A nurse is caring for a client who has bipolar disorder and is experiencing acute mania. The
nurse obtained a verbal prescription for restraints. Which
... [Show More] of the following should the actions
the nurse take? Correct Ans ➡ Document the client's condition every 15 minutes
A nursing planning care for a school-age child who is 4 hr postoperative following perforated
appendicitis. Which of the following actions should the nurse include in the plan of care?
Correct Ans ➡ Administer analgesics on a scheduled basis for the first 24 hr
A nurse is receiving change-of-shift report for a group of clients. Which of the following clients
should the nurse plan to assess first? Correct Ans ➡ A client who has a hip fracture and a
new onset of tachypnea
A nurse is preparing to apply a transdermal nicotine patch for a client. Which of the following
actions should the nurse take? Correct Ans ➡ Wear gloves to apply the patch to the client's
skin
A nurse has just received change-of-shift report for four clients. Which of the following clients
should the nurse assess first? Correct Ans ➡ A client who was just given a glass of orange
juice for a low blood glucose level
A nurse is caring for a client who is receiving intermittent enteral tube feedings. Which of the
following places the client at risk for aspiration? Correct Ans ➡ A history of
gastroesophageal reflux disease
A nurse is reviewing the laboratory results for a client who has Cushing's disease. The nurse
should expect the client to have an increase in which of the following laboratory values?
Correct Ans ➡ Serum glucose level- increased
A nurse is caring for a client who has severe preeclampsia and is receiving magnesium sulfate
intravenously. The nurse discontinues the magnesium sulfate after the client displaces toxicity.
Which of the following actions should the nurse take? Correct Ans ➡ Administer calcium
gluconate IV
Rationale: Calcium gluconate is given for magnesium sulfate toxicity. Always have an
injectable form of calcium gluconate available when administering magnesium sulfate by IV.
A charge nurse is teaching new staff members about factors that increase a client's risk to
become violent. Which of the following risk factors should the nurse include as the best
predictor of future violence? Correct Ans ➡ Previous violent behavior
Risk factors also include: past history of aggression, poor impulse control, and violence.
Comorbidity that leads to acts of violence (psychotic delusions, command hallucinations,
violent angry reactions with cognitive disorders).
A nurse is preparing to perform a sterile dressing change. Which of the following actions should
the nurse take when setting up the sterile field? Correct Ans ➡ Place the cap from the
solution sterile side up on clean surface
A nurse is providing teaching to an older adult client about methods to promote
nighttime sleep. Which of the following instructions should the nurse include?
Correct Ans ➡ Eat a light snack before bedtime
A home health nurse is preparing for an initial visit with an older adult client who lives
alone. Which of the following actions should the nurse take first? Correct Ans ➡ Identify
environmental hazards in the home
A nurse is assessing the remote memory of an older adult client who has mild dementia. Which
of the following questions should the nurse ask the client? Correct Ans ➡ "What high
school did you graduate from"
A nurse is providing teaching to an adolescent who has type 1 diabetes mellitus. Which of the
following goals should the nurse include in the teaching? Correct Ans ➡ HbA1c level less
than 7%
A nurse is caring for a client who is receiving phenytoin for management of grand mal seizures
and has a new prescription for isoniazid and rifampin. Which of the following should the nurse
conclude if the client develops ataxia and incoordination? Correct Ans ➡ The client is
showing evidence of phenytoin toxicity
A nurse is caring for a client who is 1 hr postoperative following rhinoplasty. Which of the
following manifestations requires immediate action by the nurse? Correct Ans ➡ Increase
in frequency of swallowing (may indicate bleeding)
A nurse is planning care for a preschool-age child who is in the acute phase Kawasaki disease.
Which of the following interventions should the nurse include in the plan of care? Correct
Ans ➡ Monitor the child's cardiac status
A nurse is planning an educational program for high school students about cigarette smoking.
Which of the following potential consequences of smoking is most likely to discourage
adolescents from using tobacco? Correct Ans ➡ Use of tobacco decreases the level of
athletic ability
A nurse is assessing a client who is prescribed spironolactone. Which of the following laboratory
values should the nurse monitor for this client? Correct Ans ➡ Serum potassium- diuretic
that retains potassium= hyperkalemic risk
A nurse has agreed to serve as an interpreter for an older adult client who is assigned to
another nurse. Which of the following statements by the nurse indicates an understanding of
this role? Correct Ans ➡ "I will let the client know that I am available as the interpreter."
A nurse is performing assessments on newborns in the nursery. Which of the following findings
should the nurse report to the provider? Correct Ans ➡ A two day old newborn who has a
respiratory rate of 70
(30 - 60 is normal)
A nurse on an acute unit has received change of shift report for 4 clients which of the following
clients should the nurse assess first? Pain pallor pulselessness paresthesia Correct Ans ➡ A
client who has fractured left tibia and pallor in the affected extremity
A nurse is providing discharge instructions to a client who has a new prescription for
haloperidol which of the following adverse effects should the nurse instruct the client to report
to the provider? Correct Ans ➡ Shuffling gait →A/E EPS: is an indication of parkinsonism
and should be reported
A nurse is planning discharge teaching about cord care for the parents of a newborn which of
the following instructions should the nurse plan to include in the teaching? Correct Ans ➡
Keep the cord stump dry until it falls off
Rationale: cord usually falls out within 7 to 10 days. Clean with soap and water. Cord is
expected to turn black and dry
A nurse is teaching dietary guidelines to a client who has celiac disease which of the following
food choices is appropriate for the client? Correct Ans ➡ Potato pancakes
A nurse is working in acute care mental health facility is assessing a client who has
schizophrenia. Which of the following findings should the nurse expect? Correct Ans ➡
Disorganized speech
A nurse is caring for a client who is immobile which of the following interventions is appropriate
to prevent contracture? Correct Ans ➡ Apply an orthotic to the clients foot
A public health nurse working in a rural area is developing a program to improve health for the
local population. Which of the following actions should the nurse plan to take? Correct Ans
➡ Provide anticipatory guidance classes to parents through public schools [Show Less]