaining the client on NPO status
Measuring abdominal girth every 4 hours
Starting a high-protein, low-fat diet
The nurse is assessing a client 24 hours postoperative following a total hip replacement. Which finding requires immediate intervention?
Client reports pain as 7 on a scale of 0-10
New onset of confusion and restlessness
Redness and warmth around the incision site
Total drainage of 50 mL in the suction drain
The nurse is reviewing laboratory results for a client with suspected Addisonian crisis. Which result should the nurse expect?
Blood glucose 140 mg/dL and Sodium 150 mEq/L
Blood glucose 60 mg/dL and Potassium 5.8 mEq/L
Calcium 12 mg/dL and Magnesium 3.0 mEq/L
Sodium 145 mEq/L and Potassium 3.5 mEq/L
A client with a history of asthma is brought to the emergency department in respiratory distress. The nurse notes a "silent chest" upon auscultation. What is the immediate priority?
Administer a sedative to reduce anxiety
Administer a stat dose of an inhaled corticosteroid
Prepare for emergency intubation
Start an IV infusion of normal saline
A nurse is triaging victims of a mass casualty event. Which client should be assigned a red tag (emergent)?
Client with full-thickness burns to the chest, back, and legs (expectant)
Client with wet clothing who was immersed in cold water
Client with diabetes who is unable to receive their daily insulin
Client with high-pitched, crowing inspiratory respirations (stridor)
A critical care nurse is caring for a newly admitted client with acute aortic dissection. Which prescription should the nurse prioritize while awaiting surgical revision?
Administer IV labetalol to maintain blood pressure within prescribed parameters
Initiate and maintain strict bed rest and a low-stimulation environment
Monitor bilateral lower extremity peripheral pulse strength
Prepare the client's consent form for surgical repair of the aorta
The health care provider has prescribed amitriptyline 25 mg orally every morning for an elderly client with recent shingles and severe postherpetic neuralgia. What is the priority nursing action?
Encourage increased fluid intake
Provide frequent rest periods
Teach the client to get up slowly from the bed or a sitting position
Tell the client to wear sunglasses when outdoors
The nurse is assessing a client with rheumatoid arthritis who is being considered for adalimumab therapy. Which statement made by the client needs further investigation?
"I am taking an antibiotic for a urinary tract infection."
"I had a negative tuberculosis skin test 2 weeks ago."
"I just received my yearly flu shot a week ago."
"I will continue taking naproxen at night to help with pain."
A client comes to the community mental health clinic seeking treatment for severe anxiety associated with a recent job promotion that requires a 30-minute commute via train. The nurse recognizes that this client most likely suffers from which psychological disorder?
Agoraphobia
Generalized anxiety disorder
Social anxiety disorder
Zoophobia
A nurse cares for a client with impairment of cranial nerve VIII. What instructions should the nurse provide the unlicensed assistive personnel prior to delegating interventions related to the client's activities of daily living?
"Be aware of the client's shoulder weakness and provide support as needed."
"Ensure that the client sits upright and tucks the chin when swallowing food."
"Explain all procedures in step-by-step detail before performing them."
"Make sure the items needed by the client are within reach."
The pediatric clinic nurse reinforces culturally competent care at an in-service. Which finding would be inappropriate to include as a common dermatologic effect of alternative medicine therapies?
Blisters with a garlic scent near the wrists
Circular bruised blemishes on the back
Markings appearing to be human bites on the arms
Welt-like linear lesions on the back
Which of the following tasks should the registered nurse avoid delegating to the unlicensed assistive personnel?
Obtaining a blood glucose level from a client
Assessing a client who reports a new symptom
Assisting a stable client with ambulation
Documenting intake and output for a client
The nurse is caring for a client who is nauseated and dry heaving following extensive abdominal surgery. What is the priority nursing action?
Administer a prescribed antiemetic medication
Assess the surgical incision for signs of dehiscence
Encourage the client to take deep breaths
Notify the health care provider immediately
The nurse is preparing to administer medications through a client's feeding tube. Which action is most important to ensure tube patency and avoid drug interactions?
Combine all crushed medications into one cup
Administer each medication separately and flush the tube with water before, between, and after medications
Mix crushed medications with enteral formula to ease administration
Crush extended-release tablets to ensure they pass through the tube
A client with hepatic encephalopathy is receiving lactulose. Which finding indicates the medication is achieving its desired therapeutic effect?
Improved mental status and orientation
Increased serum ammonia levels
Production of five or more watery stools per day
Reversal of the client's cirrhosis
The nurse is preparing to give a heparin injection to a client who is malnourished and cachectic. Which method of injection would be appropriate for this client?
