A home health nurse is caring for a child who has Lyme disease. Which of the following is an
appropriate action for the nurse to take? - ANS Ensure the state health department has been
notified.
A nurse is caring for a client who has a vented NG tube set to low intermittent suction and has
vomited. Which of the following actions should the nurse perform first? - ANS Evaluate
functioning of the suction device.
While performing a routine assessment, a nurse notices fraying onto the electrical cord of a
client's continuous passive motion (CPM)device. Which of the following actions should the nurse
take first? - ANS Remove the device from the room.
A nurse is setting up a sterile field to perform wound irrigation for a client. Which of the following
actions should the nurse take when pouring the sterile solution? - ANS Remove the cap and
place it sterile side up on a clean surface.
A nurse is creating a plan of care for a female client who has recurrent urinary tract infections.
Which of the following interventions should the nurse include in the plan? - ANS Wear loose
fitting underwear.
A nurse is caring for an infant who has gastroenteritis. Which of the following assessments
findings should the nurse report to the provider? - ANS Sunken fontanels and dry mucous
membranes.
A nurse is conducting health promotion education regarding contraindications to combination
oral contraceptive use to a group of women. Which of the following conditions should the nurse
include in the teaching? - ANS Hypertension
A nurse is providing teaching to a client who has a depressive disorder and a new prescription
for amitriptyline. Which of the following statements by the client indicates understanding of the
teaching? - ANS "I know it will be a couple of weeks before the medication helps me feel better."
A nurse is caring for a client who is immobile. Which of the following interventions is appropriate
to prevent contracture? - ANS Align a trochanter wedge between the client's legs.
A nurse is assessing a client who is postoperative following abdominal surgery and has an
indwelling urinary catheter that is draining dark yellow urine at 25 mL/hr. Which of the following
interventions should the nurse anticipate? - ANS Obtain a urine specimen for culture and
sensitivity
, A nurse is reporting a client's laboratory tests to the provider to obtain a prescription for the
client's daily warfarin. Which of the following laboratory tests should the nurse plan to report to
obtain the prescription for the warfarin? - ANS INR
A nurse is assessing a client who is taking haloperidol and is experiencing pseudoparkinsonism.
Which of the following findings should the nurse document as a manifestation of
pseudoparkinsonism? - ANS Shuffling gait
A nurse is caring for a client who is experiencing expressive aphasia and right hemiparesis
following a stroke. Which of the following actions by the nurse best promotes communication
among staff caring for the client? - ANS Having interdisciplinary team meetings for the client on
a regular basis.
A nurse is caring for a 2-year-old toddler. Which of the following food choices should the nurse
recommend to promote independence in eating? - ANS Banana slices
A nurse on a medical-surgical unit is notified that a mass casualty event has occurred in the
community. Which of the following actions should the nurse plan to take? - ANS Recommend to
the provider specific acute care clients for discharge.
A nurse is receiving change-of-shift report for four clients. Which of the following clients should
the nurse assess first? - ANS A client who was just given a glass of orange juice for low blood
glucose level.
A nurse is performing postmortem care for a recently deceased client prior to the client's family
visit. Which of the following actions should the nurse plan to take? - ANS Hold the client's eyes
shut for a few seconds.
A nurse is admitting a client who has schizophrenia. The client states, "I'm hearing voices."
Which of the following responses is the priority for the nurse to state? - ANS "What are the
voices telling you?"
A nurse is administering furosemide IV bolus to a client who has fluid volume excess. The nurse
should recognize which of the following as an indication that the medication has been effective?
- ANS Weight loss
A nurse is caring for a client who requires nasotracheal suctioning. Identify the sequence the
nurse should follow to perform suctioning. - ANS 1. Turn on the suction and set the pressure.
2. Don sterile gloves.
3. Insert the catheter during the client's inspiration.
4. Apply suction while rotating the catheter.
5. Rinse the catheter to remove secretions.
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