Which of these instructions should a nurse include in the teaching plan for a client who had removal of a cataract in the left eye?
a. "Forcefully cough
... [Show More] and take deep breaths every two hours to keep your airway clear."
b. "Perform the prescribed eye exercises each day to strengthen your eye muscles."
c. "Rinse your eyes with saline each morning to prevent postoperative infection."
d. "Take the prescribed stool softener to avoid increasing intraocular pressure."
A client vomits during a continuous nasogastric tube feeding. A nurse should stop the feeding and take which of these actions?
a. Suction the nasogastric tube.
b. Flush the tube with 30 mL of sterile water.
c. Remove the nasogastric tube.
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d. Check the residual volume.
Which of these actions best demonstrates cultural sensitivity by a nurse?
a. The nurse talks in a slow-paced speech.
c. The nurse uses charts and diagrams when teaching pregnant clients.
d. The nurse can speak several different languages.
b. The nurse asks clients about their beliefs and practices toward pregnancy.
Which of these manifestations should a nurse expect to observe in a 3-month-old infant who is diagnosed with dehydration?
a. Hyperreflexia.
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c. Bradypnea.
d. Agitation.
b. Tachycardia.
When assessing a client's risk of developing nosocomial infection, a nurse plans to determine potential entry portals, which include:
b. vomitus.
c. contaminated water.
d. sexual intercourse.
a. the urinary meatus.
A client who is on the inpatient psychiatric unit has a history of violence. Which of these actions should a nurse take if the client is agitated?
b. Lock the client in a secluded room.
c. Ask the other clients to give feedback regarding the client's behavior.
d. Ignore the client's inappropriate behavior.
a. Encourage the client to verbalize feelings.
Which of these measures should a nurse include when planning care for a school-aged child during a sickle cell crisis episode?
a. Monitoring for signs of bleeding.
c. Administering cool sponge baths to reduce fevers.
d. Offering a high calorie diet.
b. Providing pain relief.
Which of these instructions should a nurse include in the plan of care for a 32-week gestation client who had an amniocentesis today?
a. "Drink at least six glasses of fluids during the next six hours after the test."
b. "Call the clinic if you experience any abdominal
c. "Don't be concerned if you have some vaginal spotting in the next 12 hours."
d. "When you get home, stay on bed-rest for the next 48 hours."
b. "Call the clinic if you experience any abdominal cramps."
An adolescent has a nursing diagnosis of fatigue related to inadequate intake of iron-rich foods. Selection of which of these lunches by the client indicates a correct understanding of foods high in iron content?
a. Peanut butter and jam sandwich.
b. Chicken nuggets with rice.
c. Tuna salad sandwich.
d. Beefburger with cheese.
A client has been admitted with acute pancreatitis. Which of these laboratory test results supports this diagnosis?
a. Elevated serum potassium level.
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c. Elevated serum sodium level.
d. Elevated serum creatinine level.
b. Elevated serum amylase level.
Which of these manifestations, if assessed in a client who is two-hours postoperative after abdominal surgery, should a nurse report immediately?
b. Respiratory rate of 12/minute and urine dribbling.
c. Blood pressure of 100/60 mm Hg and wound discomfort.
d. Urine output of 100 mL/hr and flushed skin.
a. Vomiting and a pulse rate of 106/minute.
Which of these observations of a student nurse's behavior while interacting with a client who is crying indicates a correct understanding of therapeutic communication?
a. The student maintains continuous eye contact with the client.
b. The student places one arm around the client's shoulder?
d. The student leaves the room to provide privacy for the client.
c. The student sits quietly next to the client.
Which of these actions should a nurse take initially if a client who is diagnosed with diabetes mellitus develops tremors and ataxia?
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b. Administer a concentrated form glucose to the client.
c. Administer a prn dose of insulin.
d. Measure the client's urine for ketones.
a. Measure the client's blood sugar level.
An elderly client is at increased risk of developing drug toxicity to prescribed medications due to declining hepatic and renal functioning. Which of these strategies should a nurse plan to decrease this risk?
b. Limiting the client's oral fluid intake.
c. Administering the medications with meals.
d. Encouraging the client to void every three to four hours.
a. Increasing the time interval between medication doses.
A client has persistent paranoid delusions that the food on the unit is poisoned. Which of these measures should a nurse include in the client's care plan?
a. Explaining that staff does not poison clients.
b. Focusing on how the hospital staff helps clients.
d. Telling the client that not eating the food that is served will result in privilege restrictions.
c. Allowing the client to eat food from sealed containers.
Thrombophlebitis is a complication that may result due to surgery. Which of these actions should a nurse take in the operating room to prevent this complication from occurring?
a. Gatch the knee of the bed.
b. Administer anticoagulants preoperatively.
d. Maintain the legs in a dependent position.
c. Apply sequential compression devices.
When discussing weigh gain during pregnancy, a nurse should recommend that the total weight gain for a pregnant client who is at ideal body weight for her height is:
a. at least 15 pounds.
b. 15 to 20 pounds.
d. at least 45 pounds.
c. 25 to 35 pounds.
Which of these manifestations, if reported by a client who is 10-weeks-pregnant, supports the diagnosis of ruptured tubal pregnancy.
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b. Uncontrollable vomiting.
c. Marked abdominal distention.
d. Profuse vaginal bleeding.
a. Sharp unilateral abdominal pain.
Which of these assignments, if made by a nurse to a nursing assistant, indicates that the nurse needs additional instructions regarding the principles of delegation?
a. "Please bathe the client in room 12, and then bring the client to the dining room for breakfast by 9 A.M."
the client's discomfort."
c. "Please measure the intake and output for the client's in rooms 8. 9. and 10, and record each on the intake/output sheets by 2 P.M."
d. "Please toilet the clients in rooms 11, 12, and 13 mid-morning and after lunch."
b. "Please bathe the client in room 10, administer a back rub, and then evaluate if the back rub eased the client's discomfort."
A client has the following order for regular insulin (Humulin R) on a sliding scale: Blood sugar 150-180 mg: Give 2 units regular insulin
Blood sugar 181-200 mg: Give 4 units regular insulin Blood sugar 201-220 mg: Give 6 units of regular insulin Blood sugar above 220 mg: Call MD
At 11 A.M., a nurse obtains a finger stick glucose of 198 mg. The only syringe is a three milliliter one. Regular insulin is available as 100 units per milliliter. How many milliliters should the nurse administer?
b. 0.4
c. 4
d. 40 a. 0.04 [Show Less]