A nurse is assessing a client who received 2 units of packed RBCs 48 hrs ago. Which of the following
findings should indicate to the nurse that the therapy has been effective? Ans- hemoglobin 14.9 g/dL
a nurse working
...
A nurse is assessing a client who received 2 units of packed RBCs 48 hrs ago. Which of the following
findings should indicate to the nurse that the therapy has been effective? Ans- hemoglobin 14.9 g/dL
a nurse working in an emergency department is triaging four clients. which of the following clients
should the nurse recommend for treatment first? Ans- a middle adult client who has unstable vital signs
a nurse is caring for a client who has fluid volume overload. which of the following tasks should the
nurse delegate to an assistive personnel? Ans- measure the client's daily weight
a nurse is preparing to administer mannitol 0.2 g/kg IV bolus over 5 min as a test dose to a client who
has severe oliguria. The client weighs 198 lb. what is the amount in grams the nurse should administer?
Ans- 18 g
a nurse is conducting a physical examination for an adolescent and is assessing the rang of motion of the
legs, which of the following images indicates the adolescent is abducting the hip joint? Ans- Moving the
leg away from the midline of the body (off to the side, not to the front)
a nurse is caring for a client who has hyperthyroidism. which of the following findings should the nurse
expect? Ans- tremors
tachycardia, diaphoresis, weight loss, insomnia, exopthalmia
hypothyroidism has dry corase hair, bradycardia, and periorbital edema
a nurse is assessing a school age child who has bacterial meningitis. which of the following findings
should the nurse expect? Ans- nuchal rigidity
also weight loss
a nurse is assessing a newborn's heart rate. which of the following actions should the nurse take? Ansauscultate the apical pulse at least 1 min
a nurse is preparing to assist with a thoracentesis for a client who has pleurisy. the nurse should plan to
perform which of the following actions? Ans- instruct the client to avoid coughing during the procedure
a nurse is the emergency department is assessing a preschooler who has a facial laceration. the nurse
should identify which of the following findings as a potential indication of child sexual abuse? Ans- the
child exhibits discomfort while walking
a nurse is preparing to teach about dietary management to a client who has crohn's disease and an
enteroenteric fistula. which of the following nutrients should the nurse instruct the client to decrease in
their diet? Ans- fiber - reduce diarrhea and inflammation
a nurse is caring for a client who has a prescription for a continuous passive motion CPM machine
following a total knee arthroplasty. which of the following actions should the nurse take? Ans- Turn off
the CPM machine during mealtime
promote client comfort and dietary intake
a nurse is preparing to initiate IV access for an older adult client. Which of the following sites should the
nurse select when initiating the IV for this client? Ans- radial vein of the inner arm
a nurse is developing a client education program about osteoporosis for older adult clients. the nurse
should include which of the following variables as a risk factor for osteoporosis? Ans- sedentary lifestyle
also, small framed body with a thin build, estrogen deficiency
a nurse in an emergency department is caring for a child who has a fever and fluid filled vesicles on the
trunk and extremities. which of the following interventions should the nurse identify as the priority?
Ans- initiate transmission based precautions
a nurse is caring for a client who has a clogged percutaneous gastrostomy feeding tube. which of the
following actions should the nurse take first? Ans- change the position of the client
a home health care nurse is developing a teaching plan for a client who has a new ileostomy. which of
the following instructions should the nurse include? Ans- empty the appliance when it is one third to
one half full
a nurse is reviewing the laboratory report of a client who has end stage kidney disease and received
hemodialysis 24 hr ago. Which of the following laboratory values should the nurse report to the
provider? Ans- sodium 148 mEq/L
a nurse is caring for four clients. which of the following tasks should the nurse delegate to an assistive
personnel? Ans- Arrange the lunch tray for a client who has a hip fracture
a nurse is preparing a client for a paracentesis. which of the following actions should the nurse take?
Ans- instruct the client to void
a nurse has received change of shift report on four assigned clients. for which of the following clients
should the nurse intervene to prevent a potential food and medication interaction? Ans- a client who is
receiving an MAOI and is requesting a cheeseburger for dinner
a nurse is planning care for a client who has rheumatoid arthritis and has moderate to severe pain in
multiple joints. which of the following actions should the nurse plan to take? Ans- allow for frequent rest
periods throughout the day
a nurse is caring for a client who is receiving continuous bladder irrigation following a transurethral
resection of the prostate. the client reports bladder spasms, and the nurse observes a decreased urinary
output. which of the following actions should the nurse take? Ans- irrigate the catheter with 0.9%
sodium chloride irrigation
a nurse is assessing a client who has COPD. which of the following findings should the nurse expect?
