The nurse shows a teenager how to use a metered dose inhaler of ipratropium (Atrovent). Which statement if made by the client to the nurse, indicates teaching is effective? - ANSWER "I should use this... medicine to prevent asthma attacks." An older client is scheduled for a magnetic resonance imaging MRI procedure. Which of the following statements, if made by the client to the nurse, should be reported to the technician before the test? - ANSWER I had a knee replacement 5 years ago The nurse makes the following observations of a 6 hour old newborn: axillary temperature 96.4 F (35.8 C), apical pulse 148, respirations irregular at 48/minute, black sticky stool, blood glucose 60mg/dL. It is most important for the nurse to take which action? - ANSWER Wrap the newborn in a warmed blanket A client is returned to the unit at 10AM after laparoscopic gallbladder surgery. The nurse plans to get the patient out of bed for the first time at 4PM. It is MOST important for the nurse to take which of the following actions? - ANSWER Offer pain medication to the patient at 3:30 pm. OLD ANSWER: Turn the pt from side to side at 2 PM The activity therapy staff takes a group of psychiatric patients on a trip to the zoo. The nurse should intervene with which of the following patients before their departure? - ANSWER A 38 year old female who is receiving chlorpromazine (Thorazine) and is wearing a sundress without a hat or glasses A patient experiences skin eruptions due to an allergic reaction to a medication. The nurse demonstrates the BEST documentation with which of the following? - ANSWER "Multiple red welts noted over trunk and both arms. Patient states that welts itch" An older client diagnosed with emphysema is admitted to the psychiatric unit for treatment of bipolar disorder. The client receives oxygen per nasal cannula. The client expresses concern to the nurse that someone will come in and change the amount of oxygen the client is receiving. INITIALLY, the nurse should take which of the following actions? - ANSWER Place a sign above the patients bed stating that the oxygen level is not to be changed. A teenager has a positive home pregnancy test and comes to the prenatal clinic. The girl is uncertain of the date of her last menstrual period. The nurse palpates the uterine fundus midway between the symphysis pubis and the umbilicus. Which statement by the nurse is BEST? - ANSWER "You are 16 weeks pregnant. Lets talk about what that means." A client is admitted to the psychiatric unit with complaints of fatigue, inability to concentrate, lack of appetite, and repetitive thoughts. The client is reluctant to take the prescribed medications, fearing that they are harmful. After the nurse gives the client the medication, the nurse should take which of the following actions? - ANSWER Instruct the client to open her mouth and move her tongue up and down and to each side while the nurse looks inside The nurse assesses a patient 72 hours after a total joint replacement of the right hip. Which finding requires an intervention by the nurse? - ANSWER The patients legs are internally rotated A client newly diagnosed with Meniere's disease plans a trip to an amusement park with the family. The client asks the clinic nurse which of the following rides is best. The nurse should suggest which of the following rides? - ANSWER Train . A client is discharged from the hospital after coronary bypass (CABG) surgery 3 days ago. During discharge teaching, the client asks the nurse "When can I resume sexual intercourse with my wife?" it is best for the nurse to make which of the following statements? - ANSWER You can resume sexual activity when you are able to walk one block without chest pain or discomfort A woman complains to the nurse about the care provided to her husband by the nursing staff the previous night. Initially, the nurse should take which of the following actions - ANSWER Ask the wife to voice her expectations about a solution to the problem A patient is restrained bodily by the nursing team. The hands of the nurse assigned to hold down the patients leg should be placed in which of the following positions? - ANSWER One hand directly above the patient's knee and the other hand directly above the patient's ankle The nurse in the community mental health center works with a client who is diagnosed with depression. Cognitive therapy is initiated. The nurse should take which of the following actions? - ANSWER Help the client to identify the source of his depression The nurse plans to perform a physical assessment of a young adult who has been deaf since birth. Although the client indicates using sign language, no interpreter is available. The nurse should take which action? - ANSWER Write out each question, and ask the client to write out each answer A patient received morphine 4 mg IV 2 hours ago for the complaints of postoperative pain. The patient turns on the call light and tells the nurse he has to go to the bathroom. The patient has bathroom privileges. The nurse should take which of the following actions? - ANSWER Ask the patient to sit on the side of the bed b [Show More]
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