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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 [Show More]

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