A nurse is caring for an 82-year-old client in the emergency department who has
an oral body temperature of 38.3 C (101 F), pulse rate 114/min, and
... [Show More] respiratory
rate 22/min. He is restless and his skin is warm. Which of the following
interventions should the nurse take? (select all that apply)
a. obtain culture specimens before initiating antimicrobials.
B. Restrict the client's oral fluid intake.
C. Encourage the client to rest and limit activity.
D. allow the client to shiver to dispel excess heat.
E. assist the client with oral hygiene frequently. - a. obtain culture specimens
before initiating antimicrobials.
C. Encourage the client to rest and limit activity.
E. assist the client with oral hygiene frequently.
A nurse is instructing an assistive personnel about caring for a client who has a low
platelet count as a result of chemotherapy. Which of the following instructions is
the priority for measuring vital signs for this client?
A. "Do not measure the client's temperature rectally."
B. "Count the client's radial pulse for 30 seconds and multiply it by 2."
C. "Do not let the client know you are counting her respirations."
D. "Let the client rest for 5 minutes before you measure her blood pressure." - A.
"Do not measure the client's temperature rectally."
A nurse is instructing a group of nursing students in measuring a client's
respiratory rate. Which of the following guidelines should the nurse include?
(Select all that apply.)
A. place the client in semi-Fowler's position.
B. have the client rest an arm across the abdomen.
C. Observe one full respiratory cycle before counting the rate.
D. Count the rate for 30 sec if it is irregular.
E. Count and and report any signs the client demonstrates. - A. place the client in
semi-Fowler's position.
B. have the client rest an arm across the abdomen.
C. Observe one full respiratory cycle before counting the rate.
A nurse who is admitting a client who has a fractured femur obtains a blood
pressure reading of 140/94 mm Hg. The client denies any history of hypertension.
Which of the following actions should the nurse take first?A. request a prescription for an antihypertensive medication.
B. Ask the client if she is having pain.
C. Request a prescription for antianxiety medication.
D. Return in 30 min to recheck the client's blood pressure. - B. Ask the client if she
is having pain.
A nurse is performing mouth care for a client who is unconscious. Which of the
following actions should the nurse take?
A. turn the client's head to the side.
B. place two fingers in the client's mouth to open.
C. Brush the client's teeth once per day.
D. Inject a mouth rinse into the center of the client's mouth. - A. turn the client's
head to the side.
A nurse is instructing a client who has diabetes mellitus about foot care. Which of
the following guidelines should the nurse include? (Select all that apply.)
A. inspect the feet daily
B. use moisturizing lotion on the feet.
C. Wash the feet with warm water and let them air dry.
D. use over-the-counter products to treat abrasions.
E. wear cotton socks. - A. inspect the feet daily
B. use moisturizing lotion on the feet.
E. wear cotton socks.
A nurse is planning care for a client who develops dyspnea and feels tired after
completing her morning care. Which of the following actions should the nurse
include in the client's plan of care?
A. schedule rest periods during morning care.
B. discontinue morning care for 2 days.
C. perform all care as quickly as possible.
D. ask a family member to come in to bathe the client. - A. schedule rest periods
during morning care.
A nurse is beginning a complete bed bath for a client. After removing the client's
gown and placing a bath blanket over him, which of the following areas should the
nurse wash first?
A. face
B. feet
C. chest
D. arms - A. face [Show Less]