1.A nurse is caring for a client who has bipolar disorder and is experiencing acute
mania. The nurse obtained a verbal prescription for restraints. Which of the following
should the actions the nurse take? - Answer- D
...
1.A nurse is caring for a client who has bipolar disorder and is experiencing acute
mania. The nurse obtained a verbal prescription for restraints. Which of the following
should the actions the nurse take? - Answer- Document the client's condition every
15 minutes
2.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? - Answer- Administer analgesics on a scheduled basis for the first
24 hr
3.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? - Answer- A client who has a
hip fracture and a new onset of tachypnea
4.A nurse is preparing to apply a transdermal nicotine patch for a client. Which of the
following actions should the nurse take? - Answer- Wear gloves to apply the patch to
the client's skin
5.A nurse has just received change-of-shift report for four clients. Which of the
following clients should the nurse assess first? - Answer- A client who was just given
a glass of orange juice for a low blood glucose level
6.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? - Answer- A history of
gastroesophageal reflux disease
7.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? - Answer- Serum glucose level- increased
8.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? - 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.
9.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? - 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).
10A nurse is preparing to perform a sterile dressing change. Which of the following
actions should the nurse take when setting up the sterile field? - Answer- Place the
cap from the solution sterile side up on clean surface
11.A nurse is providing teaching to an older adult client about methods to promote
nighttime
sleep. Which of the following instructions should the nurse include? - Answer- Eat a
light snack before bedtime
12.A home health nurse is preparing for an initial visit with an older adult client who
lives
alone. Which of the following actions should the nurse take first? - Answer- Identify
environmental hazards in the home
13.A nurse is assessing the remote memory of an older adult client who has mild
dementia. Which of the following questions should the nurse ask the client? -
Answer- "What high school did you graduate from". Continues...
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