1 the nurse is caring for a group of clients with the help of a practical nurse. Which
nursing actions should the nurse assigned to the PN? –
1
... [Show More] perform daily surgical dressing change for a client who had an abdominal
hysterectomy
2 obtain post-operative vital signs for a client one day following unilateral
knee arthroplasty
3 administer a dose of insulin per sliding scale for a client with type 2 diabetes
mellitus
2 A lethargic one hour old infant is brought to the nursery for further assessment. In
what order should the nurse assess this infant? –
1 Heart rate
2 respirations
3 temperature
4 heel stick
3 following a gunshot wound, an adult client has a hemoglobin level of 4. The nurse
prepares to administer a unit of blood for an emergency transfusion. The client has
ab negative blood type and the blood bank sends a unit of type A Rh negative,
reporting that there is no type Ab negative blood currently available. Which
intervention should the nurse implement? - administering normal saline solution until
type Ab negative is available
4 a female client receives a prescription for alendronate sodium (Fusamax) to treat
her newly diagnosed osteoporosis. What instructions should the nurse include in the
client teaching plan? - take on an empty stomach with a full glass of water
5 a male client with cirrhosis has jaundice and Puritas. He tells the nurse that he has
been soaking in hot bath at night with no relief of his discomfort. What action should
the nurse take? - encourage the client to use cooler water and apply calamine lotion
after soaking
6 an adult female tells the nurse that her grandmother was diagnosed with colorectal
cancer at age 75. The client is implementing measures to reduce her own risk.
Which of the clients plans indicates the need for additional information? - annual
sigmoidoscopy screening
7 a mother runs into the emergency department with a toddler in her arms and tell
the nurse that her child got into some cleaning products. The child smells of
chemicals on the hands face and the front of the child's clothing. After ensuring an
patent Airway, what action should the nurse Implement first? - determine type of
chemical exposure8 the nurse enters the room of a client with Parkinson's disease who is taking
levodopa. The client is a rising slowly from the chair while the UAP stands next to
the chair. What action should the nurse take? - a firm that the client should arrive
slowly from the chair
9 a middle-aged female client tells the clinic nurse that she has lost an inch of height
in the last year. What is the priority nursing intervention? - assist the client to
schedule a bone density exam
10 an atypical antipsychotic, ziprasidone, is prescribed for a client with a diagnosis
of schizophrenia. After the client has been taking the medication for two weeks, the
nurse assesses the Drug's effectiveness. which client reports suggest that the
medication is helpful? - hears voices less often
11 prior to obtaining a trapeze bar for a client with limited Mobility, which client
assessment is most important for the nurse to obtain? - upper body muscle strength
12 a male client with heart failure reports heart palpitations and difficulty breathing
when lying flat. When he requests additional pillows, the nurse determines that his
heart rate is 125 beats per minute and respiratory rate is 22 breaths per minute.
Which intervention is most important for the nurse to implement? - obtain manual
blood pressure
13 a family member reports that the client who is bedridden has not been turned or
repositioned all night and is sleeping on a special air mattress with no sheets. What
information should the nurse provide to the family member? - clarify that an aerated
support surface does not use sheets that often cause skin breakdown
14 an S3 heart sound is auscultated in a client in her third trimester of pregnancy.
What intervention should the nurse take? - document in the client's record
15 the nurse is evaluating the diet teaching of a client with hypertension. What
dinners selection indicates that the client understands the dietary recommendations
for hypertension? - baked pork chop, apple sauce, corn on the cob, 1% milk, and
key lime pie
16 a client who had a percutaneous coronary intervention two weeks ago returns to
the clinic for a follow-up visit. The client had a post-operative ejection fraction of
30%. Today the client has lungs which are clear, slight pedal edema, and a 5 pound
weight gain. Which interventions should the nurse implement? - assess compliance
with routine prescriptions
17 the nurse is completing an admission assessment for a male client with paranoid
schizophrenia. The client tells the nurse that the staff dislikes him. What action
should the nurse take? - determine if the client has formulated any plans regarding
the staff18 an adult male was diagnosed with stage 4 lung cancer three weeks ago. His wife
approaches the nurse and asks how she will know that her husband's death is
imminent because their two adult children want to be there when he dies. What is
the best response by the nurse? - explain that the client will start to lose
consciousness and his body systems will slow down
19 a client with a history of adrenal insufficiency is admitted to the ICU with an acute
adrenal crisis. the client is complaining of nausea and joint pain. Vital signs are
temperature 102, heart rate 138, BP 80 / 60. which intervention should the nurse
Implement first? - Infuse an intravenous fluid bolus
20 following morning care, a client with a C5 spinal cord injury who is sitting in a
wheelchair becomes flushed and complains of a headache. Which intervention
should the nurse Implement first? - relieve any kinks or obstruction in the clients
Foley tubing [Show Less]