A nurse is assisting with monitoring a client who is in labor and has spontaneous rupture of
membranes following a vaginal examination. The provider reports the client's cervix is dilated to
1 cm with an unengaged presenting part. Which of the following actions should the nurse take?
- ANSApply the external fetal heart rate monitor.
A Nurse is collecting data from a client who has bipolar disorder and is experiencing acute
mania. Which of the following findings is the nurse's priority? - ANSlack of sleep
A nurse is reinforcing teaching with a client who has a type 2 diabetes mellitus and reports
waking during the night with tremors and anxiety. which of the following information should the
nurse provide to help the client manage his symptoms? - ANSEat a bedtime snack
a Nurse is reinforcing teaching for a client who has a coronary artery disease and is taking
low-dose aspirin daily. The nurse should include that this medication has which of the following
therapeutic effects for CAD? - ANSAntiplatelet
A nurse is collecting data from a client who has an unprepared femur fracture and rates his pain
as 8 on a scale of 0 to 10. The client is talking and caught with a visitor. Which of the following
of the prescribed medication should the nurse administer? - ANSHydromorphone 5 mg orally.
A nurse is reinforcing preoperative teaching with a client scheduled for a bowel retention with
ileostomy. which of the following descriptions should the nurse give of the expected output from
a mature ileostomy? - ANSliquid with little odor
A nurse is caring for a client who is 16 hr postoperative following a total hip arthroplasty. the
client reports numbness, pain, and tingling in the affected leg. Which of the following actions
should the nurse take first? - ANScompare capillary refill in toes bilateraly
A nurse is reinforcing teaching with a client who has acute diverticulitis. Which of the following
statements by the client indicates an understanding of the teaching about the acute phase of
diverticulitis? - ANS"I will receive the nutrient I need through my IV Fluid"
A nurse in reinforcing teaching with a client about cancer prevention. The nurse should include
that frequent consumption of which of the following foods increases the risk of cancer? -
ANSLamb
, A nurse is assisting in teaching a group of staff nurses about hepatitis A. Which of the following
modes should the nurse include as a method of transmitting hepatitis A? - ANSConsumption of
contaminated food.
A nurse is reinforcing teaching with a client who is bottle feeding he full-term newborn with
formula. Which of the following instructions should the nurse include in the teaching? -
ANSAlthough is is unnecessary to be rigid about feeding times, six to eight feedings every 24
hrs should support a full-term newborn's nutrition adequately. Fewer feedings in the initial weeks
could delay the estabilment of an adequate weight-gain pattern.
A nurse is assisting with the plan of care for a client following a transurethral resection of the
prostate. Which of the following interventions should the nurse include in the plan of care? -
ANSThe nurse should irrigate the bladder using strict sterile technique and maintain closed
catheter drainage system to minimize the rick of infection.
A nurse is reviewing a client's electronic medical record and finds that an assistive personnel
recorder the client's temperature as 35.3 degrees Celsius (95.5 degrees F) 2 hrs earlier. Which
of the following actions should the nurse take firsT? - ANSCheck the client's temperature.
A nurse is receiving change-of-shift report for four clients. Which of the following clients should
the nurse see first? - ANSA client whose urinary output was 100mL for the past 12 hrs
A nurse in reinforcing teaching about weight loss with a female older adult client who is
overweight. Which of the following statements should the nurse include in teaching? - ANSkeep
fat intake to no more that 30% of daily caloric intake.
A nurse is collecting data from a client who has iron deficiency anemia. Which of the following
findings should the nurse expect? - ANSDifficulty concentrating.
A Nurse is collecting data from an older adult client who is 48 hr postoperative following
abdominal surgery. The provider writes a prescription to advance the client to a regular Diet. For
which of the following findings should the nurse notify the provider? - ANSThe client has absent
bowel sounds.
A nurse is reinforcing discharge teaching with a client who is postoperative following
transurethral resection fo the prostate. Which of the following instructions should the nurse
include in the teaching? - ANSperform Kegel exercises daily.
A nurse is reinforcing teaching about ways to reduce solid fat consumption with a client who has
an elevate cholesterol level. which of the following strategies should the nurse include in the
teaching? - ANSpurchase beef that is a loin cut.
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