Patient refused a newly open fentanyl patch. Which of the following actions should the nurse take? AnsAsk another nurse to witness the disposal of the new patch.
Client receiving heparin continuous IV infusion and warf
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Patient refused a newly open fentanyl patch. Which of the following actions should the nurse take? AnsAsk another nurse to witness the disposal of the new patch.
Client receiving heparin continuous IV infusion and warfarin 5 mg PO daily. Lab values are aPTT 98
seconds and INR 1.8 Ans- Withhold the heparin infusion
A nurse at an urgent care clinic is assessing a client who reports impaired vision in one eye . Which
indicates the client has a detached retina Ans- Floating dark spots
infant with hydrocephalus 6 hr post op following ventriculoperitoneal shunt placement . finding to
report to provider Ans- Irritability when being held. signifies increased ICP
Assessing a newborn heart rate follow actions the nurse should take Ans- Auscultate the apical pulse
and count beats for at least 1 min.
Caring for a client who has a fecal impaction actions to be taken when digitally evacuating the stool AnsInsert a lubricated gloved finger and advance along the rectal wall.
Dietary teaching for a new prescription of phenelzine Ans- Broccoli, Yogurt, Cream Cheese
Nurse administers incorrect dose of medication. Which facts related to incident report should the nurse
document in the client's medical record? Ans- Time the medication was given
Nurse on pediatric unit received shift report on 4 children. Which should the nurse assess first? Ans- A
10-year old child who is awaiting surgery for an appendectomy and experienced sudden relief of pain.
Can indicate peritonitis from a ruptured appendix.
Community health nurse providing teaching on home safety for older adults Ans- Have grab bars
installed around your bathtub and toilet.
School age child with scald burns on both hands and wrists suspected abuse Ans- Contact child
protective services.
Client who has acute blood loss following trauma refuses potentially life saving blood transfusion AnsExplore the client's reasons fro refusing the treatment
Discussing common prenatal discomfort 20 weeks gestational Ans- I will wear a supportive bra overnight
Discharge instructions to client to received home oxygen therapy Ans- Wear clothing made with cotton
fabrics while oxygen is in use.
Preparing an educational session about advocacy to a group of nurses Ans- Advocacy is a leadership role
that helps others to self actualize
Continuous bladder irrigation following transurethral resection of prostate. Bladder spasms and
decreased urinary output Ans- Irrigate the catheter with 0.9% sodium chloride irrigation
Child with sickle cell anemia and is having a vaso-occlusive crisis Ans- Infuse IV fluids
Client teaching about the basal body temp method for birth control Ans- Your body temperature might
decrease slightly just prior to ovulation
Caring for a client who is unconscious and requires emergency medical procedures. Unable to locate
family to obtain consent Ans- Proceed with provision of medical care
Client who has fluid volume overload. Which tasks can nurse delegate to UAP Ans- Measure the client's
daily weight
Checking for Chvostek's sign Ans- The nurse should assess for a Chvostek's sign by tapping the client's
facial nerve about an inch in front of the tragus of the ear. Facial twitching is a positive finding that
indicates hypocalcemia.
Reviewing urinalysis report of client with acute glomerulonephritis expected findings Ans- Protein
Newly admitted child. Which of the following actions should the nurse include in the plan AnsAdminister high dose antibiotic therapy
Client with cancer deciding between two treatment plans Ans- tell me more about your understanding
of the options.
Caring for a client receiving hemodalysis with AV fistula Ans- Auscultate the affected extremity for a
bruit
Oncology unit nurse is administering doxorubicin to breast cancer patient Ans- Inspect the client's
mucosa for petechiae every 8 hrs. This med causes thrombocytopenia and increases the risk of bleeding
Hospice nurse consulting about receiving home services Ans- We can expect the hospice nurse to
provide support for us after our mother's death
Client with major depressive disorder has signed informed consetn for ECT. Client states I'm not sure
about this now I'm afraid it's too risky Ans- You have the right to refuse to have the ECT even after you
have agreed to it
Discharge instructions about newborn care to a client 2 days postpartum Ans- I will cover my baby's
body when I wash her hair. I will use the bulb syringe first in her mouth and then in her nose.
Assigning task roles for group of clients in community mental health clinic. Which should be assigned to
group functioning the orienter Ans- Noting the progress of the group toward assigned goals
Nurse must recommend clients for discharge in order to make room for several critically injured clients
from a local disaster Ans- A client who has cellulitis and is receiving oral antibiotics every 8 hours.
Developing a client education program about osteoporosis for older adult clients Ans- Sedentary lifestyle
Charge is providing educational session about infection control for a group of staff on isolation
precautions Ans- A client who requires airborne precautions should be placed in a negative pressure
airflow room
Preparing to assist with a thoracentesis for a client who has pleurisy Ans- Instruct the client to avoid
deep breathing during the procedure
Caring for a school age child taking valporic acid. Diagnostic tests Ans- Serum liver enzyme levels
Inpatient mental health unit is monitoring a visit between client with aggressive behavior and the
client's partner Ans- The client is pacing around the chair in which his partner is sitting.
Home health nurse evaluating a school age child with cystic fibrosis initiates a request for high frequency
chest compression vest Ans- My child has only a small amount of mucus after percussion therapy
Planning care for a client with left sided weakness following a stroke Ans- Support the client's left arm
on a pillow while sitting
caring for a client who has schizophrenia who recently started risperidone Ans- Implement fall
precautions for the client
Caring for a child with a fever and fluid filled vesicles on trunk and extremities. Identify priority AnsInitiate transmission based precautions
Assessing client for compartment syndrome expected findings Ans- Edema
Just received change of shift report on 4 clients. Which should the nurse assess first Ans- A client who is
postop with abdominal distention and no bowel sounds
Assessing a client after administering epinephrine for anaphylactic reactions. Identify adverse effect of
this med Ans- Report of Chest pain
Provide teaching to client 24 wks gestation scheduled for glucose tolerance test Ans- You will need to
fast the night before the test.
Assessing older adult client with pneumonia Ans- acute confusio
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