1. Wheezing is often associated with asthma- assess breathing patterns and learn about any precipitating factors that caused the onset of the wheezing
2. A male client with limited mobility is discharged with home healt
...
1. Wheezing is often associated with asthma- assess breathing patterns and learn about any precipitating factors that caused the onset of the wheezing
2. A male client with limited mobility is discharged with home health services. When the home health nurse arrives, the client asks what he does for the swelling in his leg. Which should the nurse implement?
✓ -instruct the client to flex both of his feet several times a day
3. A client at an outpatient clinic submits a clean-catch midstream urine specimen for routine urinalysis. In later review of the client’s medical record, which data indicates to the nurse that the specimen collection should be repeated?
✓ -the urine specimen shows multiple organisms in low colony counts
Rationale: *often indicates that a contaminated specimen was obtained
4. During the admission assessment of a terminally ill male client, the client states that he is an agnostic. What is the best nursing action in response to this statement?
✓ -document the statement in the client’s spiritual assessment
5. The nurse observes a newly admitted older adult female take short stems and walk very slowly while pushing a walker in front of her. What action should the nurse take in response to these observations?
✓ -complete a full fall risk assessment of the client
6. The nurse notes that a client has cyanosis of the toes and fingertips. Which vital signs should the nurse obtain first?
✓ -respiratory rate
Rationale: *cyanosis is a bluish discoloration, an indication of hypoxemia
7. A middle-aged male client tells the nurse that two weeks ago, he began exercising four times a week to lose weight and to help him sleep better. He states that it still takes him an hour to fall asleep at night. Which action should the nurse implement?
✓ -ask the client to describe the exercise schedule that he has been following
Rationale: *to determine if he is exercising too close to bedtime
8. While suctioning a client's nasopharynx, the nurse observes that the patient's oxygen saturation remains at 94%, which is the same reading obtained before starting the procedure. What action should the nurse take in response to this finding?
✓ -complete the intermittent suction of nasopharynx *suctioning can be continued if the client’s oxygen saturation remains above 90% or does not decrease 5% from the initial baseline
9. An older male client returns to the clinic for chronic pain management after taking morphine sulfate (MS Contin) 25 mg every 12 hours. He states he took the medication only when the pain was too severe to sleep. What action should the nurse implement?
✓ -instruct the client to take the MS Contin every 12 hours as prescribed
10. A female, unlicensed assistive personnel (UAP) is assigned to take the vital signs of a client with pertussis for whom droplet precautions have been implemented. The UAP requests a change in assignment, stating she has not yet been fitted for a particulate filter mask. What action should the nurse take first?
✓ -instruct the UAP that a standard face mask is sufficient for the provision of care for the assigned client
Rationale: *a particulate filter mask is indicated for clients with airborne precautions
11. The community health nurse is making a home visit when the client, who is sitting at the kitchen table, begins to have a seizure. What action should the nurse take first?
✓ -assist the client to the floor
12. A client is in contact isolation due to a stage IV coccyx wound infected with methicillin resistant staphylococcus aureus (MRSA). The nurse plans interventions to prevent multiple re-entries in the client’s room. In which order should the nurse perform the interventions?
✓ -restart the IV, perform tracheostomy care, change the coccyx dressing
13. A client who has been taking diuretics for premenstrual swelling reports muscle weakness. Which serum electrolyte value should the nurse report to the healthcare provider?
✓ -Potassium 3.1 mEq/L (3.1 mmol/L)
14. A client diagnosed with primary open-angle glaucoma received a prescription for miotic eye drops, pilocarpine HCl (Pilocarpine). What instructions should the nurse plan to include in the client’s teaching?
✓ - “do not allow the dropper bottle to touch the eye.”
15. *Sleeping side
✓ lying with hips and knees flexed prevents unnecessary pressure on support muscles, ligaments, and lumbosacral joints and reduces low back pain
16. *Obesity
✓ a BMI greater than 30
17. *Hygiene self-care deficit
✓ evaluate the client’s participation in self-care to an optimal level of capacity is the best goal to evaluate progress in recovery
18. The unlicensed assistive personnel (UAP) describes the appearance of the bowel movement s of several clients. Which descriptions warrant additional follow-up by the nurse?
✓ -multiple hard pellets, tarry appearance, and brown liquid
19. A client with a gastronomy tube is recovering a continuous feeding, and the nurse suspects that the client has aspirated some of the feedings. What is the action by the nurse?
✓ -stop the tube feeding and assess the client
20. *it is the best response for the nurse to provide a response that reflects what the client stated and confirms their condition is serious.
[Show More]
