1. A nurse is assisting with the plan of care for a client who has aspiration pneumonia and hypoxia. Which of the following actions should the nurse plan
... [Show More] to take?
Initiate fall precautions
2. A nurse is caring for an older adult client immediately following a bronchoscopy with biopsy. Which of the following is the priority action the nurse should take?
Check for gag reflex (NPO)
3. A nurse is reinforcing health promotion education at a community health fair. Which of the following statements by attendees indicates understanding of the teaching?
―I will examine my breasts a week after each menstrual period‖
4. A nurse is collecting data from a client who had a long arm cast applied 2 hr ago. Which of the following findings of the affected extremity should the nurse report to the provider immediately?
The clients fingers are cool to the touch (Circulation)
5. A nurse in a long term care facility is collecting data from an older adult client. Which of the following findings indicates that the client might be dehydrated?
Recent onset of confusion
6. A nurse in a long term care unit is assisting in the care of a client who has Alzhiemers disease. Which of the following actions should the nurse take?
Participate in reminiscence therapy with the client
A nurse is caring for a client who is postoperative following a right radical mastectomy. Which of the following actions should the nurse take to prevent the development of lymphedema?
Use the clients left arm to obtain blood samples
7. A nurse is assisting the provider with removing a client's lower leg cast. Which of the following statements by the nurse is appropriate?
―You should hold still to prevent injury to your skin‖
8. A nurse on a medical surgical unit is caring for an older adult client who has developed sepsis due to a urinary tract infection. A member of the client's family tells the nurse not to perform any heroic measures to keep the client alive. Which of the following responses by the nurse is appropriate?
―Let me check the client's medical record for advance directives‖
9. A nurse is planning care for a client who is receiving radiation therapy to treat throat cancer and reports a change in the taste of food. Which of the following interventions should the nurse include in the plan of care?
Heat before serving
10. A nurse working the night shift is caring for an older adult client who has dementia and is at risk for falls. Which of the following actions should the nurse take?
Apply a motion sensor mat to the clients bed
11. A nurse is reinforcing teaching with a client about increasing her intake of fiber. Which of the following foods should the nurse encourage the client to eat?
Pears
12. A nurse is reviewing the medical record of a client who reports his urine is red-orange. The nurse should identify which of the following medications can cause this adverse effect?
Rifampin
13. A nurse is caring for a client in hospice care who is dying. The client's partner expresses concern that the client is sleeping more than in the previous week. Which of the following is an appropriate response by the nurse?
―Sitting quietly near the bedside can provide comfort and support‖
14. A nurse is reinforcing teaching with a client who is postoperative following a tympanoplasty. Which of the following information should the nurse include?
Plan to shampoo hair in 1 week
16. A nurse is reinforcing discharge teaching about dietary changes with a client who has a new colostomy. Which of the following foods should the nurse recommend?
Bananas
15. A nurse is caring for a client who has diabetes mellitus. Which of the following laboratory results should the nurse report to the provider?
Glycosylated hemoglobin 5.2%
16. A nurse is caring for an older adult client who has heart failure. Which of the following findings should the nurse report to the provider?
PaCO2 55 mm Hg ✅
17. A nurse is caring for a client who has diabetic neuropathy of the lower extremities and has a new prescription for a heating pad. The prescription reads, ―Apply to the left foot for 20 min.‖
Which of the following actions should the nurse take? Clarify the prescription with the provider
18. A nurse is reinforcing teaching with a client who has a new colostomy. Which of the following statements by the client indicates an understanding of the teaching?
―I should avoid broccoli and chewing gum‖
19. A nurse is collecting data from a client who has a newly placed colostomy. Which of the following findings should indicate to the nurse the client has accepted their new altered body image?
Participates in performing ostomy care [Show Less]