81 A client is admitted with acute pancreatitis. The client admits to drinking a pint of bourbon . The nurse medicates the client for pain and monitors vital every 2 hours. Which finding shoul
81 A client is admitted with acute pancreatitis. The client admits to drinking a pint of bourbon . The nurse medicates the client for pain and monitors vital every 2 hours. Which finding should the nurse report immediately to the health care provider?
A Abdominal pain and vomiting .
B Yellowing and itching of skin.
C Confusion and tremors .
D Anorexia and abdominal distention .
82 Which information is most important for the nurse to obtain when determining a clients risk for obstructive sleep syndrome (OSAS)?
A Body mass index
B Level of consciousness .
C Self -description of pain .
D Breath sounds .
83 The nurse is caring for a one week old infant who has a ventriculoperitoneal (VP) shunt that was placed 2 days after birth. Which findings are indication of a postoperative complication ? (Select all that apply )
A Leakage of cerebral spinal fluid from the incisional site
B Poor feeding and vomiting .
C White blood cell count of 10000 / m * m ^ 3 * (10 * 10 ^ 0 / L) .
D Hyperactive bowel sounds.
E Abdominal distention
84 The nurse is assessing an older client who is having difficulty remembering events from earlier in the day and concentrating on the questions being asked. A family member shares that the client’s home was recently sold and the client has just moved in with them . Which nursing response best promotes effective communication with the family ?
A If the dementia is a result of Alzheimer’s disease , it is often reversible even in the late stages .
B The client’s delirium may be due to depression and is possibly reversible .
C The client is exhibiting symptoms of dementia and because of age , it may be permanent
D Delirium is often a sign of underlying mental illness and institutionalization is often necessary .
85 A client presents to the clinic with concerns regarding her left breast. Which assessment finding is most important for the nurse to report to the healthcare provider ?
A Multiple firm, round , freely movable masses.
B Bloody discharge from the nipple .
C A fixed nodular mass with dimpling of skin.
D A slight asymmetry of the breasts.
86 Which information should the nurse include in the discharge teaching plan of a client with low back pain who is taking cyclobenzaprine to control muscle spasms ?
A Use cold and allergy medications only as directed by a healthcare provider.
B Avoid using heat or ice to injured muscles while taking this medication.
C Take this medication on an empty stomach .
D Discontinue all nonsteroidal anti-inflammatory medications .
87 An 11-year-old client is admitted to the mental health unit after trying to run away from home and threatening self-harm. The nurse establishes a goal to promote effective coping and plans to ask the client to verbalize three ways to deal with stress. Which activity is best to establish rapport and accomplish this therapeutic goal?
A Bring the client to the team meeting to discuss the treatment plan.
B Play a board game with the client and begin talking about stressors.
C Ask the client to write feelings in a journal and then review it together.
D Explain the purpose of each medication the client is currently taking.
88 A client is admitted to the surgical intensive care unit following the removal of a large portion of the intestines due to a gunshot wound to the abdomen . The client begins to display signs of septic shock and a sepsis protocol is initiated . Which intervention is most important for the nurse to include in the plan of care ?
A Maintain strict intake and output .
B Assess warmth of extremities .
C Keep head of bed raised 45 degrees .
D Monitor blood glucose level .
89 The nurse is providing teaching to a school-age child with a left femoral osteomyelitis and the child’s parent prior to discharge. Which instruction should the nurse provide related to the initial phase of treatment ?
A Ensure no weight bearing on the affected extremity .
B Schedule ice pack applications to the infected area .
C Administer topical antibiotic therapy daily .
D Provide passive range of motion exercises.
90 The healthcare provider prescribes amiodarone 360 mg intravenously () to be infused over 6 hours for client with a ventricular dysrhythmia The IV bag is contains amiodarone 360 mg in dextruse 5% in water (D ,W) 200 How many hour should the nurse program the infusion pump? (Enter numerical value only . If rounding is required , round to the nearest whole number .)
91 After receiving a change of shift report for clients on a medical surgical unit, which task should the nurse assign to the practical nurse (PN)?
A Perform urinary catheter irrigations with normal saline .
B Complete comprehensive assessments .
C Begin initial sterile wound care for surgical clients .
D Initiate teaching for client care after discharge .
92 An adult client with severe depression was admitted to the psychiatric unit yesterday evening. Although the client ran a marathon one year ago, his spouse states that the client no longer runs, but sits and watches television most of the day . Which intervention is most important for the nurse to include in this client’s plan of care for today?
A Help client to develop a list of daily affirmations.
B Schedule client for a group that focuses on self-esteem.
C Encourage client to participate for one hour in a team sport
D Assist client in identifying goals for the day .
93 A client whose blood type O-negative delivers an Infant who is O-positive. Six hours after delivery the client has a negative Indirect Coombs. Which intervention should the nurse implement? A.Teach the mother about incompatibility of Rh factors.
