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 - 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 - 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 - 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 - 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.) - 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 - 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
Perform the irrigation using a 20 mL syringe - Subtract the amount of irritant used from the client's urine output
A home health nurse is performing a follow-up visit for a client who has a gastrostomy tube through which they receive intermittent feedings & medications. The client has recently developed diarrhea. Which of the following findings should the nurse identify as a possible cause of the diarrhea?
The client is receiving normal formula at room temperature
The feedings infuse at a slow, continuous drip over 8 hr each night.
The client's caregiver washes of the feeding bag with warm water once every 24 hr
The client's caregiver flush's the tubing before and after administering medications. - The client's caregiver washes of the feeding bag with warm water once every 24 hr
A nurse is initiating a protective environment for a client who has had an allogeneic stem cell transplant. Which of the following precautions should the nurse plan for this client?
Make sure the client's room has at least six air exchanges per hour.
Make sure the client wears a mask when outside her room if there's construction in the area.
Place the client in a private room with negatives-pressure airflow.
Wear an N95 respirator when giving client direct care. - Make sure the client wears a mask when outside her room if there's construction in the area.
A nurse is caring for a client who is postoperative and is exhibiting signs of hemorrhagic shock. the nurse notifies the surgeon, who tells the nurse to continue to measure the client's vital signs every 15 min & to report back in 1 hr. Which of the following actions should the nurse take next?
Document the providers statement in the medical record
Complete an incident report
Consult the facility's risk manager
Notify the nursing manager - Notify the nursing manager
A nurse is planning to insert a peripheral IV catheter for an older adult client. Which of the following actions should the nurse plan to take?
Insert the catheter at a 45 degree angle
Place the client's arm in a dependent position
Shave excess hair from the insertion site
Initiate IV therapy in the veins of the hand - Place the client's arm in a dependent position
A nurse is caring for a client who has dementia. Which of the following interventions should the nurse take to minimize the risk of injury to the client?
Use a bed exit alarm system
Raise four side rails while the client is in bed
Apply soft wrist restraint
Dim the lights in the client's room - Use a bed exit alarm system
A nurse is talking with the partner of a client who has dementia. The client's partner expresses frustration about finding time to manage household responsibilities while caring for their partner. The nurse should identify that the partner is experiencing which of the following types of role-performance stress?
Role ambiguity
Sick role
Role overload
Role conflict - Role overload
A nurse is caring for a client who has a terminal illness & is at the end of life. The nurse should recognize that which of the following statements by the client's partner indicates effective coping?
"I am not worries because I still have hope that he will be okay."
"I am relying on support from our family during this time."
"We can plan our family reunion once he recovers & comes home."
"We don't see any reason to start discussing funeral arrangements right now." - "I am relying on support from our family during this time."
A nurse is administering 1 L of 0.9% sodium chloride to a client who is postoperative and has fluid volume deficit. Which of the following changes should the nurse identify as an indication that the treatment was successful?
Increase hematocrit
Increase respiratory rate
Decrease heart rate
Decrease in capillary refill time - Decrease heart rate
A nurse is planning strategies to manage time effectively for client care. Which of the following strategies should the nurse implement?
Combine client care tasks when caring for multiple clients
Wait until the end of the shift to document client care
Use the planning step of the nursing process to prioritize client care delivery
Allow for interruptions in tasks to discuss client care issues with colleagues - Use the planning step of the nursing process to prioritize client care delivery
A nurse is providing discharge instructions to a client who will be using a walker. Which of the following client statements indicates an understanding of the teaching?
"I can place an extension cord across my living room to plug in my television."
"I will hire someone to trim the tree that hangs low over the stairs of my front porch."
"I will place my alarm clock on my bedroom dresser across the room."
"I will replace the old throw rug in my kitchen with a new one." - "I will hire someone to trim the tree that hangs low over the stairs of my front porch."
A nurse is assessing four adult clients. Which of the following physical assessment techniques should the nurse use?
Use the Face, Legs, Activity, Cry, & Consolability (FLACC) pain rating scale for a client who is experiencing pain.
Ensure the bladder of the blood pressure cuff surrounds 80% of the client's arm.
Obtain an apical heart rate by auscultating the third intercostal space left of the sternum.
Palpate the client's abdomen before auscultating bowel sounds. - Ensure the bladder of the blood pressure cuff surrounds 80% of the client's arm.
A nurse is admitting a client who is having an exacerbation of heart failure. In planning this client's care, when should the nurse initiate discharge planning?
During the admission process
As soon as the client's condition is stable
During the initial team conference
After consulting with the client's family - During the admission process
A nurse is caring for a client who has pharyngeal diphtheria. Which of the following types of transmission precautions should the nurse initiate? [Show Less]