1. A nurse is planning care for a client who is receiving heparin to treat a deep-vein thrombosis of the left lower leg. Which of the following
... [Show More] interventions should the nurse include in the plan of care?
- Elevate the affected leg
- Rationale: the nurse should elevate the client’s affected extremity to reduce edema and decrease the risk of chronic venous insufficiency
2. A nurse is teaching a group of guardians about child safety measures. Which of the following statements by a guardian indicates an understanding of the teaching?
- I should have my child avoid sun exposure between 10 am and 2 pm
- Rationale: to prevent sunburns, guardians should apply sunscreen, dress their child in protective clothing and avoid sun exposure between 1000 and 1400
3. A nurse is providing teaching about infection prevention to a client who has been receiving chemotherapy. Which of the following statements by the client indicated an understanding of the teaching?
- “I will walk for short distances throughout the day”
- Rationale: The client should ambulate for short distances as tolerated throughout the day. This will help to reduce pulmonary stasis and prevent the development of respiratory infections.
4. A nurse is providing dietary teaching to the parents of a 6-month-old infant. Which of the following instructions should the nurse include?
- Introduce new foods one at a time over 5 to 7 days
- Rationale: The parent should introduce new foods one at a time over 5 to 7 days to identify potential food allergies
5. A charge nurse is planning care for a client who has mechanical restraints in place. Which of the following interventions should the nurse include in the plan of care?
- Provide a staff member to stay with the client continuously
- Rationale: a staff member must remain continuously with a client who is in restraints or view the client via audiovisual equipment, if necessary, due to risk of injury.
6. A community health nurse is assisting with the development of a disaster management plan. The nurse should include which of the following nursing responsibilities in the disaster response stage of the plan?
- Performing a rapid needs assessment
- Rationale: disaster management includes prevention, preparedness, response, and recovery stages. The nurse should perform a rapid needs assessment during the response phase of the disaster cycle. A rapid needs assessment allows the nurse to identify the severity of the incident, the health needs of the community, and the priority actions needed during the response stage.
7. A nurse manager is assisting with the orientation of a newly licensed nurse. Which of the following actions by the nurser requires the nurse manager to intervene?
- Tells the hospital chaplain a client’s diagnosis
- Rationale: discussing a client’s diagnosis with the hospital chaplain is a breach of client confidentiality and a violation of HIPAA
8. A nurse is caring for a client who is in labor at 39 weeks of gestation. During the second stage of labor, the nurse observes early decelerations on the monitor tracing. Which of the following actions should the nurse take?
- Continue observing the fetal heart rate
- Rationale: early decelerations indicate the progression of labor and are an expected finding. The nurse should monitor the fetus by observing the fetal heart rate and tracing.
9. A nurse manager is planning to make changes to the current scheduling system on the unit. To facilitate the staff’s acceptance of this change, which of the following actions should the nurse manager take first?
- Provide information about scheduling issues to the staff
- Rationale: the first stage of the change process is the unfreezing stage, when the nurse should inform the staff about the current staffing issues. This can increase their understanding of why the changes are necessary.
10. A nurse is planning teaching about allowable foods for a client who has a history of uric acid- based urinary calculi formation. Which of the following foods should the nurse include in the teaching?
- Oranges
- Rationale: a client who is prone to uric acid calculi formation can eat citrus fruits
11. A charge nurse is teaching a newly licensed nurse how to identify true labor. Which of the following should the nurse include in the teaching?
- The cervix transitions to an anterior position
- Rationale: in true labor the cervix transitions to an anterior position and begins to filate in the preparation for birth.
12. A nurse on a medical-surgical unit is caring for a client prior to a surgical procedure. Which of the following findings should indicate to the nurse that the client has the ability to sign the informed consent?
- The client is able to accurately describe the upcoming procedure
- Rationale: the ability of the client to accurately describe the upcoming procedure indicates that the provider adequately informed the client, and that the client is able to sign the informed consent form
13. A charge nurse assigns a newly licensed nurse to care for a client who has a chest tube. The nurse expresses concern about having limited experience with monitoring chest tube drainage. Which of the following actions should the charge nurse take first to provide teaching about chest tubes?
- Ask the nurse about their knowledge of the procedure
- Rationale: the first action the charge nurse should take nursing the nursing process is to assess the newly licensed nurse’s knowledge about the procedure. By assessing the nurse’s knowledge the charge nurse can identify the nurse’s learning needs.
14. A nurse is teaching a client who has a new prescription for estradiol. For which of the following adverse effects of this medication should the nurse instruct the client to monitor and report to the provider?
- Headaches
- Rationale: the nurse should instruct the client to monitor for and report headaches. Headaches can be an indication of thromboembolic stroke because estradiol increases the risk for adverse cardiovascular events.
15. Dosage problem: we already know this shi*
16. A nurse is caring for a client who is 12 hours postoperative, is receiving PCA for pain control, and requires a blood pressure check in 10 minutes. Which of the following staff members should the nurse assign to collect this information?
- An assistive personnel (AP) who is assisting a client to return to bed
- Rationale: Performing a blood pressure check is within the range of function of an AP, and the AP should be available to obtain a blood pressure within the specified time. [Show Less]