2013ATIRNComprehensivePredictorFormB
Nursingintegration(MiamiRegionalUniversity)
A nurse is assessing a client who has
... [Show More] left-sided heart failure. Which of the following will the nurse identify as the highest priority?
Jugulardistention
Frothypink septum
Hepatomegaly
Weightgain
Anurseintheemergencydepartmentis assistingwiththesuturingofalacerationtothe client. Which of the following actions should the nurse take?
Pourthesterilecleansingsolution holdingonthe bottle10cm(4 in)abovethesterile
field
Pullthe top flap ofthe suturetraytowards thebodywhen opening
Placethebottleoflocalanesthetics 5cm(2 in)insidethesterilefieldborder.
Dropthesuturepackageonthesterilefieldfrom a distanceof30cm (12in)
Anurseisassessingaclient1hrfollowingdeliveryandnotesthat heruterusisboggyand located near the umbilicus. Which of the following actions should the nurse take fisrt?
Massagethefundus
Assesslochia
Takevitalsigns
Giveoxytocin(Pitocin)IVbolus
Anurseintheemergencydepartmentisassistingwiththesuturingofalacerationtothe client. Which of the following actions should the nurse take?
Pourthesterilecleansing solutionholdingonthe bottle10cm(4 in)abovethesterile
field
Pullthe top flap ofthesuturetraytowards thebodywhen opening
Placethebottleoflocalanesthetics 5cm(2 in)insidethesterilefieldborder.
Dropthesuturepackageonthesterilefieldfrom a distanceof30cm (12in)
A nurse is caring for a client who is 1 day postoperative following a hypophysectomy for removalofapituitarytumor.Whichofthefollowingfindingsrequiresfurtherassessmentbythe nurse?
Urinaryoutput greaterthanfluidintake
Report of drymouth
Glasgowcomascalescoreof15
Bloodydrainageonthenasaldressingsmeasuring3cm
Anurseinanemergencydepartmentiscaringforaclientwhohasmultiplewoundsdueto a motor-vehicle crash. Which of the following interventions are appropriate? (Select all that apply)
Applydirectpressuretobleedingwounds
Cleanlacerationsandabrasionswithhydrogenperoxide
Administer650mgaspirin POasneededfor pain
Coverthewoundwithsteriledressing
Determinedateoflasttetanustoxoid vaccination [Show Less]