An AP and a nurse are turning a client onto the right side. Which of the following actions by the AP requires the nurse to intervene?
place a pillow
... [Show More] under the client's right arm
- should be under left arm
A nurse is assessing a client who has Raynaud's disease. Which of the following findings should the nurse expect?
blanching of the fingers and toes
A nurse is providing teaching about improving nutrition for a client who has MS. Which of the following instructions should the nurse include? (Select all that apply)
- speech pathologist will be performing a swallowing study for you
- you should rest before eating a meal
- thicken your beverages before drinking
A nurse is caring for an older adult client. Which of the following findings should the nurse recognize as a physiological change associated with aging?
- decreased lung expansion
A nurse is caring for a client who is immediately postoperative following a total vaginal hysterectomy. Which of the following actions should the nurse take first?
measure the client's VS
A nurse is assessing a client who has delirium. Which of the following manifestations should the nurse expect?
rapid speech
A nurse is caring for a client who states, "My boss accused me of stealing yesterday. I was so angry I went to the gym and worked out." The nurse should recognize the client is demonstrating which of the following defense mechanisms?
sublimation
- sub socially unacceptable for acceptable
A nurse is performing an intermittent cath for a client who has urinary retention. Which of the following images indicates the catheter the nurse should use?
straight cath
A client who is 24 hr postoperative following abdominal surgery refuses to ambulate. Which of the following actions should the nurse take first?
ask the client to rate their pain level
A nurse is teaching the parents of a preschooler about sleep promotion. The parents report that their child is demonstrating reluctance in going to bed at night and states, "I am not tired." Which of the following statements by the parents indicates and understanding of the teaching?
we should read a story together every night before bedtime
A nurse is assessing a 2 mo old during a well-baby exam. Which of the following actions should the nurse take to assess the infant's rooting reflex?
stroke the infant's cheek
A nurse is providing discharge teaching to a client following a cataract extraction. Which of the following statements by the client indicates an understanding of the teaching?
i will bend at my knees when picking an object up off the floor
A nurse is caring for a group of clients. For which of the following events should the nurse complete an incident report?
IV pump delivers inadequate dose of med
A nurse is teaching a client who is to start taking misoprostol and currently is on long-term therapy with NSAIDs for arthritis. The nurse should provide the client with which of the following information?
complete a serum pregnancy test before taking the med
A nurse is caring for a client who is at 28 weeks of gestation. The client asks the nurse to explain what causes her to have constipation. Which of the following responses should the nurse make?
the enlarged uterus compresses the intestines and causes constipation
A nurse is caring for a client who has a fractured femur and has had a fiberglass leg cylinder cast for 24 hr. Which of the following assessment findings should the nurse identify as the priority?
the client's heel is reddened and tender
- pressure injury
A nurse is in an acute mental health facility is planning care for a client who has anorexia nervosa. Which of the following interventions should the nurse include in the client's plan of care?
supervision the client during and after eating
A nurse is teaching a client about foods high in vitamin A. Which of the following foods should the nurse recommend as having the highest amount of vitamin A?
1 medium raw carrot
A nurse is teaching a newly admitted client who has heart failure about advance directives. Which of the following statements should the nurse make?
you should complete advance directives in the event you cannot express your own wishes
A nurse is assessing a client who has been taking lithium carbonate for the past month to treat bipolar disorders. Which of the following assessment findings should the nurse identify as the priority?
confusion
A case manager is reviewing the medical records of several clients. For which of the following clients should the nurse request an interprofessional care conference?
a client who has diabetes mellitus and has had repeated hospitalization for DKA
A community health nurse is assisting with the development of disaster management plan. The nurse should include which of the following nursing responsibilities in the disaster response stage of the plan?
performing a rapid needs assessment
A nurse is teaching a client who has a new prescription for estradiol. For which of the following adverse effects of this medication should the nurse instruct the client to monitor and report to the provider?
headaches
A charge nurse is observing a newly licensed nurse performing a physical assessment on a client. Which of the following actions by the nurse indicates that the charge nurse should intervene?
the newly licensed nurse writes detailed notes while performing the head-to-toe
A nurse is assessing a client who has macular degeneration. Which of the following findings should the nurse expect?
decreased central vision
A nurse is providing colostomy care for a client using a two-piece pouching system. Which of the following actions should the nurse take?
place the skin barrier over the stoma and hold for 30 sec
An Rn is planning care for a group of clients and is working with a licensed practice nurse and an AP. Which of the following tasks should the RN delegate to the LPN?
insertion of a nasogastric tube
A nurse is preparing a sterile field in order to insert an indwelling urinary cath for a male. Which of the following techniques should the nurse use to maintain surgical aseptic technique.
set the cath tray on the overbed table at waist height
A nurse is providing dietary teaching to the parents of a 6 mo old. Which of the following instructions should the nurse include?
introduce new foods one at a time over 5 to 7 days
A nurse is planning care for a client who is receiving heparin to treat a deep-vein thrombosis of the left lower leg. Which of the following interventions should the nurse include in the plan of care?
elevate the affected leg
A nurse is teaching about TPN and IV lipid emulsions with a client who has an extensive burn injury. Which of the following information should the nurse include?
you will receive finger sticks for blood glucose testing [Show Less]