a nurse in a mental health facility is caring for a client who is exhibiting violent behavior and has been placed in seclusion which of the following actions should the nurse take
Provide the client with food every 3
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a nurse in a mental health facility is caring for a client who is exhibiting violent behavior and has been placed in seclusion which of the following actions should the nurse take
Provide the client with food every 3 hr.
Ensure the provider evaluates the secluded client within 8 hr.
Document the client's status every 15 min.
Explain to the client that seclusion is punishment for violent behavior
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a nurse in a long Term Care Facility discovers a small fire in the client's trash can after moving the client to safety which of the following actions should the nurse take next
Return to the room to extinguish the fire.
Close the doors and windows on the unit.
Pull the alarm to notify emergency services.
Turn off oxygen and electrical equipment.
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a nurse is assessing a client who has fibromyalgia which of the following treatment modality prescription should the nurse expect for the clients mix pain
Referral for a nutritional consult
PCA infusion pump with morphine
Pregabalin PO twice daily
Progressive exercise plan leading to running three times per week
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a nurse in the orthopedic clinic is documenting data about several clients, which of the following actions should the nurse take to comply with the regulations of the health insurance portability and accountability act (HIPAA)
Lock or log off computers whenever he leaves the area.
Discard hard copies of client-specific data in wastebaskets in "staff only" areas.
Place clients' flow sheets in racks outside the examination room.
Ask the provider to log into the system and document on the provider's behalf.
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a nurse manager is developing a facility policy about the use of a fax machine to communicate information from a client electronic medical record EMR which of the following actions should the nurse include in the policy
Disable the speed-dial keys on the fax machine.
Fax the client's entire EMR for consultations.
Save the printed copies of the EMR used for faxing for at least 30 days.
Use a cover sheet when sending a fax from the health care unit.
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the charge nurse is teaching a group of newly licensed nurses how to prevent errors during the administration of blood transfusions which following actions should the nurse include
Complete the administration of 1 unit of packed RBCs within 6 hr of initiation of the transfusion.
Infuse 500 mL of lactated Ringer's when administering whole blood.
Vigorously massage the blood bag to mix the cells prior to administration.
Use a new blood administration tubing set for each blood bag infused.
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a nurse in an emergency room is caring for an infant who requires emergency surgery the infant is a company by his sixteen-year-old mother and his maternal grandfather which of the following actions should the nurse take when assisting with informed consent
Witness consent obtained from the infant's mother.
Inform the family that informed consent is not needed due to emergency surgery.
Notify the maternal grandfather that he is required to give informed consent.
Request that a court-appointed representative provide informed consent.
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a nurse is performing a focused assessment on a client who has chronic pain due to fibromyalgia which of the following question should the nurse ask to assess the quality of the clients paint
"How long do your episodes of pain typically last?"
"Do you have nausea when you're in pain?"
"Can you describe what your pain feels like?"
"Could you rate your pain on a scale of 0 to 10?"
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a nurses caring for a two-year-old toddler who is immediately post-operative which of the following Pain Scale should the nurse use to assess the toddler's pain level
FACES scale
COMFORT scale
Visual analog scale
FLACC scale
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A nurse is developing a plan of care for an older adult client who is at risk of falling. Which of the following fall prevention measures should the nurse include in the theplan?
Ask the client to demonstrate how to use the call light.
Place wool socks on the client prior to ambulation.
Store the client's eyeglasses in the bathroom at night time.
Keep the bed in a flat position when the client is sleeping.
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A nurse is teaching the parent of a toddler about home injury prevention. When discussing snacks, which of the following statements by the parent indicates an understanding of the teaching?
"I can offer her grapes as long as I peel them first."
"I can give her watermelon pieces after I remove the seeds."
"I should give her popcorn that is air-popped and without salt or butter."
"I should cut hot dogs into thin, round slices before giving them to her."
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A charge nurse is educating unit staff about the cultural aspects of client care following death which of the following statements by an assistive personnel indicates an understanding of the teaching
"The body of a client who practices Islam is washed and wrapped in a cloth following death."
"The body of a client who practices Judaism is left alone for 24 hr following death."
"The youngest child of a client who is Chinese might want to stay with the body for 12 hr following death."
"The body of a client who practices Buddhism is prepared by the oldest female family member."
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A nurse is caring for a child who has celiac disease. Which of the following items should the nurse remove from the child's meal tray
Corn-flake cereal
Orange juice
Scrambled eggs
Oatmeal with raisins
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A nurse is caring for a client who has dysphagia following a stroke which of the following actions shuld the nurse take to facilitate safe swallowing and decrease the risk of aspiration? (dysphagia=difficulty swallowing)
Delay the client's meal-time if he is fatigued.
Instruct the client to tilt his head to the side when swallowing.
Assist the client with fluid intake by inserting it into the client's mouth with a syringe.
Encourage the client to focus on a television program during meal time.
Delay the client's meal-time if he is fatigued. Client should be well rested prior to meal time.
A nurse is providing dietary teaching to a client who has diarrhea. Which of the following instructions should the nurse include?
"Decrease your intake of soluble fiber while you are experiencing diarrhea."
"Decrease your intake of sodium while you are experiencing diarrhea."
"Increase your intake of potassium-rich foods while you are experiencing diarrhea."
"Increase your intake of caffeinated beverages while you are experiencing diarrhea."
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A nurse is planning to implement bladder retraining for a client who has urge urinary incontinence. WHich of the following actions should the nurse plan to take?
Assist the client to the toilet as soon as the urge to void is reported.
Apply an adult diaper to the client during nighttime hours.
Gradually lengthen the time between the client's scheduled voids.
Decrease the client's fluid intake beginning at 2000.
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A nurse at a provider's office is counseling a client who reports insomnia. Which of the following statements should the nurse make to include the clients preferences into a sleep promotion plan?
"If alcoholic beverages are desired, consume them in the early evening."
"Sleep in the location of your home where you feel you rest best."
"Turn on a favorite television show just before going to bed."
"Allow your sleep and wake times to vary depending on how you feel each day."
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A nurse is caring for a client who is 2 days postoperative following an above-the-knee amputation the client states he is experiencing a dull, burning pain in the leg that was amputated. which of the following actions should the nurse take to treat the clients pain
Inform the client that phantom limb pain is not real.
Administer a beta-blocking medication to the client.
Place the client on a soft mattress.
Loosen the bandage on the client's residual limb.
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