A Chinese-American client who just delivered a baby states that she will not
be able to take the prescribed sitz baths to help heal her episiotomy
incision because this will cause an unhealthy balance of cold and hot forces.
When planning nursing care, what nursing diagnosis has the highest
priority? - ANS ✓Impaired tissue integrity related to episiotomy
17. A 2-year-old with sickle cell anaemia has an axillary temperature of 102
F. In planning care for this child, which nursing diagnosis has the highest
priority? - ANS ✓High risk for fluid volume deficit related to temperature
elevation
During the first trimester of pregnancy, a client who was treated for genital
herpes with acyclovir (Zovirax) prior to this pregnancy tells the nurse that
she is experiencing an episode of genital herpes. Which nursing
intervention has the highest priority? - ANS ✓Determine if the client has
taken acyclovir (Zovirax) for this outbreak of genital herpes
The nurse is obtaining a medication history for a client with a new
prescription for paroxetine (Paxil). The client reports current use of the
MAO inhibitor isocarboxazid
(Marplan). What intervention is most important for the nurse to
implement? - ANS ✓Notify the healthcare provider that the client is currently
taking Marplan
While performing a skin inspection on a newborn, the nurse finds a small
dimple and a dark tuft of hair in the lumbosacral area of the infant's back.
What is the most likely indication of this finding? - ANS ✓External
manifestation of a spinal abnormality
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What action should the nurse implement first when delegating nursing
activities to an unlicensed assistive personnel (UAP)? - ANS ✓Evaluate the
experience of the UAP
A female resident of a long-term care facility is being admitted to the
medical department. The client has a fractured hip and has methicillin-
resistant
staphylococcus aureus (MRSA). Which room should the charge nurse assign
this client? - ANS ✓A semi-private room with a client who also has methicillin-
resistant staphylococcus
aureus (MRSA)
The nurse is preparing a client for surgery. Which finding indicates that the
client is ready to proceed to the operating room (OR) for a scheduled
surgical procedure? - ANS ✓Hemoglobin 10.1 grams
The nurse is preparing to administer an intramuscular injection in the
ventrogluteal site of a client who weighs 80 kg. What size needle should the
nurse select? - ANS ✓21-gauge, 1.5-inch needle
A client at 38-weeks gestation is in active labor, and a vaginal birth after
Cesarean section (VBAC) is planned. Vaginal exam indicates that the client
is 6 cm dilated, 90% effaced, and at station 0 with intact membranes. As the
client's contraction become stronger, the fetal heart rate decelerates
during the contractions but returns to baseline. What action should the
nurse take? - ANS ✓Continue to monitor the client's labor progress
An elderly client with limited mobility reports frequent episodes of
nocturia. To reduce the risk for urinary incontinence, what action should
the nurse implement? - ANS ✓Keep the call bell within the client's reach
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Which diagnostic tests are most important for the nurse to monitor when
providing care for a client with a bowel obstruction? - ANS ✓Serum
electrolytes
28. A 72-year-old male client reports that he has felt depressed since his
wife died six months ago. What question is most important for the nurse to
ask this client? - ANS ✓"Have you ever felt like hurting yourself?"
After administering the first dose of newly prescribed to four clients within
a thirty minute time frame, the nurse evaluates each client for therapeutic
responses or any adverse reactions. Which medication should the nurse
evaluate first? - ANS ✓HYdromorphone (Dilaudid)
What is the most important symptom the nurse should monitor the client
for while assisting with the insertion of a subclavian central venous
catheter? - ANS ✓Shortness of breath
The nurse is developing a plan of care for a client who has a prescription
for the calcium channel-blocker nifedipine (Procardia) to treat angina
pectoris. What is the purpose for administration of this medication? - ANS
✓Decrease myocardial oxygen demands
While transcribing a new prescription, the nurse notes that the prescribed
dosage is much lower than the recommended dosage listed in the drug
reference guide. Which client data supports this dosage reduction? - ANS
✓Increased liver enzymes
The nurse notes that a postoperative adult client's respiratory rate is 10
breaths/minute. Which factor in the client's history is the most likely
explanation for
this finding? - ANS ✓The PCA pump containing morphine sulfate was
discontinued 15 minutes before vital
signs were taken
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