4. A nurse is caring for a client who had an embolic stroke and has a prescription for alteplase. Which of
the following in the client’s history should
... [Show More] the nurse identify as a contraindication for receiving
alteplase?
A. Hip arthroplasty 1 week ago correct
B. Obstructive lungs disease
C. Retinal detachment
D. Acute kidney failure 6 months ago
15. A nurse is providing discharge teaching for a client who has a new implantable cardioverter
defibrillator (ICD). Which ofthe following clientstatements demonstrates understanding of the
teaching?
A. “I willsoak in the tub rather than showering.”
B. “I can hold my cellphone on the same side of my body as the ICD.”
C. “I will wear loose clothing over my ICD.”
D. “I will avoid using my microwave oven at home because of my ICD.”
16. A nurse is assessing a client who is postoperative following abdominal surgery and has an indwelling
urinary catheter that is draining dark yellow urine at 25ml/hr. Which of the following interventions
should the nurse anticipate?
A. Clamp the catheter tubing for 30 min
B. Initiate continuous bladder irrigation
C. Obtain a urine specimen for culture and sensitivity
D. Administer a fluid bolus
17. A nurse is caring for a client who has experienced a stillbirth. Which of the following actions should
the nurse take during the initial grieving process?
A. Avoid talking to the client about the newborn
B. Discourage the client from allowing friendsto see the newborn
C. Offer to take pictures of the newborn for the client
D. Assure the client that she can have additional children
18. A nurse is caring for a client who has a major burn injury. Which of the following actions is the
nurse’s priority to prevent wound infection?
A. Use sterile dressings for wound care
B. Apply topical antibiotics to the client’s wounds.
C. Place the client in protective isolation.
D. Maintain consistent hand washing by staff.
19. A nurse is speaking with the caregiver of a client who has Alzheimer’s disease. The caregiver states,
“Providing constant care is very stressful and is affecting all areas of my life.” Which of the following
actions should the nurse take?
A. Discuss methods of how to communicate with the client about problem solving behaviors.
B. Suggest that the caregiver seek a prescription for an antipsychotic medication for the client.
C. Assist the caregiver to arrange a daycare program for the client.
D. Recommend allowing the client to have time alone in their room throughout the day.
20. A nurse is caring for a client who is 1 hr postpartum and unable to urinate. Which of the following
actions should the nurse take?
A. Administer a benzodiazepine
B. Perform a fundal massage
C. Place an ice pack on the client’s perineum
D. Place the client’s hand in warm water
21. A nurse on a medical-surgical unit is performing medication reconciliation for a newly admitted
client. Which of the following actions should the nurse take?
A. Compare a list of common medications to treat a condition to the actual prescriptions
B. Compare the prescription to the allergy history of the client
C. Compare the medication label to the provider’s prescription on three occasions before
administration
D. Compare the client’slist of home medicationsto the admission prescriptions written for the
client.
22. A nurse is preparing to administer betamethasone to a client who is 25 weeks of gestation and has
preterm labor. Which of the following findings should the nurse identify as an adverse effect of this
medication?
A. Hyperglycemia
B. Uterine contractions
C. Proteinuria
D. Hypotension
23. A nurse is preparing to obtain a blood sample from a client who has a central venous catheter. Which
of the following actions should the nurse take? (SATA)
A. Apply a tourniquet above the catheter insertion site.
B. Access the catheter using a large bore needle.
C. Aspirate for blood return to access catheter patency.
D. Flush the catheter with 0.9% sodium chloride.
E. Apply force when resistance is met while flushing the catheter.
24. A nurse is preparing to perform a dressing change on a preschooler. Which of the following actions
should the nurse take to prepare the child for the procedure?
A. Explain in simple terms how the procedure will affect the child.
B. Ask the parents to wait outside the room during the procedure.
C. Limit teaching sessions about the procedure to 20 min.
D. Instruct the child in deep-breathing methods prior to the procedure.
25. A nurse is performing wound care for a client who has an abdominal incision. Which of the following
techniques should the nurse implement?
A. Irrigate the wound using a 10-mL syringe.
B. Cleanse the wound starting at the bottom and moving upward.
C. Cleanse the insertion site of the drain using a circular motion towardsthe center.
D. Irrigate the wound with a low-pressure flow of solution.
26. A nurse on an antepartum unit is prioritizing care for multiple clients. Which of the following clients
should the nurse see first?
A. A client who is at 36 weeks of gestation and has a biophysical profile score of 8.
B. A client who has preeclampsia and reports a persistent headache [Show Less]