A nurse is caring for a client who had abdominal surgery 24 hours ago. Which of
the following actions is the priority?
A. Assess fluid intake every 24
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B. Ambulate three times a day
C. Assist with deep breathing and coughing
D. Monitor the incision site for findings of infection - C
A nurse is talking with a client who has stage IV breast cancer. The nurse should
recognize which of the following statements by the client as a constructive use of a
defense mechanism?
A. I have experienced physical discomfort when intimate with my partner since my
diagnosis
B. I wish other women would stop socializing with my partner
C. I told my doctor that I would like to start a support group for other women who
are sick in my community
D. I used to mistrust my doctor, but now I know that she is the best one to care for
me during my illness - C
A nurse is caring for a client who has immunosuppression and a continuous IV
infusion. Which of the following actions should the nurse take?
A. Assess the clients IV site every 8 hours
B. Check the clients WBC count every 48 hours
C. Monitor the clients mouth every 8 hours
D. Change the clients IV tubing every 48 hours - C
A nurse is caring for a 2-month-old infant who has Hirschsprung disease (HD).
Which of the following areas should the nurse assess for manifestations of HD?
A. Eyes area
B. Chest area
C. Lower abdominal area - C
A nurse at a mental health clinic is caring for four clients. The nurse should
recognize that which of the following clients is using dissociation as a defense
mechanism?
A. A client forgets to buy their partner a birthday gift after a disagreementB. A client who was abused as a child describes the abuse as if it happened to
someone else.
C. A client who is shorter than average is verbally assertive with coworkers
D. A client states that they did not get a job promotion because the boss did not
like them - B
A nurse is providing teaching to a client who has a new diagnosis of type 1
diabetes mellitus. The nurse should instruct the client to monitor for which of the
following findings as a manifestation of hypoglycemia?
A. irritability
B. increased urination
C. vomiting
D. facial flushing - A
A nurse in an outpatient mental health clinic is caring for four clients. The nurse
should recognize that which of the following clients is effectively using
sublimation as a defense mechanism?
A. A client who transfers their anger about their job onto their family and then
apologizes
B. A client who misses provider appointments because they say they are too busy
C. A client who channels their energy into a new hobby following the loss of their
job
D. A client whose partner died 4 years ago sets a place for him at dinner each night
- C
A hospice nurse is consulting with a client and her family about receiving home
services. Which of the following statements should the nurse identify as an
indication that the family understands home hospice care?
A. "We can expect the hospice nurse to provide support for us after our mother's
death."
B. A hospice nurse will come to the house each time our mother needs pain
medication
C. Now that my mother is receiving hospice services, we will not be able to get
respite care
D. Hospice care focuses on arranging treatment that will prolong our mother's life -
A
A nurse is caring for a client who has active pulmonary tuberculosis. Which of the
following actions should the nurse take?
A. Wear a surgical mask when providing client careB. Have visitors maintain a distance of 1.8m (6 feet) from the client
C. Restrict fresh flowers from the clients room
D. Assign the client to a private room with negative air pressure - D
A nurse is providing teaching to a client who is at 24 weeks of gestation and is
scheduled for a 3-hr oral glucose tolerance test. Which of the following
instructions should the nurse include in the teaching?
A. Limit your fat intake for 72 hours before the test
B. You will need to fast the night before the test
C. We will collect a urine sample the day after testing
D. A blood sample will be collected every 15 minutes during the test - B
A nurse on a pediatric unit has received change-of-shift report for four children.
Which of the following children should the nurse assess first?
A. A 6month old infant who has croup and an O2 saturation of 92% on room air
B. A 15 year old adolescent who is 2 hour postop following an open reduction and
internal fixation of the left ankle and is requesting pain medication
C. A 3 year old toddler who has gastroenteritis, moderate dehydration, and had 2
loose bowel movements over the past 24 hours
D. A 10-year-old child who is awaiting surgery for an appendectomy and
experienced sudden relief from pain. - D
A nurse in a community center is providing an educational session to a group of
clients about ovarian cancer. Which of the following manifestations of ovarian
cancer should the nurse include in the teaching?
A. Diarrhea
B. Urinary retention
C. Purulent discharge
D. Abdominal bloating - D
A nurse is caring for a client who is postoperative after receiving moderate
(conscious) sedation. The client suddenly becomes restless and reports feeling
lightheaded. Which of the following actions should the nurse take?
A. Check the clients temperature
B. Prepare to administer acetylcysteine to the client
C. Place the client in the Trendelenburg position
D. Check the client's oxygen saturation level - D [Show Less]