1. A nurse is planning care for a client who has a prescription for a boweltraining program following a spinal cord injury. Which of the following
... [Show More] actions
should the nurse include in the plan of care?
A. Encourage a maximum Huid intake of 1,500 ml per day.
B. Increase the amount of reNned grains in the client’s diet.
C. Provide the client with a cold drink prior to defecation.
D. Administer a rectal suppository 30 minutes prior to scheduled
defecation times.
2. A nurse in a pediatric unit is preparing to insert an IV catheter for 7-yearold. Which of the following actions should the nurse take?
A. (Unable to read)
B. Tell the child they will feel discomfort during the catheter insertion.
C. Use a mummy restraint to hold the child during the catheter insertion.
D. Require the parents to leave the room during the procedure.
3. A nurse is caring for a client who has arteriovenous Nstula Which of the
following Nndings should the nurse report?
A. Thrill upon palpation.
B. Absence of a bruit.
C. Distended blood vessels
D. Swishing sound upon auscultation.
4. A nurse is providing discharge teaching for a client who has an
implantable cardioverter deNbrillator which of the following statements
demonstrates understanding of the teaching?
A. “I will soak in the tub rather and showering”
B. “I will wear loose clothing around my ICD”
C. “I will stop using my microwave oven at home because of my ICD”
D. “I can hold my cellphone on the same side of my body as the ICD”
5. A nurse is caring for a client who is at 14 weeks gestation and reports
feelings of ambivalence about being pregnant. Which of the following
responses should the nurse make?
A. “Describe your feelings to me about being pregnant”
B. “You should discuss your feelings about being pregnant with your
provider”
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C. “Have you discussed these feelings with your partner?”
D. “When did you start having these feelings?”
6. A nurse is caring for a client who is in active labor and requests pain
management. Which of the following actions should the nurse take?
A. Administer ondansetron.
B. Place the client in a warm shower.
C. Apply fundal pressure during contractions.
D. Assist the client to a supine position.
7. a nurse in an emergency department is performing triage for multiple
clients following a disaster in the community. To which of the following types
of injuries should the nurse assign the highest priority?
A. Below-the knee amputation
B. Fractured tibia
C. 95% full-thickness body burn
D. 10cm (4in) laceration to the forearm
8. A nurse is planning for a client who practices Orthodox Judaism. The client
tells the nurse that (Unable to read) Passover holiday. Which of the following
action should the nurse include in the plan of care?
A. Provide chicken with cream sauce.
B. Avoid serving Nsh with Nns and scales.
C. Provide unleavened bread.
D. Avoid serving foods containing lamb.
9. A nurse is caring for a client who has a pulmonary embolism. The nurse
should identify the edectiveness of the treatment
A. A chest x-ray reveals increased density in all Nelds.
B. The client reports feeling less anxious.
C. Diminished breath sounds are auscultated bilaterally
D. ABG results include Ph 7.48 PaO2 77 mm Hg and PaCO2 47 mm Hg.
10. A nurse in an emergency department is assessing a client who reports
ingesting thirty diazepam tablets (Unable to read) a respiratory rate of
10/min. After securing the client’s airway and initiating an IV, which of the
following actions should the nurse do next.
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A. Monitor the client’s IV site for thrombophlebitis.
B. Administer Humazenil to the client.
C. Evaluate the client for further suicidal behavior.
D. Initiate seizure precautions for the client.
11. a nurse manager is updating protocols for the use of belt restraints.
Which of the following guidelines should the nurse include?
A. Remove the client’s restraint every 4hr
B. Document the client’s condition every 15 min
C. Attach the restrain to the bed’s side rails
D. Request a PRN restrain prescription for clients who are aggressive [Show Less]