27 gauge, 1/4 in (0.6 cm) long needle at 90 degrees
25 gauge, 1/2 in (1.3 cm) long needle at 45 degrees
25 gauge, 1/2 in (1.3 cm) long needle at 90 degrees
21 gauge, 1 in (2.5 cm) long needle at 90 degrees
The nurse is caring for a client with a history of heart failure who is being discharged with a prescription for a low-sodium diet. Which of the following food choices should the nurse instruct the client to avoid? Select all that apply.
Canned soups and vegetables
Fresh fruits and berries
Frozen dinners
Grilled chicken breast
Processed meats (e.g., deli turkey, ham)
A client is admitted to the hospital with a diagnosis of acute cholecystitis. Which of the following clinical manifestations should the nurse expect to find during assessment?
Left-sided abdominal pain that radiates to the back
Pain in the right upper quadrant that radiates to the right shoulder
Pain in the umbilical region that moves to the right lower quadrant
Severe epigastric pain relieved by leaning forward
The nurse is providing teaching to a client with a new prescription for warfarin. Which of the following statements by the client indicates a need for further instruction?
"I will need to have my blood checked regularly to monitor the medicine's effect."
"I should avoid eating large amounts of leafy green vegetables like spinach."
"I will use a soft-bristled toothbrush to prevent my gums from bleeding."
"I'll start taking a daily aspirin to help the warfarin work better."
The nurse is assessing a 2-day-old infant and notes a yellow tint to the skin and sclera. Which action should the nurse take first?
Encourage the mother to breastfeed the infant more frequently
Notify the health care provider to obtain a serum bilirubin level
Place the infant under phototherapy lights immediately
Reassure the parents that this is a normal finding in newborns
A client with chronic obstructive pulmonary disease (COPD) is receiving oxygen via a nasal cannula at 2 L/min. The nurse notes that the client's SpO2 is 89%. What is the most appropriate nursing action?
Increase the oxygen flow rate to 4 L/min immediately
Instruct the client to perform pursed-lip breathing
Notify the health care provider that the oxygen is ineffective
Prepare the client for arterial blood gas (ABG) analysis
The nurse is caring for a client with a chest tube that was inserted 12 hours ago for a pneumothorax. The nurse notes continuous bubbling in the water-seal chamber. Which of the following is the most likely cause?
The client is experiencing an active air leak from the lung
The suction pressure is set too high on the drainage system
There is an air leak in the chest tube drainage system
This is a normal finding as the lung begins to re-expand
The nurse is preparing to administer an intravenous bolus of furosemide to a client with pulmonary edema. Which of the following should the nurse monitor most closely after administration?
Blood pressure and heart rate
Oxygen saturation and respiratory rate
Serum potassium and sodium levels
Urinary output and daily weight
A client is admitted with a diagnosis of deep vein thrombosis (DVT) in the right leg. Which of the following nursing interventions should be included in the plan of care?
Apply a heating pad to the right calf to reduce pain
Encourage the client to ambulate in the hallway twice a day
Maintain the client on strict bed rest with the right leg elevated
Perform vigorous massage of the right calf to improve circulation
The nurse is caring for a client whose spouse is dying. The spouse's heart rate is slowing, and breathing is becoming irregular with long pauses. The spouse asks, "Do you think he'll be here for our anniversary tomorrow?" Which response by the nurse is most therapeutic?
"Happy anniversary! I'll go get the anniversary memory that you shared."
"That would be very special, but please understand that it may not happen."
"We never know, so try not to worry about it."
"I think he will make it through the night."
Which would be the appropriate client criteria for activating a rapid response team at the hospital? Select all that apply.
Glasgow coma scale (GCS) score of 9 throughout shift
Heart rate remaining at 58 beats/min for more than 1 hour
Postoperative pain rated at 10
Respiratory rate maintaining an increase to 30 breaths/min
Sustained change in level of consciousness for 10 minutes
The nurse is preparing to suction a client with a tracheostomy. Which of the following actions should the nurse perform? Select all that apply
Apply suction while inserting the catheter into the airway
Hyperoxygenate the client with 100% oxygen before suctioning
Limit suctioning to no more than 10 seconds per pass
Select a suction catheter that is half the size of the tracheostomy tube
Use a clean technique when performing the procedure
A client with chronic obstructive pulmonary disease (COPD) is being discharged with a new prescription for a long-acting beta-agonist (LABA) inhaler. Which of the following instructions should the nurse include in the teaching?
"Take this medication as soon as you feel short of breath."
"Use this inhaler every day, even if you are not feeling sick."
"Rinse your mouth with water immediately after each use."
"This medication replaces your quick-relief albuterol inhaler."
