Which assessment finding of a postmenopausal woman necessitates a referral by the nurse to the
healthcare provider for evaluation of thyroid
... [Show More] functioning? (ANS- Cold sensitivity
A client with hyperthyroidism is admitted to the postoperative after subtotal thyroidectomy. Which of the
client's serum laboratory values requires intervention by the nurse? (ANS- Total calcium 5.0 mg/dl
A female client on the mental health unit frequently asks the nurse when she can be discharged. Then,
becoming more anxious, she begins to pace the hallway. What intervention should the nurse implement
first? (ANS- Explore the client's reasons for wanting to be discharged.
The nurse is assessing a primigravida a 39-weeks gestation during a weekly prenatal visit. Which
finding is most important for the nurse to report to the healthcare provider? (ANS- Fetal heart
rate of 200 beats/minute
A female client receives a prescription for alendronate sodium (Fosamax) to treat her newly diagnose
osteoporosis. What instruction should the nurse include in the client's teaching plan? (ANS- Take on an
empty stomach with a full glass of water
The nurse is assessing a female client's blood pressure because she reported feeling dizzy. The blood
pressure cuff is inflated to 140 mm hg and as soon as the cuff is deflated a korotkoff sound is heard.
Which intervention should the nurse implement next? (ANS- Wait 1 minute and palpate the systolic
pressure before auscultating again.
After administering a proton pump inhibitor (PPI), which action should the nurse take to evaluate the
effectiveness of the medication? (ANS- Ask the client about gastrointestinal pain
To reduce staff nurse role ambiguity, which strategy should the nurse-manager implement? (ANS-
Review the staff nurse job description to ensure that it is clear, accurate, and current
A client with pneumonia has arterial blood gases levels at: PH 7.33; PaCO2 49 mm/hg; HCO3 25 mEq/L;
PaO2 95. What intervention should the nurse implement based on these results? (ANS- Institute coughing
and deep breathing protocols
The healthcare provider explains through an interpreter the risks and benefits of a scheduled surgical
procedure to a non-English speaking female client. The client gives verbal consent and the healthcare
provider leaves, instructing the nurse to witness the signature on the consent form. The client and the
interpreter then speak together in the foreign language for an additional 2 minutes until the interpreter
concludes, "She says it is OK." What action should the nurse take next? (ANS- Ask for a full explanation
from the interpreter of the witnessed discussion
While assisting a male client who has muscular dystrophy (MD) to the bathroom, the nurse observes that
he is awkward and clumsy. When he expresses his frustration and complains of hip discomfort, which
intervention should the nurse implement? (ANS- Place a portable toilet next to the bed
A client with hyperthyroidism who has not been responsive to medications is admitted for evaluation. What
action should the nurse implement? (Click on each chart tab for additional information. Please scroll to the
bottom right corner of each tab to view all information contained in the client's medical record.) (ANS-
Notify the healthcare provider
While taking vital signs, a critically ill male client grabs the nurse's hand and ask the nurse not to leave.
What action is best for the nurse to take? (ANS- Pull up a chair and sit beside the client's bed
The practical nurse (PN) is assigned to work with three registered nurses (RN) who are caring for
neurologically compromised clients. The client with which change in status is best to assign to the PN?
(ANS-Viral meningitis whose temperature changed from 101 F to 102 F.
An IV antibiotic is prescribed for a client with a postoperative infection. The medication is to be
administered in 4 divided doses. What schedule is best for administering this prescription? (ANS- 1000,
1600, 2200, 0400
A male client notifies the nurse that he feels short of breath and has chest pressure radiating down his
left arm. A STAT 12-lead electrocardiogram (ECG) is obtained and shows ST segment elevation in leads II,
II, aVF and V4R. The nurse collects blood samples and gives a normal saline bolus. What action is most
important for the nurse to implement? (ANS- Asses for contraindications for thrombolytic therapy
A client with Addison's crisis is admitted for treatment with adrenal cortical supplementation. Based on
the client's admitting diagnosis, which findings require immediate action by the nurse? (Select all that
apply) (ANS- Headache and tremors Postural hypotension Pallor and diaphoresis Irregular heart beat
Which actions should the nurse implement with auscultating anterior breath sounds? (Place the
first action on top and last action on the bottom.) (ANS- 1. Place stethoscope in suprasternal area
to auscultate from bronchial sounds
2. Auscultate bronchovesicular sounds from side to side of the first and second intercostal spaces
3. Displace female breast tissue and apply stethoscope directly on chest wall to hear vesicular
sounds
4. Document normal breath sounds and location of adventitious breath sounds
The nurse is preparing a community education program on osteoporosis. Which instruction is helpful
in preventing bone loss and promoting bone formation? (ANS- Recommend weigh bearing physical
activity
The husband of an older woman, diagnosed with pernicious anemia, calls the clinic to report that his wife
still has memory loss and some confusion since she received the first dose of nasal cyanocobalamin two
days ago. He tells the nurse that he is worried that she might be getting Alzheimer's disease. What action
should the nurse take? (ANS- Explain that memory loss and confusion are common with vitamin B12
deficiency
A female client who is admitted to the mental health unit for opiate dependency is receiving clonidine 0.1 mg
PO for withdrawal symptoms. The client begins to complain of feeling nervous and tells the nurse that her
bones are itching. Which finding should the nurse identify as a contraindication for administering the
medication? (ANS- Blood pressure 90/76 mm Hg
During discharge teaching, an overweight client heart failure (HF) is asked to make a grocery list for the
nurse to review. Which food choices included on the client's list should the nurse encourage? (Select all
that apply)
A. Canned fruit in heavy syrup.
B. Plain, air-popped popcorn.
C. Cheddar cheese cubes.
D. Natural whole almonds.
E. Lightly salted potato chips (ANS- B. Plain, air-popped popcorn.
D. Natural whole almonds. [Show Less]