B. Give a standard dose of RhoGAM within 72 hours of delivery.
C. Report the negative indirect Coombs to nursery personnel.
D. Assess the direct Coombs’ results for the infant.
94 The nurse is reviewing a client’s prenatal laboratory results. Based on the results, which immunization should the nurse instruct the client to receive after pregnancy?
A Diphtheria, pertussis, tetanus
B Influenza vaccine.
C Meningitis B.
D Measles, mumps , rubella .
95 The parent of a child born with a myelomeningocele asks the nurse, What did I do to deserve this? Which response is most helpful?
A “This must be a very difficult time for you.”
B “You didn’t do anything wrong .”
C Is there any particular reason why you think this is your fault ?”
D With surgery , your baby should have a full recovery .”
96 Which instruction should the nurse provide a client who was recently diagnosed with Raynaud’s disease?
A Walk regularly to increase circulation
B Wear gloves when removing packages from freezer.
C Use a heating pad at night to keep feet warm.
D Wear knee- high support stockings during the day.
97 A client with myasthenia gravis (MG) is receiving immunosuppressive therapy. Review of recent laboratory test results show that the client’s serum magnesium level has decreased below the normal range. In addition to contacting the healthcare provider, what nursing action is most important?
A Observe rhythm on telemetry monitor .
B Note most recent hemoglobin level .
C Check for visual difficulties .
D Assess for hip and hand joint pain .
98 When conducting teaching for a client who is on a postoperative full liquid diet, which foods should the nurse encourage the client to eat? (Select all that apply)
A Cheese.
B Tea.
C Potato soup.
D Lentils.
E Whole grain breads.
99 A 16 – year -old male who has been treated in the past for a seizure disorder is admitted to the hospital . Immediately after admission he begins to have a grand mal seizure. Which action should the nurse Implement?
A Observe the client carefully.
B Call the rapid response team .
C Place a padded tongue blade between client’s teeth.
D Obtain assistance in holding him to prevent injury .
100 A female client receives a prescription for alendronate sodium to treat her newly diagnosed osteoporosis. Which instruction should the nurse include in the client’s teaching plan?
A Eat within 30 minutes of taking the medication.
B Ingest an antacid 30 minutes prior to taking the tablet
C Take on an empty stomach with a full glass of water.
D Consume a light snack with the medication.
101 A client recently diagnosed with diabetes mellitus is taken to the emergency department experiencing extreme thirst and weakness with blurred vision. Which interventions should the nurse implement? (Select all that apply.)
A Obtain a fingerstick blood glucose.
B Administer a PRN dose regular insulin.
C Give client 1 cup diet carbonated soda.
D Give the client 4 ounces of orange juice.
E Have client recall food intake for last 24 hours.
102 A client with Addison’s disease becomes weak, confused, and dehydrated following the onset of an acute viral infection. The client’s laboratory values include: sodium 129 mEqL (129 mmol), glucose 54 mg/dl (2.97 SI) and potassium 5.3 mEqL (5.3 L ). When reporting the findings to the healthcare provider, the nurse anticipates a prescription for which intravenous medication?
A Regular insulin.
B Broad spectrum antibiotic.
C Potassium chloride .
D Hydrocortisone.
103 Which newly prescribed medication will require a nurse to monitor the for therapeutic response or adverse reaction 30 minutes post administration?
A Enoxaparin.
B Hydromorphone .
C Naloxone .
D Ondansetron
104 A 10-year-old child with is scheduled for a bone marrow aspiration. Lidocaine prilocaine (EMLA) cream is prescribed. Which action should the nurse Implement prior to the procedure ?
A Apply the cream to the iliac crest and cover one hour prior to the procedure .
B Administer a sedative and anxiolytic agent before applying the cream .
C Position with a pillow under the iliac crest to secure the cream application .
D Use ice to numb the skin and then apply the cream at the injection site .
105 An older client with a history of heart failure is admitted with influenza and requests assistance to sit up in bed to eat lunch. The nurse observes the unlicensed assistive personnel (UAP) wearing a gown and gloves to assist the client. Which action should the nurse take?
A Remind the UAP to apply a fitted respirator mask before entering the client’s room .
B Review the need for the UAP to wear a face mask while in close contact with the client .
C Instruct the UAP to notify the nurse of any changes in the client’s respiratory status .
D Assign the UAP to provide care for another client and assume full care of the client
106 A client who weighs 325 pounds (148 kg) is admitted because of ureteral colic and is now telling the nurse about a sharp pain radiating towards genital area. The client has hematuria and is hypertensive. Which Intervention in most important for the nurse to include in the clients plan of care?
A Document blood pressures.
B Monitor hematuria
C Encourage low calorie diet
D Manage pain.
107 The nurse assesses a client being treated for Herpes zoster (shingles). Which assessments should the nurse include when evaluating the effectiveness of treatment? (Select all that apply)
A Pain scale .
B Functional ability
C Bowel sounds .
D Skin integrity .
