A nurse in a pediatric unit is preparing to insert an I.V catheter for 7-year-old. Which of the following actions should the nurse take?
(Ans- B. Tell
... [Show More] the child they will feel discomfort during the catheter insertion.
A nurse is caring for a client who has arteriovenous fistula Which of the following findings should the nurse report?
(Ans- B. Absence of a bruit.
A nurse is providing discharge teaching for a client who has an implantable cardioverter defibrillator which of the following statements demonstrates understanding of the teaching?
(Ans- B. "I will wear loose clothing around my ICD"
A nurse is caring for a client who is at 14 weeks gestation and reports feelings of ambivalence about being pregnant. Which of the following responses should the nurse make?
(Ans- A. "Describe your feelings to me about being pregnant"
A nurse is planning care for a client who has a prescription for a bowel- training program following a spinal cord injury. Which of the following actions should the nurse include in the plan of care?
(Ans- D. Administer a rectal suppository 30 minutes prior to scheduled defecation times.
A nurse is caring for a client who is in active labor and requests pain management. Which of the following actions should the nurse take?
(Ans- B. Place the client in a warm shower.
A nurse in an emergency department is performing triage for multiple clients following a disaster in the community. To which of the following types of injuries should the nurse assign the highest priority?
(Ans- A. Below-the knee amputation (urgent)
A nurse manager is updating protocols for the use of belt restraints. Which of the following guidelines should the nurse include?
(Ans- B. Document the client's condition every 15 min
A nurse is teaching an in-service about nursing leadership. Which of the following information should the nurse include about an effective leader? (Ans- A. Acts as an advocate for the nursing unit.
A nurse is reviewing the laboratory findings of a client who has and reports that she has been following her care. The nurse should identify which of the following findings indicates a need to revise the client's plan of care.
(Ans- C. Hba1c 10 %
A nurse in a provider's office is reviewing the laboratory results of a group of clients. The nurse should identify that which of the following sexually transmitted infections is a nationally notifiable infectious disease that should be reported to the state health department?
(Ans- A. Chlamydia
A nurse is teaching a newly licensed nurse about therapeutic techniques to use when leading a group on a mental health unit. Which of the following group facilitation techniques should the nurse include in the teaching? (Ans- D. Use modeling to help the clients improve their interpersonal skills
A nurse is planning for a client who practices Orthodox Judaism. The client tells the nurse that its Passover holiday. Which of the following action should the nurse include in the plan of care?
(Ans- C. Provide unleavened bread.
A nurse is caring for a client who has a pulmonary embolism. The nurse should identify the effectiveness of the treatment:
(Ans- B. The client reports feeling less anxious.
A nurse in an emergency department is assessing a client who reports ingesting thirty diazepam tablets and has respiratory rate of 10/min. After securing the client's airway and initiating an I.V, which of the following actions should the nurse do next.
(Ans- B. Administer flumazenil to the client.
A nurse in an emergency department is caring for a client who reports cocaine use 1hr ago. Which of the following findings should the nurse expect?
(Ans- D. Elevated temperature
A nurse is assessing a newborn who has a blood glucose level of 30 mg/dl. Which of the following manifestations should the nurse expect?
(Ans- B. Jitteriness
A nurse in a pediatric clinic is reviewing the laboratory test results of a school age child. Which of the following findings should the nurse report to the provider?
(Ans- D. WBC 14,000/mm3 (elevated)
A charge nurse is teaching a newly licensed nurse about clients designating a health care proxy in situations that require a durable power of attorney for heal care (DPSHC). Which of the following information should the charge nurse include?
(Ans- C. "The proxy can make treatment decisions if the client is under anesthesia."
A nurse in the PACU is caring for a client who reports nausea. Which of the following actions should the nurse take first?
(Ans- A. Turn the client on their side.
A nurse is caring for a client who has a history of depression and is experiencing a situational crisis. Which of the following actions should the nurse take first?
(Ans- A. Confirm the client's perception of the event
A nurse is caring for a client who has bipolar disorder and is experiencing acute mania. The nurse obtained a verbal prescription for restraints. Which of the following actions should the nurse take?
(Ans- d. Document the client's condition every 15 minutes.
A nurse is caring for a client who has end-stage kidney disease. The client's adult child asks the nurse about becoming a living kidney donor for her father. Which of the following condition in the child's medical history should the nurse identify as a contraindication to the procedure?
(Ans- C. Hypertension
A charge nurse on a medical-surgical unit is planning assignments for a licensed practical nurse (LPN) who has been sent from the postpartum unit due to a staffing shortage for the shift. Which of the following client should the nurse delegate to the LPN?
(Ans- C. A client who is postoperative following a bowel resection with an NG tube set to
continuous suction.
A nurse is working on a surgical unit is developing a care plan for a client who has paraplegia. The client has an area of no blanchable erythema over his ischium. Which of the following interventions should the nurse include in the care plan?
(Ans- B. Teach the client to shift his weight every 15 min while sitting
A nurse is caring for a client who is dilated to 10 cm and pushing. Which of the following pain-management is a safe option for the client?
(Ans- G. Pudendal block.
A nurse is caring for a client who has left homonymous hemianopsia. Which of the following is an appropriate nursing intervention?
(Ans- b. Place the bedside table on the right side of the bed.
A nurse is assessing a client who has major depressive disorder. Which of the following findings should the nurse identify as the suicidal?
(Ans- D. The client reports giving away personal items.
A nurse is providing teaching about immunizations to a client who is pregnant. The nurse should inform the client that she can receive which of the following immunizations during pregnancy? (Select all that apply)
(Ans- C. Tetanus diphtheria and acellular pertussis vaccine
E. Inactivated influenza vaccine.
(NO live vaccines)
A nurse is providing discharge teaching for a group of clients. The nurse should recommend a referral to a dietitian
(Ans- B. A client who has gout and states, "I can continue to eat anchovies on my pizza." (These are high in uric acid) [Show Less]