1. The nurse is caring for a client following an appendectomy. The client reports nausea and complains of surgical site pain at a 6 on a 0 to 10 scale. The client's employer is present in the room and states he is paying
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1. The nurse is caring for a client following an appendectomy. The client reports nausea and complains of surgical site pain at a 6 on a 0 to 10 scale. The client's employer is present in the room and states he is paying for the insurance and wants to know what pain medication has been prescribed by the physician. Which of the following is the appropriate nurse response?
A. Answer any questions the employer may have as he pays for the insurance.
B. Tell the employer his question is inappropriate and that the information is none of his business.
C. Explain to the employer that you cannot release private information and ask the employer to step out while you conduct your assessment of the client.
D. Ask the employer to leave and wait until the client returns home to visit. - C. Explain to the employer that you cannot release private information and ask the employer to step out while you conduct your assessment of the client.
2. The nurse is caring for a client with a history of advanced chronic obstructive pulmonary disease (COPD). The client had conventional gallbladder surgery 2 days previously. Which intervention has priority for preventing respiratory complications?
A. Incentive spirometry every 4 hours.
B. Coughing and deep breathing four times daily.
C. Getting the client out of bed 4 times daily as ordered by the physician.
D. Giving oxygen at 4 L/minute according to the physician's order. - C. Getting the client out of bed 4 times daily as ordered by the physician
3. A nurse is developing a care plan for a client with acute mania. Place the following behaviors in the order in which they occur as the client develops acute mania. Use all of the options.
A. Delusions of grandeur.
B. Relevant, calm speech patterns.
C. Highly productive and competitive in work and leisure activities.
D. Easily irritated.
E. Poor judgment and impulse control. -
4. When educating a pregnant client about home safety, which of the following information is appropriate for the nurse to include in the teaching plan? Select all that apply.
A. When taking a shower, place a non-skid mat on the floor of the tub or shower.
B. Avoid climbing stairs.
C. Avoid wearing high heels.
D. Use non-slip rugs on the floors. - A. When taking a shower, place a non-skid mat on the floor of the tub or shower.
B. Avoid climbing stairs.
C. Avoid wearing high heels.
5. A client had a C5 spinal cord contusion that resulted in quadriplegia. Two days after the injury occurred, the nurse sees his mother crying in the waiting room. The mother asks the nurse whether her son will ever play football again. Which of the following is the best initial response?
A. "Given time and motivation, your son can return to normal function."
B. "I'm not sure, but I'll call the physician to talk to you right away."
C. "What do you know about your son's injury?"
D. "Getting upset isn't in you son's best interest." - C. "What do you know about your son's injury?"
6. The nurse is caring for a client who will undergo surgical repair of a detached retina. Which of the following is the most likely preoperative nursing diagnosis for this client?
A. Anxiety related to loss of vision and potential failure to regain vision.
B. Deficient knowledge (preoperative and postoperative activities) related to lack of information.
C. Acute pain related to tissue injury and decreased circulation to the eye.
D. Risk for infection related to the eye injury. - A. Anxiety related to loss of vision and potential failure to regain vision.
7. When assessing a client with glaucoma, a nurse expects which of the following findings?
A. Complaints of double vision.
B. Complaints of halos around lights.
C. Intraocular pressure of 15 mm Hg.
D. Soft globe on palpation. - B. Complaints of halos around lights.
8. A client had a Caesarean delivery and is postpartum day 1. She asks for pain medication when the nurse enters the room to do her shift assessment. The client states that her pain level is an 8 on a scale of 1 to 10. What should be the nurse's priority of care?
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