1. A nurse is caring for four clients. Which of the following client statements
should the nurse attend to first?: "My heartburn pain is going into my
... [Show More] jaw now."
2. A nurse is caring for a client who is receiving mechanical ventilation via an
endotracheal tube. Which of the following actions should the nurse
take?: Perform oral care every 2 hr.
3. A nurse is caring for a client who is receiving warfarin 5 mg PO daily.
Which of the following laboratory values should the nurse check prior
to administering the medication?: PTINR
4. A nurse is collecting data from a client who is at 9 weeks of gestation
and has hyperemesis gravidarum. Which of the following findings should
the nurse expect?: Weight loss
5. A nurse is reinforcing teaching with a client about the importance of a low
sodium diet. Which of the following foods should the nurse recommend as
the best choice to include in a low sodium diet?: 2 tbsp of peanut butter
6. A nurse is collecting data from an 18 month old toddler at a well child visit.
Which of the following findings should the nurse report to the
provider?: The toddler can say four words.
7. A nurse is collecting data from a client who has diabetes mellitus. Which of
the following findings indicates that the client might be experiencing
diabetic ketoacidosis?: Kussmaul respirations
8. A nurse is reinforcing teaching with a client who has a permanent pacemaker
in place. Which of the following statements by the client indicates
an understanding of the teaching?: "I need to record my pulse rate daily."
9. A nurse is caring for a client who is in mechanical restraints after becoming
violent with a staff member. Which of the following actions should the
nurse take?: Document in the clients medical record every 15 min.
10. A nurse is reinforcing teaching about self-administration of nasal drops
with a client. Which of the following positions should the nurse
recommend for instillation of the drops?: Supine
11. A nurse is preparing to administer furosemide to a client who has heart
failure. Which of the following laboratory results should the nurse review
prior to administering the medication?: Potassium
12. A nurse is caring for a client who has methicillin-resistant staphylococcus
aureus (MRSA) infection. Which of the following actions should the nurse
plan to take care?: Don a gown and gloves when providing perineal
13. A nurse is assisting with the plan of care for a client who has dementia
and often wanders in the halls at night. Which of the following interventions
should the nurse recommend including in the plan of care?: Labeling the
clients bathroom door
14. A charge nurse is reinforcing teaching with a newly hired licensed practical
nurse about scope of practice. Which of the following responsibilities
should the nurse include in the teaching?: Providing direct client care
15. A nurse is working on a mental health unit is meeting with a client who
has been in the unit for 2 days. The nurse greets the client and asks, "What
has been happening with you today?" Which of the following therapeutic
techniques is the nurse using?: Reflecting
16. A nurse us reinforcing teaching with a group of expectant parents regarding
the proper use of a car seat. Which of the following statements by a
parent indicates an understanding of the teaching?: "I will secure the seat belt
across my newborns lap."
17. A nurse from a medical surgical unit is floating to a postpartum unit.
Which of the following clients is an appropriate assignment for the nurse
to accept?: placenta who underwent removal A client of a retained
18. A nurse is assisting with planning care for a newly admitted client who
has anorexia nervosa. Which of the following interventions should the
nurse recommend to include in the plan of care?: Reinforce teaching about
healthy eating during meals
19. A nurse is admitting a client who is scheduled for an elective surgery.
Which of he following actions should the nurse take to verify the statu
stheclients advance directives?: Ask the client whether they have advance
directives [Show Less]