The healthcare provider prescribes a sepsis protocol for a
client with multi-organ failure caused by a ruptured appendix.
Which intervention is most
... [Show More] important for the nurse to include
in the plan of care?
A. Assess warmth of extremities
B. Keep head of bed raised 45 degrees
C. Monitor blood glucose level
D. Maintain strict intake and output - ...ANSWER...D.
Maintain strict intake and output
A client presses the call bell and requests pain medication for
a severe headache. To assess the quality of the client's pain,
which approach should the nurse use?
A. Ask the client to describe the pain
B. Observe body language and movement
C. Identify effective pain relief measures
D. Provide a numeric pain scale - ...ANSWER...A. Ask the
client to describe the pain
A client presents to the labor and delivery unit with a report of
leaking fluid that is greenish-brown vaginal discharge. Which
action should the nurse take first?
A. Start an intravenous infusion
B. Administer oxygen via facemask
C. Perform a vaginal exam
D. Begin continuous fetal monitoring - ...ANSWER...D.
Begin continuous fetal monitoring
A client asks the nurse for information about how to reduce
risk factors for benign prostatic hyperplasia (BPH). Which
information should the nurse provide?
A. Consume a high protein diet
B. Increase physical activity
C. Take vitamin supplements
D. Obtain a prostate-specific antigen blood level test -
...ANSWER...B. Increase physical activity
Following a cardiac catheterization and placement of a stent
in the right coronary artery, the nurse administers prasugrel, a
platelet inhibitor, to the client. To monitor for adverse effects
from the medication, which assessment is most important for
the nurse to include in this client's plan of care?
A. observe color of urine
B. Measure body temperature
C. Assess skin turgor
D. Check for pedal edema - ...ANSWER...A. Observe color of
urine
A client fell in the bathroom when left unattended by the
unlicensed assistive personnel (UAP). Which information
should the nurse include in the client's health record?
A. The UAP left the client to assist another client
B. The last time client was assisted to the bathroom
C. The unit was understaffed when the client fell
D. The client fell sustaining a fracture to the left hip -
...ANSWER...D. The client fell sustaining a fracture to the left
hip
The nurse is reviewing the diagnostic tests prescribed for a
client with a positive skin test. Which subjective findings
reported by the client supports the diagnosis of tuberculosis?
A. Barking cough and vomiting
B. Mucopurulent cough and night sweats
C. Dry cough and chest tightness
D. Chronic cough and fatty stools - ...ANSWER...B.
Mucopurulent cough and night sweats
In assessing a client with type 1 diabetes mellitus, the nurse
notes that the client's respirations have changed from 16
breaths/min with a normal depth to 32 breaths/min and deep,
and the client become lethargic. Which assessment data
should the nurse obtain next?
A. Temperature
B. Breath sounds
C. Blood glucose
D. White blood cell count - ...ANSWER...C. Blood glucose
A nurse receives report on a client who is four hours post-total
abdominal hysterectomy. The previous nurse reports that it
was necessary to change the client's perineal pad hourly and
that it is again saturated. The previous nurse also reports that
the client's urinary output has decreased. Which action should
the nurse implement first?
A. Evaluate the skin turgor
B. Assess for weakness or dizziness
C. Change the perineal pad
D. Measure the urinary output - ...ANSWER...B. Assess for
weakness or dizziness
The father of a 4-year-old has been battling metastatic lung
cancer for the past 2 years. After discussing the remaining
options with his healthcare provider, the client requests that
all treatment stop and that no heroic measures be taken to save
his life. When the client is transferred to the palliative care
unit, which action is most important for the nurse working on
the palliative care unit to take in facilitating continuity of
care?
A. Reassure the client that his child will be allowed to visit
B. Provide the client written information about end-of-life
care
C. Obtain a detailed report from the nurse transferring the
client
D. Mark the chart with client's request for no heroic measures
- ...ANSWER...C. Obtain a detailed report from the nurse
transferring the client
While assessing a client who is admitted with heart failure and
pulmonary edema, the nurse identifies dependent peripheral
edema, an irregular heart rate, and a persistent cough that
produces pink blood-tinged sputum. After initiating
continuous telemetry and positioning the client, which
intervention should the nurse implement?
A. Obtain sputum sample
B. Document degree of edema
C. Initiate hourly urine output measurement
D. Administer intravenous diuretics - ...ANSWER...A. Obtain
sputum sample [Show Less]