1. A client who has been in active labor for 12 hours suddenly tells the nurse that she has a strong urge to have a bowel movement. What action should the nurse take? Correct Answer: Perform a sterile vaginal exam.
2
...
1. A client who has been in active labor for 12 hours suddenly tells the nurse that she has a strong urge to have a bowel movement. What action should the nurse take? Correct Answer: Perform a sterile vaginal exam.
2. The nurse assesses a 78-year-old male client who has left sided heart failure. Which symptoms would the nurse expect this client to exhibit? Correct Answer: Dyspnea, cough and fatigue
3. A female client comes to the clinic complaining of fatigue and inability to sleep because she is the full-time caretaker for a 22-year-old son who was paralyzed by a motor vehicle collision. She adds that her husband left her because he says he can't take her behavior anymore since all she does is care for their son. What intervention should the nurse implement? Correct Answer: Acknowledge the client's stress and suggest that she consider respite care.
4. The nurse plans to administer a scheduled dose of metoprolol (Toprol SR) at 0900 to a client with hypertension. At 0800, the nurse notes that the client's telemetry pattern shows a second-degree heart block with a ventricular rate of 50. What action should the nurse take? Correct Answer: Hold the scheduled dose of Toprol and notify the healthcare provider of the telemetry pattern
5. A client who developed Syndrome of Inappropriate Antidiuretic Hormone (SIADH) associated with small cell carcinoma of the lung is preparing for discharge. When teaching the client about self-management with demeclocycline (Declomycin), the nurse should instruct the client to report which condition to the healthcare provider? Correct Answer: Muscle Cramping
6. In determining the client position for insertion of an indwelling urinary catheter, it is most important for the nurse to recognize which client condition? Correct Answer: Orthopnea (SOB)
7. The nurse is reviewing a client's electrocardiogram and determines that the PR interval (PRI) is prolonged. What does this finding indicate? Correct Answer: Increased conduction time from the SA node to the AV junction.
8. The nurse is teaching a male client with multiple sclerosis how to empty his bladder using the Crede Method. When performing a return demonstration, the client applies pressure to the umbilical area of his abdomen. What instruction should the nurse provide? Correct Answer: Apply downward manual pressure at the suprapubic region
9. A 35-year-old female client has just been admitted to the postanesthesia recovery unit following a partial thyroidectomy. Which statement reflects the nurse's accurate understanding of the expected outcome for the client following this surgery? Correct Answer: Supplemental hormonal therapy will probably be unnecessary
10. A client with gestational diabetes, at 39-weeks gestation, is in the second stage of labor. After delivery of the fetal head, the nurse recognizes that shoulder dystocia is occurring. What intervention should the nurse implement first? Correct Answer: Assist the client to sharply flex her thighs up against the abdomen
11. The nurse should observe most closely for drug toxicity when a client receives a medication that has which characteristic? Correct Answer: Narrow therapeutic index.
12. Following insertion of a LeVeen shunt in a client with cirrhosis of the liver, which assessment finding indicates to the nurse that the shunt is effective? Correct Answer: Decreased abdominal girth.
13. When finding a client sitting on the floor, the nurse calls for help from the unlicensed assistive personnel (UAP). Which task should the nurse ask the UAP to do? Correct Answer: Get a blood pressure cuff
14. During the initial newborn assessment, the nurse finds that a newborn's heart rate is irregular. Which intervention should the nurse implement? Correct Answer: Document the finding in the infant's record
15. A client is diagnosed with a frontal lobe glioma, which is a benign brain tumor. When teaching the client about the tumor, which information should the nurse consider? Correct Answer: Personality changes or expressive aphasia are likely
16. A client who has suffered 3rd degree burns over 60% of the body is admitted to the emergency department. The healthcare provider writes a prescription for "IV Lactated Ringer's 350 ml/hr". Which intervention should the nurse implement? Correct Answer: Obtain an intravenous infusion pump prior to administering the IV
17. A male client with HIV, who is being admitted to a healthcare facility, tells the nurse that he is concerned about his right to have access to his records and explanations regarding his treatment and the cost of such treatment. Which resource should guide the nurse's response to this client? Correct Answer: The Patient's Bill of Rights.
18. When assessing the oral temperature of an adult client at 6:00 pm, the nurse notes that the client's temperature at 6:00 am was 97.2, and is now 98.8. Which intervention should the nurse implement? Correct Answer: Document this temperature variation on the graphic sheet.
19. It would be of greatest benefit for the client with which problem related to diabetes mellitus to change from the use of insulin syringes to using an insulin pen for medication administration? Correct Answer: Diminished dexterity due to finger paresthesias
20. A one-year-old child with neuroblastoma is crying continuously and is curled into a fetal position. What action is most important for the nurse to implement? Correct Answer: Give a prescribed analgesic
[Show More]