Ans- pH 7.31
a nurse in a community center is providing an educational session to a group of client about ovarian
cancer. which of the following manifestations of ovarian cancer should the nurse include in the
teaching? Ans- abdominal bloating
increase in abdominal girth, pelvic or abdominal pain, early satiety, urinary frequency of urgency
a nurse is caring for a client who has active tuberculosis TB. which of the following actions should the
nurse plan to take to prevent the transmission of the disease? Ans- Have the client wear a surgical mask
while being transported outside the room
a nurse is caring for a group of clients. which of the following clients should the nurse attend to first?
Ans- an older adult client who is anxious and attempting to pull out an IV line
an RN is observing a licensed practical nurse LPN and an assistive personnel AP move a client up in bed.
for which of the following situations should the nurse intervene? Ans- The LPN and the AP grasp the
client under his arms to lift him up in bed
a nurse is preparing to administer insulin to a client via a pen device. which of the following actions
should the nurse take? Ans- hold the insulin pen device perpendicular to the client's skin to inject the
medication
a nurse is caring for a client who has immunosuppression and a continuous IV infusion. which of the
following actions should the nurse take? Ans- monitor the client's mouth every 8 hours
a nurse is providing teaching about advance directives to a middle adult client. which of the following
client responses indicates an understanding of the teaching? Ans- "I can designate my partner as my
health care surrogate"
a nurse is assessing a client following a vaginal delivery and notes heavy lochia and a boggy fundus.
which of the following medications should the nurse expect to administer? Ans- oxytocin
a nurse manager is planning to use a democratic leadership style with the nurses on the unit. Which of
the following actions by the nurse manager demonstrates a democratic leadership style? Ans- seeks
input from the other nurses
a nurse is assigning task roles for a group of clients in a community mental health clinic. which of the
following tasks should the nurse assign to the member of the group functioning as the orienteer? Ansnoting the progress of the group toward assigned goals
a nurse is creating a plan of care for a newly admitted child. which of the following actions should the
nurse include in the plan? Ans- Administer high dose antibiotic therapy
cystic fibrosis kid with lung infection
a nurse is caring for a newborn immediately after delivery. which of the following interventions should
the nurse implement to prevent heat loss by conduction? Ans- use a protective cover on the scale when
weighing the infant
a nurse is caring for a client who has abdominal surgery 24 hr ago. which of the following actions is the
nurse's priority? Ans- assist with deep breathing and coughing
a nurse in an outpatient mental health clinic is caring for four clients. the nurse should recognize that
which of the following clients is effectively using sublimation as a defense mechanism? Ans- a client who
channels their energy into a new hobby following the loss of their job
a nurse is assessing for correct placement of a client's NG feeding tube prior to administering a bolus
feeding. which of the following actions should the nurse take? Ans- aspirate contents from the tube and
verify the pH level
an antepartum nurse is caring for four clients. for which of the following clients should the nurse initiate
seizure precautions? Ans- a client who is at 33 weeks of gestation and has severe gestational
hypertension
a nurse is providing discharge teaching to a client who is to receive home oxygen therapy. which of the
following instructions should the nurse include in the teaching? Ans- wear clothing made with cotton
fabrics while oxygen is in use
use water soluble lubricant not petroleum based lubricant
a nurse is providing teaching for a client who has a fracture of the right fibula with a short leg cast in
place a new prescription for crutches. The client is non weight bearing for 6 weeks. which of the
following instructions should the nurse include in the teaching? Ans- use a three point gait
a nurse is preparing to transfer a client from the ICU to the medical floor. The client was recently
weaned from mechanical ventilation following a pneumonectomy. which of the following information
should the nurse include in the change of shift report? Ans- The time of the client's last dose of pain
medication
a nurse is assessing an infant who has hydrocephalus and is 6 hr postoperative following placement of a
ventriculoperitoneal VP shunt. Which of the following findings should the nurse report to the provider?
Ans- irritability when being held - increased intracranial pressure
a nurse is caring for a client who has a prescription for chlorpromazine. which of the following findings
should the nurse identify as an indication that the medication is effective? Ans- decreased hallucinations
a nurse is providing teaching about lithium to a client who has bipolar disorder. which of the following
statements should the nurse include in the teaching? Ans- "Notify your provider if you experience
increased thirst"
a nurse is caring for a client who has a fecal impaction. which of the following actions should the nurse
take when digitally evacuating the stool? Ans- insert a lubricated gloved finger and advance along the
rectal wall
a nurse is planning to delegate client care tasks to an assistive personnel AP. which of the following tasks
should the nurse plan to delegate to the AP? Ans- perform gastrostomy feedings through a client's
established gastrostomy tube
a nurse manager is preparing an educational session for nursing staff about
[Show More]
