1. A nurse is caring for a client who had abdominal surgery 24 hr ago. Which of the
following actions is the nurse's priority?
- Assist with deep
... [Show More] breathing and coughing
2. A nurse is talking with a client who has stage IV breast cancer. The nurse should
recognize which of the following statements by the client as a constructive use of
a defense mechanism?
- "I told my doctor that I would like to start a support group for other women who
are sick in my community"
3. A nurse is caring for a client who has immunosuppression and a continuous IV
infusion. Which of the following actions should the nurse take?
- Monitor the client's mouth every 8 hr
4. A nurse is caring for a 2-month-old infant who has Hirschsprung disease (HD).
Which of the following areas should the nurse assess for manifestations of HD?
– C The nurse should assess the infant's abdomen for distention and visible
peristalsis, which are manifestations of HD
5. A nurse at a mental health clinic is caring for four clients. The nurse should
recognize the following clients is using dissociation as a defense mechanism?
- A client who was abused as a child describes the abuse as if it happened to
someone else
6. A nurse is providing teaching to a client who has a new diagnosis of type 1
diabetes mellitus. The nurse should instruct the client to monitor for which of the
following findings as a manifestation of hypoglycemia?
- irritability
7. A nurse in an outpatient mental health clinic is caring for four clients. The nurse
should recognize that which of the following clients is effectively using
sublimation as a defense mechanism?
- A client who channels their energy into a new hobby following the loss of their
job
8. A hospice nurse is consulting with a client and her family about receiving home
services. Which of the following statements should the nurse identify as an
indication that the family understands home hospice care?
- "We can expect the hospice nurse to provide support for us after our mother's
death"9. A nurse is caring for a client who has active tuberculosis. Which of the following
actions should the nurse take? - Assign the client to a private room with negative
air pressure
10.A nurse is providing teaching to a client who is at 24 weeks of gestation and is
schedule for a 3 hour oral glucose tolerance test. Which of the following
instructions should the nurse include in the teaching? - "You will need to fast the
night before the test"
11.A nurse on a pediatric unit has received change of shift report for four children.
Which of the following children should the nurse assess first? - A 10 year old
child who is awaiting surgery for an appendectomy and experienced sudden
relief from pain
12.A nurse in a community center is providing an education session to a group of
clients about ovarian cancer. Which of the following manifestations of ovarian
cancer should the nurse include in the teaching? - Abdominal bloating
13.A nurse is caring for a client who is postoperative after receiving moderate
(conscious) sedation. The client suddenly becomes restless and reports feeling
lightheaded. Which of the following actions should the nurse take? - Check the
client's oxygen saturation level
14.A nurse is working in an emergency department is triaging four clients. Which of
the following clients should the nurse recommend for treatment first? - A middle
adult client who has unstable vital signs
15.A nurse is providing teaching for a client who has a fracture of the right fibula with
a short leg cast in place and a new prescription for crutches. The client is nonweight bearing for 6 weeks. Which of the following instructions should the nurse
include in the teaching? - Use a three-point gait
16.A nurse is preparing to initiate IV access for an older adult client. Which of the
following sites should the nurse select when initiating the IV for this client? -
Radial vein of the inner arm
17.A nurse is planning to delegate client care tasks to an AP. Which of the following
tasks should the nurse plan to delegate to the AP? - Perform gastrostomy
feedings through a client's established gastrostomy tube
18.A nurse is caring for a newborn immediately after delivery. Which of the following
interventions should the nurse implement to prevent heat loss by conduction? -
Use a protective cover on the scale when weighing the infant19.A nurse is caring for a client who is receiving a continuous heparin infusion.
Which of the following laboratory tests should the nurse review prior to adjusting
the client's heparin? - aPTT
20.A nurse administers an incorrect dose of medication to a client. The nurse
recognized the error immediately and completes and incident report. Which of
the following facts related to the incident should the nurse document in the
client's medical record? - Time the medication was given [Show Less]