• A nurse assesses an older adult’s skin. Which findings require immediate referral?
(Select all that apply. Lesion with various colors Asymmetric
... [Show More] 6-mm dark lesion on forehead
• A nurse reads on a hospitalized client’s chart that the client is receiving teletherapy.
What action by the nurse is best? Coordinate continuation of the therapy.
• A nurse cares for a dying client. Which manifestation of dying should the nurse treat first?
Pain
• A postoperative client vomited. After cleaning and comforting the client, which action by the nurse is most important? Auscultate lung sounds.
• A nurse cares for a client who is prescribed vancomycin (Vancocin) 500 mg IV every 6 hours
for a methicillin-resistantStaphylococcus aureus (MRSA) infection. Which action should the nurse take? Assess the IV site at least every 2 hours for thrombophlebitis.
• A nurse is caring for a client who has a pressure ulcer on the right ankle. Which action
should the nurse take first? Assess the right leg for pulses, skin color, and temperature
• A nurse assesses a client who is prescribed a medication that inhibits angiotensin I from
converting into angiotensin II (angiotensin-converting enzyme [ACE] inhibitor). For which expected therapeutic effect should the nurse assess? Blood pressure decrease from 180/72 mm Hg to 144/50 mm Hg
• A client is hospitalized with Pneumocystis jiroveci pneumonia. The client reports shortness of
breath with activity and extreme fatigue. What intervention is best to promote comfort? Pace activities, allowing for adequate rest.
• A nurse is assessing clients on a medical-surgical unit. Which adult client should the
nurse identify as being at greatest risk for insensible water loss? Anxious client who has tachypnea
• A nurse plans care for a client who has a wound that is not healing. Which focused
assessments should the nurse complete to develop the client’s plan of care? (Select all that apply.) Height, Alcohol use, Prealbumin laboratory results
• A client is in the oncology clinic for a first visit since being diagnosed with cancer. The nurse
reads in the client’s chart that the cancer classification is TISN0M0. What does the nurse conclude about this client’s cancer? There are no distant metastases noted in the report.
• A nurse is working with a community group promoting healthy aging. What
recommendation is best to help prevent osteoarthritis (OA)? Lose weight if needed
• The nurse working in the orthopedic clinic knows that a client with which factor has an absolute contraindication for having a total joint replacement?Severe osteoporosis
• After teaching a client about advance directives, a nurse assesses the client’s
understanding. Which statement indicates the client correctly understands the teaching?
"An advance directive will specify what I want done when I can no longer make decisions about health care." [Show Less]