a nurse is planning care for a client who is receiving heparin to treat a deep vein thrombosis of
the left lower leg. which of the following interventions should the nurse include in the plan of
care? Ans- elevate th
...
a nurse is planning care for a client who is receiving heparin to treat a deep vein thrombosis of
the left lower leg. which of the following interventions should the nurse include in the plan of
care? Ans- elevate the affected leg
ambulation should be encouraged
a nurse is teaching a group of guardians about child safety measures. which of the following
statements by a guardian indicates an understanding of the teaching? Ans- I should have my
child avoid sun exposure between 10 am and 2 pm
a home health nurse is providing teaching about infection prevention to a client who has cancer
and is receiving chemotherapy. Which of the following statements by the client indicates an
understanding of the teaching? Ans- I will walk for short distances throughout the day
a nurse is providing dietary teaching to the parents of a 6 month old infant. which of the
following instructions should the nurse include? Ans- Introduce new foods one at a time over 5
to 7 days
a charge nurse is planning care for a client who has mechanical restraints in place. which of the
following interventions should the nurse include in the plan? Ans- Provide a staff member to stay
with the client continuously
can be physically or using an audiovisual device
need to document every 15-30 minutes, a new prescription should be in every 4 hrs for adults,
every 3 hrs for 9-17 years and every hour for those younger
a community health nurse is assisting with the development of a disaster management plan. the
nurse should include which of the following nursing responsibilities in the disaster response
stage of the plan? Ans- performing a rapid needs assessment
a nurse manager is assisting with the orientation of a newly licensed nurse. which of the
following actions by the nurse requires the nurse manager to intervene? Ans- tells the hospital
chaplain a clients diagnosis
a nurse is caring for a client who is in labor at 39 weeks of gestation. during the second stage of
labor, the nurse observes early deceleration on the monitor tracing. which of the following
actions should the nurse take? Ans- continue observing the fetal heart rate
these are an expected finding
a nurse manager is planning to make changes to the current scheduling system on the unit. to
facilitate the staff's acceptance of this change, which of the following actions should the nurse
manager take first? Ans- provide information about scheduling issues to the staff
unfreezing stage - increase understanding of why change is needed
a nurse is planning teaching about allowable foods for a client who has a history of uric acid
based urinary calculi formation. which of the following foods should the nurse include in the
teaching? Ans- oranges
can eat citrus fruits
no chicken, no organ meats like liver, no red wine (avoiding purine)
a charge nurse is teaching a newly licensed nurse how to identify true labor. which of the
following should the nurse include in the teaching? Ans- the cervix transitions to an anterior
position
contractions will be felt in the lower abdomen and back, intensity increases with ambulation,
cervix shortens and thins
a nurse on a medical surgical unit is caring for a client prior to a surgical procedure. which of the
following findings should indicate to the nurse that the client has the ability to sign the informed
consent? Ans- the client is able to accurately describe the upcoming procedure
a charge nurse assigns a newly licensed nurse to care for a client who has a chest tube. The nurse
expresses concern about having limited experience with monitoring chest tube drainage. which
of the following actions should the charge nurse take first to provide teaching about chest tubes?
Ans- ask the nurse about their knowledge of the procedure
a nurse is teaching a client who has a new prescription for estradiol. for which of the following
adverse effects of this medication should the nurse instruct the client to monitor and report to the
provider? Ans- headaches - can be indicative of a thromboembolic stroke
a nurse is preparing to administer diazepam 0.3mg/kg IV bolus to a toddler who weighs 22 lb
and is experiencing a grand maul seizure. availabale is diazepam solution for injection 5mg/mL.
how many mL should the nurse administer? 0 Ans- 0.6 mL
a nurse is caring for a client who is 12 hours postoperative, is receiving PCA for pain control,
and requires a blood pressure check in 10 min. which of the following staff members should the
nurse assign to collect the information? Ans- An assistive personnel (AP) who is assisting a
client to return to bed
a nurse is creating a plan of care for a child who has acute lymphoid leukemia and an absolute
neutrophil count of 400/mm^3. which of the following interventions should the nurse include in
the plan? Ans- withhold administering the varicella vaccine to the child - it is a live vaccine and
should not be given
a nurse is providing teaching about improving nutrition for a client who has multiple sclerosis.
which of the following instructions should the nurse include? select all Ans- A speech
pathologist will be performing a swallowing study for you
you should rest before eating meal
thicken your beverage before drinking
a nurse is assessing a client who has schizophrenia and is taking chlorpromazine. which of the
following findings is the priority for the nurse to report to the provider? Ans- temperature 39.4
(102.9)
a client is receiving lorazepam IV for panic attacks and develops a respiratory rate of 6/min and a
blood pressure of 90/44 mm Hg. Which of the following medications should the nurse anticipate
administering? Ans- flumazenil
a nurse is caring for an older adult client in the PACU following general anesthesia. which of the
following findings should the nurse report to the provider
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