A nurse in a long-term care facility is assisting with an in- service for newly hired assistive personnel about legal issues within the facility.
... [Show More] WhichofIthe following should the nurse include as an example ofIassault?
ANS: Informing a client the nurse is going to administer an injection even though the client refuses
.
A nurse is collecting data from who is severe pain. Which ofIthe following questions should the nurse ask first?
ANS: "Where is your pain located?"
A nurse is reviewing the laboratory results for a client who is at 29 weeks gestation. For which of the following results should the nurse notify the provider?
ANS: Platelet count 95,000 mm3
A nurse is performing a dressing change for a client who had abdominal surgery 5 day s ago. The nurse notes organs protruding from the incision. Which of the following act ions should the nurse take?
ANS: Cover the exposed area with sterile, saline-soaked dressings.
A nurse is speaking with the adult daughter ofIa client who has Alzheimer's disease. T he daughter states, "I love my dad, but
caring for him is wearing me out." Which of th e following response should the nurse make?
ANS: "Let's discuss how caring for your father is afollowingecting your health.
A nurse is contributing to the plan ofIcare for a care for a client who has chest tube co nnected to a closed drainage system. Which ofIthe following actions should the nurse i nclude in the plan of care?
ANS: Maintain the drainage system below the level ofIthe client's chest.
A nurse in an acute mental health facility is caring for a client who has borderline personality disorder and reports. "I am going to kill my girlfriend when I get out ofIhere." Which ofIthe following actions should the nurse take?
ANS: Notify the client's care team of the threats against the partner
A nurse is admitting a client who is at high risk for suicide. Which ofIthe following actions is the nurse's priority? ANS: Search the client's personal belongings
A nurse is caring for a client who is 1 day postoperative and is unable to ambulate. W hich ofIthe following actions should the nurse take to promote the client's venous return?
ANS: Maintain the sequential compression device.
A nurse on an acute care unity is collecting data from a school- age Child who has cystic fibrosis. Which ofIthe following
findings is the priority for the nurse?
ANS: Reports lack ofIappetite
a nurse working in a provider's ofollowingice receives a phone call from the parent ofIa school-
age child who has varicella. The parent asked the nurse when the child can return to school. Which ofIthe following responses should the nurse make?
ANS: "When the lesions have scabbed over."
A nurse in a pediatric clinic is collecting the data from a school- age child whose injuries are inconsistent with the parent's stated cause. Which ofIthe following actions should the nurse take? ANS: Report the suspected abuse to a appropriate agency.
A nurse is collecting data from a middle adult female client who is taking melatonin.Which ofIthe following responses to the med should the nurse expect?
ANS: Improved sleep
A nurse on a pediatric unit is collecting data from four newly admitted clients. Which ofIthe following clients should the nurse identify as being at risk for urinary retention? ANS: A school-
age child who has allergic rhinitis and is taking diphenhydramine.
A nurse is preparing to administer purified protein derivative (PPD) to a client who ha s suspected TB. Which ofIthe following actions should the nurse plan to take?
ANS: Ensure the injection produces a wheal on the skin
A client who is diagnosed with Parkinson's disease verbalizes frustration due to increas e difollowingiculty with ambulation. Which ofIthe following responses should the nurs e take?
ANS: Perform active ROM with your arms and legs two times a day.
a Nurse is collecting data from a client who has multiple fractures following a motor-vehicle crash. For which ofIthe following client statements
ANS: "I am so frustrated. I cannot even open my milk carton for breakfast."
A nurse is caring for a client who is 4 hr postoperative following a total thyroidectomy
. Which of the following manifestations should the nurse report to the provider as indicating possible hypocalcemia?
ANS: Tingling ofIfingers
A nurse is caring for a client who has a Penrose drain. To ensure proper placement an d functioning ofIthe drain, which ofIthe following should the nurse expect to observe? ANS: The safety pin is present at the distal end ofIthe drain.
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