A nurse is assessing a client who has required bed rest for the past month. Which of the
following findings should the nurse identify as an indication
... [Show More] that the client has developed
thrombophlebitis?
Bladder distention
Decreased blood pressure
Calf swelling
Diminished bowel sounds - CORRECT ANSWER Calf swelling
A nurse is administering an optic medication to an older adult client. Which of the following
actions should the nurse take to ensure that the medication reaches the inner ear?
Press gently on the tracks of the clients ear
Pack a small piece of cotton deep into the clients ear canal
Move the client's auricle down and back toward her head
Tilt the client's head backward for 5 min - CORRECT ANSWER Press gently on the tragus of
the clients ear
A nurse on a medical-surgical unit is caring for a client who has a new prescription for wrist
restraints. Which of the following actions should the nurse take?
Pad the client's wrist before applying the restraints
Evaluate the client's circulation every 8 hr after application
Remove the restraints every 4 hr to evaluate the client's status
Secure the restraints to the bed's side rails - CORRECT ANSWER Pad the client's wrists before
applying the restraints
A nurse is admitting a new client. Which of the following actions should the nurse take while
performing medication reconciliation?
Verify the client's name on their identification bracelet with the medication administration record
Call the pharmacy to determine whether the client's medications are available
Compare the clients home medications with the provider's prescriptions
Place the client's home medication bottles in a secure location - CORRECT ANSWER Compare
the client's home medications with the provider's prescriptions
The nurse is preparing to administer 0.9% sodium chloride 750 mL IV to infuse over 7 hr. The
nurse should set the infusion pump to deliver how many mL/hr? (Round to the nearest whole
number. Use a leading zero if it applies. Do not use a trailing zero.) - CORRECT ANSWER 107
mL/hr
A nurse is planning care for a client who has had a stroke, resulting in aphasia and dysphagia.
Which of the following tasks should the nurse assign to an assistive personnel (AP)? (Select all
that apply.)
Assist the client with a partial bed bath
Measure the client's BP after the nurse administers antihypertensive medication.
Test the client's swallowing ability by providing thickened liquids
Use a communications board to ask what the client wants for lunch
Irrigate the client's indwelling catheter - CORRECT ANSWER Assist the client with a partial
bed bath
Measure the client's BP after the nurse administers antihypertensive medication.
Use a communications board to ask what the client wants for lunch
A nurse is using an open irrigation technique to irrigate a client's indwelling urinary catheter.
Which of the following actions should the nurse take?
Place the client in a side-lying position
Instill 15 mL of irrigation fluid into the catheter with each flush
Subtract the amount of irritant used from the clients urine output [Show Less]