A nurse is caring for four clients. Which of the following client statements should thenurse attend to first? - "My heartburn pain is going into my jaw now." A nurse is caring for a client who is receiving mechanical ventilation via an endotracheal tube. Which of the following actions should the nurse take? - Perform oral care every 2 hr. A nurse is caring for a client who is receiving warfarin 5 mg PO daily. Which of thefollowing laboratory values should the nurse check prior to administering the medication? - - PT - INR A nurse is collecting data from a client who is at 9 weeks of gestation and has hyperemesis gravidarum. Which of the following findings should the nurse expect? - Weight loss A nurse is reinforcing teaching with a client about the importance of a low sodium diet. Which of the following foods should the nurse recommend as the best choice to includein a low sodium diet? - 2 tbsp of peanut butter A nurse is collecting data from an 18 month old toddler at a well child visit. Which of the following findings should the nurse report to the provider? - The toddler can say four words. A nurse is collecting data from a client who has diabetes mellitus. Which of the following findings indicates that the client might be experiencing diabetic ketoacidosis? - Kussmaul respirations A nurse is reinforcing teaching with a client who has a permanent pacemaker in place. Which of the following statements by the client indicates an understanding of the teaching? - "I need to record my pulse rate daily." A nurse is caring for a client who is in mechanical restraints after becoming violent with a staff member. Which of the following actions should the nurse take? - Document in the clients medical record every 15 min. A nurse is reinforcing teaching about self-administration of nasal drops with a client. Which of the following positions should the nurse recommend for instillation of the drops? - Supine A nurse is preparing to administer furosemide to a client who has heart failure. Which ofthe following laboratory results should the nurse review prior to administering the medication? - Potassium A nurse is caring for a client who has methicillin-resistant staphylococcus aureus (MRSA) infection. Which of the following actions should the nurse plan to take? - Don agown and gloves when providing perineal care A nurse is assisting with the plan of care for a client who has dementia and often wanders in the halls at night. Which of the following interventions should the nurserecommend including in the plan of care? - Labeling the clients bathroom door A charge nurse is reinforcing teaching with a newly hired licensed practical nurse about scope of practice. Which of the following responsibilities should the nurse include in the teaching? - Providing direct client care A nurse is working on a mental health unit is meeting with a client who has been in theunit for 2 days. The nurse greets the client and asks, "What has been happening with you today?" Which of the following therapeutic techniques is the nurse using? - Reflecting A nurse us reinforcing teaching with a group of expectant parents regarding the properuse of a car seat. Which of the following statements by a parent indicates an understanding of the teaching? - "I will secure the seat belt across my newborns lap." A nurse from a medical surgical unit is floating to a postpartum unit. Which of the following clients is an appropriate assignment for the nurse to accept? - A client who underwent removal of a retained placenta A nurse is assisting with planning care for a newly admitted client who has anorexia nervosa. Which of the following interventions should the nurse recommend to include in the plan of care? - Reinforce teaching about healthy eating during meals A nurse is admitting a client who is scheduled for an elective surgery. Which of hefollowing actions should the nurse take to verify the status of the clients advance directives? - Ask the client whether they have advance directives A nurse is collecting data from a client who is receiving a continuous IV infusion of 0.9% sodium chloride. The nurse discovers the IV infusion pump was set incorrectly and the client received 200 ml more than prescribed. Data collection reveals that the client is stable. The nurse recognizes that this incident is not considered malpractice for which ofthe following reasons? - The client was not harmed as a result of the incident A nurse is caring for a client who has COPD. The nurse should identify that which of the following findings is the priority to report? - Productive cough with green sputum A nurse is caring for a newborn who just had a circumcision. Which of the following findings should the nurse identify as a nonverbal sign of pain? - The newborn continuesto cry despite efforts to console