A nurse is caring for a client who has bipolar disorder and is experiencing
acute mania. The nurse obtained a verbal prescription for restraints.
... [Show More] Which
of the following should the actions the nurse take? - Correct Answer
-Document the client's condition every 15 minutes
A nursing planning care for a school-age child who is 4 hr postoperative
following perforated appendicitis. Which of the following actions should the
nurse include in the plan of care? - Correct Answer -Administer analgesics on
a scheduled basis for the first 24 hr
A nurse is receiving change-of-shift report for a group of clients. Which of the
following clients should the nurse plan to assess first? - Correct Answer -A
client who has a hip fracture and a new onset of tachypnea
A nurse is preparing to apply a transdermal nicotine patch for a client. Which
of the following actions should the nurse take? - Correct Answer -Wear gloves
to apply the patch to the client's skin
A nurse has just received change-of-shift report for four clients. Which of the
following clients should the nurse assess first? - Correct Answer -A client who
was just given a glass of orange juice for a low blood glucose level
A nurse is caring for a client who is receiving intermittent enteral tube
feedings. Which of the following places the client at risk for aspiration? -
Correct Answer -A history of gastroesophageal reflux disease
A nurse is reviewing the laboratory results for a client who has Cushing's
disease. The nurse should expect the client to have an increase in which of
the following laboratory values? - Correct Answer -Serum glucose levelincreased
A nurse is caring for a client who has severe preeclampsia and is receiving
magnesium sulfate intravenously. The nurse discontinues the magnesium
sulfate after the client displaces toxicity. Which of the following actions
should the nurse take? - Correct Answer -Administer calcium gluconate IV
Rationale: Calcium gluconate is given for magnesium sulfate toxicity. Always
have an injectable form of
calcium gluconate available when administering magnesium sulfate by IV.
A charge nurse is teaching new staff members about factors that increase a
client's risk to become violent. Which of the following risk factors should the
nurse include as the best predictor of future violence? - Correct Answer
-Previous violent behavior
Risk factors also include: past history of aggression, poor impulse control,
and violence. Comorbidity that leads to acts of violence (psychotic delusions,
command hallucinations, violent angry reactions with cognitive disorders).
A nurse is preparing to perform a sterile dressing change. Which of the
following actions should the nurse take when setting up the sterile field? - [Show Less]