59 yo male client is brought to the emergency room where he is assessed to have a Glasgow coma scale of 3. based on this assessment, how should the nurse
... [Show More] characterize the clients condition?
a. client has increase icp
b. he has a good prognosis for recovery
c. this client is conscious, but is not oriented to time and place
d. he is in a coma and has a very poor prognosis - Correct Answers ✅d. he is in a coma and has a very poor prognosis
at a community health fair, 50 yo female tells the nurse that she has an annual physical exam that includes a breast exam and an annual mammogram. how should the nurse respond?
a. encourage the woman to explore her fears about breast cancer
b. ask the woman if she performs monthly breast self exams
c. recommend the women for adhering to the recommend cancer detection guidelines
d. advise the woman that mammogram are only needed every two yrs of age - Correct Answers ✅b. ask the woman if she performs monthly breast self exams
which assessment finding should indicate to the nurse that client with arterial hypertension is expericing a cardiac complication?
a. complaints of occipaital headache
b. palpable dorsal is pedis pulse bilaterally
c. complaints of SOB on exertion
d. bp of 160/90 - Correct Answers ✅c. complaints of SOB on exertion
a college student who is diagnosed with vaginal infection and vulva irritation describes the vaginal discharge as having cottage cheese appearance. which prescription should the nurse implement first?
a. cleanse perineum with warm soapy water 3 times per day
b. instill the first dose of nystatin vaginally per applicator
c. perform glucose measurement using capillary blood sample
d. obtain a blood speciment for sexually transmitted disease - Correct Answers ✅b. instill the first dose of nystatin vaginally per applicator
a client in acute renal failure has serum potassium of 7.5. based on this finding, the nurse should anticapate implementing which action?
a. administer IV NS rapidly and NPH subq
b. administer a retention enema of kayexalate
c. add 40 KCL to present IV solution
d. administer lidocaine bolus IV push - Correct Answers ✅b. administer a retention enema of kayexalate
A client who had an intraosseous (IO) cannula placed by the healthcare provider for an emergent fluid resuscitation is complaining of severe pain and numbness below the IO site. The skin around the site is pale and edematous. What action should the nurse takes first?
a. Discontinue the IO infusion
b. Administer an analgesic via the IO site
c. Elevate the extremity with the IO site
d. Notify the healthcare provide - Correct Answers ✅a. Discontinue the IO infusion
The nurse-manager of a perinatal unit is notified that one client from the medical-surgical unit needs to be transferred to male room for new admissions. Which client should the nurse recommend for transfer to the antepartal unit?
a. A 45-year-old who has a chronic hepatitis B.
b. A 35-year-old with lupus erythematous
c. A 19-year-old who is diagnosed with rubella
d. A 25-year-old with herpes lesions of the vulva - Correct Answers ✅b. A
35-year-old with lupus erythematous
A nurse is teaching a client postoperative breathing techniques using an incentive spirometer (IS). What should the nurse encourage this client to do to maintain sustained maximal inspiration?
a. Breathe into the spirometer using normal breath volumes
b. Exhale forcefully into the tubing for 3 to 5 seconds
c. Inspire deeply and slowly over 3 to 5 seconds
d. Perform IS breathing exercises every 6 hours - Correct Answers ✅c.
Inspire deeply and slowly over 3 to 5 seconds
The nurse plans to educate a client about the purpose for taking the prescribed antipsychotic medication clozapine (Clozaril). Which statement should the nurse provide?
a. You will be able to cope with your symptoms
b. It will help you function better in the community
c. The medication will help you think more clearly - Correct Answers ✅c.
The medication will help you think more clearly
A male client with diabetes mellitus takes Novolin 70/30 insulin before meals and azithromycin (Zithromax) PO daily, using medication he brought from home.
When the nurse delivers his breakfast tray, the client tells the nurse that he took his insulin but forgot to take his daily dose of the Zithromax an hour before breakfast as instructed. What action should the nurse implement?
a. Offer to obtain a new breakfast tray in an hour so the client can take the
Zithromax
b. Instruct the client to eat his breakfast and take the Zithromax two hours after eating
c. Tell the client to skip that day's dose and resume taking the Zithromax the next day
d. Provide a PRN dose of an antacid to take with the Zithromax right afterbreakfast - Correct Answers ✅b. Instruct the client to eat his breakfast and take the Zithromax two hours after eating
What instruction is most important for the nurse to provide a female client who has just been diagnosed with trichomoniasis?
a. Avoid douching
b. Treat sexual partner (s) concurrently
c. Avoid using moist washcloths when bathing
d. Postpone becoming pregnant until the infection is treated - Correct
Answers ✅b. Treat sexual partner (s) concurrently
A primigravida at term comes to the prenatal clinic and tells the nurse that she is having contractions every 5 min. The nurse monitors the client for one hour, using an external fetal monitor, and determines that the client's contractions every 5 minutes. The nurse monitors the client for one hour, using an external fetal monitor, and determines that the client's contractions are 7 to 15 minutes apart, lasting 20 to 30 seconds, with mild intensity by palpation. What action should the nurse take?
a. Tell the client to go directly to the hospital for admission to labor and delivery for active labor
b. Send the client home and instruct her to call the clinic when her contractions occur
5 minutes apart for one hour
c. Tell the client to check into the hospital within the next hour for evaluation of possible urinary tract infection - Correct Answers ✅b. Send the client home and instruct her to call the clinic when her contractions occur
Which instruction should the nurse provide to an elderly client who is taking an ACE inhibitor and a calcium channel blocker?
a. Wear long-sleeved clothing when outdoors
b. Report the onset of sore throat
c. Eat plenty of potassium-rich food
d. Change the position slowly - Correct Answers ✅d. Change the position slowly
Assessment finding of a 3-hour-old newborn include: axillary temperature of 97.7F, heart rate of 140 beats/minute with a soft murmur, and irregular respiratory rate at 42 breaths/min. Based on these findings, what action should the nurse implement?
a. Place a pulse oximeter on the heel
b. Swaddle the infant in a warm blanket
c. Record the findings on the flow sheet
d. Check the vital signs in 15 minutes - Correct Answers ✅c. Record the findings on the flow sheet
A client admitted to the hospital for depression is escorted to a private room. Prior to leaving the room, what intervention is most important for the nurse to implement?
a. Explain the programs guidelines
b. Search all personal belongings
c. Initiate psychosocial assessment
d. Review the healthcare's provider's prescription - Correct Answers ✅b.
Search all personal belongings
An experienced nurse tells the nurse-manager that working with a new graduate is impossible because the new graduate will not listen to suggestions. The new graduate
comes to the nurse-manager describing the senior nurse's attitude as challenging and offensive. What action is best for the nurse manager to take?
a. Have both nurses meet separately with the staff mental healthconsultant
b. Listen actively to both nurses and offer suggestions to solving dilemma
c. Ask the senior nurse to examine mentoring strategies used with the newgraduate
d. Ask the nurses to meet with the nurse-manager to identify ways of working together - Correct Answers ✅d. Ask the nurses to meet with the nursemanager to identify ways of working together
Which nursing diagnosis has the highest priority when planning care for a client in cardiogenic shock?
a. Risk for imbalance body temperature
b. Excess fluid volume
c. Fatigue
d. Ineffective Tissue Perfusion - Correct Answers ✅d. Ineffective Tissue
Perfusion [Show Less]