1. a nurse is assessing the pain level of a client who has dementia and difficulty communicating, which pain assessment technique should the nurse
... [Show More] use?
behavioral indicators, (increased agitation, restlessness)
2. a nurse receives a report from an assistive personnel that a client's BP is 160/95, what should the nurse do first?
recheck the clients BP, (reassess prior to any intervention)
3. a nurse is caring for a client who has an indwelling urinary cath, what should the nurse identify as a cath occlusion?
bladder distention, (inability to empty the bladder, impaired elimination)
4. a nurse is discussing immunity with a client who has received an immunization, the nurse should identify that an immunization functions as part of which of the following types of immunity?
acquired immunity, (artificial/acquired immunity occurs when antigens from toxoids or immunizations are ADMINISTERED to a client, once in the body, the stimulate the production of antibodies)
5. a nurse is reviewing the health history of an OA who has a hip fracture the nurse should identify what is a risk of developing pressure injuries?
urinary incontinence, (r/f skin breakdown--> pressure injury, poor nutrition, infection, poor tissue perfusion, friction and shear, immobility, alterations in sensory perception)
6. a nurse is assessing the IV infusion site of a client who reports pain at the site. the site is red and there is warmth along the coarse of the vein, what should the nurse do?
d/c the infusion, (assessment suggest phlebitis, d/c, apply warm compress//if continued therapy required, start new IV)
7. a nurse is caring for an OA who has a nonpalpable skin lesion that is less than 0.5cm (0.2in) in diameter. which of the following terms should the nurse use to document this finding?
Macule, (nonpalpable smaller than 1cm, ex: freckle)
8. a community health nurse is teaching a group of clients about first aid for different types of wounds. which of the following clieont statements indicates an understanding of the teaching?
I should apply clean dressings over the top of blood saturated dressings and hold pressure, (to prevent disruption of wound tissue)
9.a nurse is sitting with the partner of a client who recently died. which of the following actions should the nurse take to facilitate mourning?
encourage the partner to ask for help when needed [Show Less]