A nurse is assisting with the care of a client who has a femur fracture and is in skeletal traction. Which of the following actions should the nurse
... [Show More] take?
1) Loosen the knots on the ropes if the client is experiencing pain. 2) Ensure the client’s weights are hanging freely from the bed.
3) Check the client’s bony prominences every 12 hr.
4) Cleanse the client’s pin sites with povidone-iodine.
A nurse in a provider’s of ce is reinforcing teaching with a client who has anemia and has been taking ferrous gluconate for several weeks. Which of the following instructions should the nurse include?
1) Take this medication between meals.
2) Limit intake of Vitamin C while taking this medication.
3) Take this medication with milk.
4) Limit intake of whole grains while taking this medication.
A nurse in a provider’s of ce is reinforcing teaching with a client who has anemia and has been taking ferrous gluconate for several weeks. Which of the following instructions should the nurse include?
1) Take this medication between meals.
2) Limit intake of Vitamin C while taking this medication.
3) Take this medication with milk.
4) Limit intake of whole grains while taking this medication.
A nurse is reviewing the plan of care for a client who has cellulitis of the leg. Which of the following interventions should the nurse recommend?
1) Apply topical antifungal agents.
2) Apply fresh ice packs every 4 hr.
3) Wash daily with an antibacterial soap.
4) Keep draining lesions uncovered to air dry.
A nurse is reinforcing teaching with a client who is postoperative after having an ileostomy established. Which of the following instructions should the nurse include in the teaching?
1) Empty the pouch immediately after meals.
2) Change the entire appliance once a day.
3) Limit f uid intake.
4) Avoid medications in capsule or enteric form.
A nurse is caring for a client with severe burns to both lower extremities. The client is scheduled for an escharotomy and wants to know what the procedure involves. Which of the following statements is appropriate for the nurse to make?
1) "An escharotomy surgically removes dead tissue."
2) "A cannula will be inserted into the bone to infuse f uids and antibiotics."
3) "A piece of skin will be removed and grafted over the burned area."
4) "Large incisions will be made in the burned tissue to improve circulation."
A nurse is collecting data from a client who has a possible cataract. Which of the following manifestations should the nurse expect the client to report?
1) Notify the provider.
Answer Rationale:
The nurse should check for kinks and take other measures before notifying the provider.
2) Verify that the suction regulator is on.
3) Continue to monitor the client because this is an expected f nding.
4) Milk the chest tube to dislodge any clots in the tubing that may be occluding it.
A nurse is assisting with the care of a client immediately following a lumbar puncture. Which of the following actions should the nurse take? (Select all that apply.)
1) Encourage f uid intake.
2) Monitor the puncture site for hematoma.
3) Insert a urinary catheter.
4) Elevate the client’s head of bed.
5) Apply a cervical collar to the client.
A nurse is assisting with the care of a client who is postoperative following surgical repair of a fractured mandible. The client’s jaw is wired shut to repair and stabilize the fracture. The nurse should recognize which of the following is the priority action?
1) Relieve the client's pain.
2) Check the client’s pressure points for redness.
3) Provide oral hygiene.
4) Prevent aspiration.
A nurse is collecting data from a client who has scleroderma. Which of the following f ndings should the nurse expect?
1) A dry raised rash
2) Excessive salivation
3) Periorbital edema
4) Hardened skin
A nurse is caring for an older adult client who has dysphagia and left-sided weakness following a stroke. Which of the following actions should the nurse take?
1) Instruct the client to tilt her head back when she swallows.
2) Place food on the left side of the client's mouth.
3) Add thickener to f uids.
4) Serve food at room temperature.
A nurse is caring for a client who has partial-thickness and full-thickness burns of his head, neck, and chest. The nurse should recognize which of the following is the priority risk to the client?
1) Airway obstruction
2) Infection
3) Fluid imbalance
4) Contractures
A nurse is reinforcing teaching with a client who is newly diagnosed with myasthenia gravis and is to start taking neostigmine. Which of the following instructions should the nurse include in the teaching?
1) Take the medication 45 minutes before eating.
2) Expect diaphoresis as a side ef ect of the neostigmine.
3) If a medication dose is missed, wait until the next scheduled dose to take the medication.
4) Treat nasal rhinitis with an over-the-counter antihistamine.
A nurse is caring for a client who is 12 hours postoperative following a transurethral resection of the prostate (TURP) and has a 3-way urinary catheter with continuous irrigation. The nurse notes there has
not been any urinary output in the last hour. Which of the following actions should the nurse perform f rst?
1) Notify the provider.
2) Administer a prescribed analgesic.
3) Of er oral f uids.
4) Determine the patency of the tubing.
A nurse is caring for a client scheduled for a bone marrow biopsy. The client expresses fear about the procedure and asks the nurse if the biopsy will hurt. Which of the following responses should the nurse make?
1) "You must be very worried about what the biopsy will show."
2) "You'll be asleep for the whole biopsy procedure and won't be aware of what’s happening."
3) "Your provider scheduled this, so she will want to know you still have questions about the procedure."
4) "The biopsy can be uncomfortable, but we will try to keep you as comfortable as possible."
A nurse is assisting with planning care for a client who is recovering from a left-hemispheric stroke. Which of the following interventions should the nurse include in the plan?
1) Control impulsive behavior.
2) Compensate for left visual f eld def cits.
3) Re-establish communication.
4) Improve left-side motor function. [Show Less]