The nurse is caring for a client with a history of seizures who is currently having a generalized tonic-clonic seizure. Which of the following actions is a priority?
Insert a padded tongue blade into the client's mouth
Place the client in a side-lying position
Restrain the client's arms and legs to prevent injury
Start an IV line to administer anti-seizure medication
The nurse is assessing a client with suspected appendicitis. Which of the following findings should the nurse report to the health care provider immediately?
Client reports pain in the right lower quadrant
Client's white blood cell count is 12,000/mm³
Client has a temperature of 100.2 F (37.9 C)
Sudden relief of pain followed by increased fever
A client is admitted to the hospital with a diagnosis of bacterial meningitis. Which of the following precautions should the nurse implement?
Airborne precautions
Contact precautions
Droplet precautions
Standard precautions only
The nurse is teaching a client about a clear liquid diet. Which of the following items should the nurse inform the client are allowed? Select all that apply
Apple juice
Chicken broth
Frozen yogurt
Orange juice with pulp
Tea with sugar
The nurse is caring for a client who is receiving a blood transfusion. Ten minutes into the transfusion, the client reports chills, low back pain, and nausea. What is the nurse's first action?
Check the client's vital signs
Notify the health care provider
Slow the rate of the transfusion
Stop the transfusion immediately
A client with type 2 diabetes mellitus is scheduled for an elective surgery in the morning. The client is NPO after midnight. The nurse notes that the client's 7:00 AM blood glucose is 180 mg/dL. What should the nurse do next?
Administer the client's regular dose of oral metformin
Administer the client's regular dose of insulin glargine
Call the health care provider for instructions
Give the client 4 oz of orange juice to prevent hypoglycemia
A client's spouse is brought to the family waiting room after the client was unexpectedly admitted to the intensive care unit following a "near-drowning accident." The spouse is crying hysterically and says, "I can't believe this is happening. It's all my fault!" Which response by the nurse is most therapeutic?
"I'll call the hospital chaplain to come and talk with you."
"It sounds like you are feeling overwhelmed. Tell me more about what happened."
"This is a very difficult situation. Please try to stay calm for your spouse."
"You shouldn't blame yourself; accidents can happen to anyone."
The nurse is caring for a client at 39 weeks gestation in active labor who is receiving an oxytocin infusion. The nurse notes persistent late decelerations on the fetal monitor. Which of the following actions should the nurse take? Select all that apply
Administer oxygen via a nonrebreather face mask
Change maternal position to the left side
Discontinue the oxytocin infusion
Notify the health care provider
Perform a nitrazine test
The nurse is reviewing teaching with the parents of a child who has tinea capitis and is newly prescribed griseofulvin oral suspension and selenium sulfide shampoo. Which statement by the parent indicates a need for further teaching?
"I will apply the selenium sulfide shampoo to my child's scalp twice a week."
"I will give the griseofulvin with a high-fat food like ice cream."
"I will stop the griseofulvin as soon as the bald spots start to grow hair."
"My child should avoid sharing hats or hairbrushes with other children."
The nurse is assessing a client with acute cholecystitis. Which of the following findings should the nurse expect? Select all that apply
Low-grade fever with chills
Pain in the left upper quadrant
Pain radiating to the right shoulder
Right upper quadrant tenderness
Steatorrhea
A client with chronic obstructive pulmonary disease (COPD) is admitted with an exacerbation. The client is receiving oxygen via a Venturi mask. Which of the following is the most important benefit of using a Venturi mask for this client?
It allows for the delivery of high concentrations of oxygen.
It can deliver a precise, guaranteed concentration of oxygen.
It is more comfortable for the client than a nasal cannula.
It prevents the client from rebreathing exhaled carbon dioxide.
The nurse is caring for a client with a history of heart failure who is receiving a dose of IV furosemide. Which of the following laboratory values should the nurse monitor most closely?
Blood urea nitrogen (BUN)
Hemoglobin and hematocrit
Serum potassium
Serum sodium
The nurse is providing discharge instructions to a client who had a permanent pacemaker inserted. Which of the following statements by the client indicates a correct understanding of the teaching?
"I should avoid using a microwave oven for cooking."
"I will need to carry my pacemaker identification card with me."
"I will notify the airport security before walking through the metal detector."
"I will refrain from using a cell phone indefinitely."
A client is admitted to the psychiatric unit with a diagnosis of major depressive disorder. The client stays in their room all day and refuses to participate in activities. Which of the following actions by the nurse is most appropriate?
Encourage the client to attend a group therapy session.
Leave the client alone until they feel ready to interact.
Sit with the client for 15 minutes in silence.
Tell the client that they must participate in at least one activity.