E Heart sounds
108 The nurse is caring for a who reports sudden right-sided numbness and weakness of the arm and leg. The nurse also observes a distinct right-sided facial droop. After reporting the findings to the healthcare provider, the nurse receives several prescriptions for the client , including a STAT computerized tomography scan of the head. After obtaining vital signs, the nurse should implement which intervention?
A Keep the bed in the lowest position and initiate seizure and fall precautions .
B Administer aspirin to prevent further clot formation and platelet clumping .
C Test for a swallowing reflex and perform communication deficit assessments .
D Notify the stroke team to assist with acute assessment and management
109 A female client on the mental health unit frequently asks the nurse when she can be discharged . Becoming more anxious, the client begins to pace in the hallway. Which intervention should the nurse implement first?
A Review the current treatment plan with the client
B Determine if the client has PRN medication for anxiety .
C Explore the client’s reasons for wanting to be discharged .
D Inform the healthcare provider about the client’s behaviors .
110 When performing suctioning for a client with a tracheostomy, which action should the nurse include?
A Instruct the client to cough as the suction tip is removed .
B Wear protective goggles while performing the procedure .
C Instill 3 mL of normal saline before suctioning .
D Apply a water soluble lubricant to the catheter .
111 Which long-term outcome is most important for the nurse to include in the plan of care for an older adult client with chronic pyelonephritis?
A Maintains blood pressure within normal limits .
B Manages activities of daily living independently .
C Measures oral temperature daily .
D Restricts fluid intake to 1 L/day .
112 A client with a C-6 spinal cord injury is in rehabilitation. In the middle of the night the client reports a severe, pounding headache, and has observable or goose bumps”. The nurse should assess for which trigger?
A Loud hallway noise.
B Frequent cough .
C Full bladder .
D Fever
113 An adult client with a broken femur is transferred to the medical surgical unit to await surgical internal focation after the application of an external traction device to stabilize the leg. An hour after an opioid analgesic was administered, the client reports muscle spasms and pain at the fracture site. While waiting for the client to be transported to surgery, which action should the nurse implement?
A Reduce the weight on the traction device.
B Check client’s most recent electrolyte values.
C Administer PRN dose of a muscle relaxant.
D Observe for signs of deep vein thrombosis.
114 The practical nurse (PN) reports that a client who has a fingerstick glucose of 35 mg/ ( 1.94 ) is alert and diaphoretic What action should the charge nurse take ?
A Assess client for polyuria and polyphagia.
B Give the client a glass of orange juice.
C Notify the healthcare provider.
D Collect a blood sample for hemoglobin A1c.
115 A primiparous woman presents in labor with the following labs: hemoglobin 10.9 g/dL (109 g/L), hematocrit 29% (0.29), hepatitis surface antigen positive, group B Streptococcus positive, and rubella non-immune. Which intervention should the nurse implement?
A Transfuse two units packed red blood cells.
B Inject hepatitis B immune globulin 0.5 mL.
C Administer ampicillin 2 grams intravenously .
D Give measles , mumps , rubella vaccine 0.5 mL
116 The nurse observes the external genitalia of a female client in preparation for inserting an indwelling urinary catheter. At what location should the catheter be ? (Mark location on image )
117 The nurse is performing tracheostomy care for a client when a code blue is called for another client on the unit who experiences a cardiopulmonary arrest. Which action should the nurse take?
A Respond to the code.
B Finish the procedure .
C Call for an assistant
D Close the room door .
118 of 160 The nurse is developing educational program for older clients who are being discharged with new antihypertensive medications. The nurse should ensure that the educational material include which characteristics? (Select that apply.)
A Printed using a 12-point type font
B Contains a list with definitions of unfamiliar terms.
C Written a twelfth-grade reading level.
D Uses pictures to help illustrate complex ideas.
E Uses common words with few syllables.
119 of 160 A client is being discharged home after being treated for heart failure (HF). Which instruction should the nurse include in this client’s discharge teaching plan?
A Limit fluid intake to 1,500 mL daily.
B Perform range of motion exercises.
C Eat a high protein diet
D Weigh every morning.
120 of 160 Which instruction should the nurse provide to a client who is preparing to have a cystoscopy? A Lay prone for 24 hours after the procedure.
B Avoid strenuous activity and sports for at least 2 weeks.
C Report any painful urination, blood in urine, or fever.
D Report any allergies to shellfish or iodine.
121 of 160 While caring for a client after a small bowel resection, the nurse is informed that the client has a history of methicillin -resistant Staphylococcus ( MRSA). To reduce the risk of recurrence of the MRSA in the postoperative wound, which intervention is most important for the nurse to implement?
A Report any increase in the white blood cell count
B Change the surgical dressing readily when soiled .
C Instruct the family to adhere to contact precautions .
D Wear a face mask while performing wound care .
122 of 160 A client is admitted with a severe asthma attack. For the last 3 the has experienced increasing shortness of breath. Arterial blood gas results are pH 7.22; PaCO, 55 mmHg, HCO, 25 mEqL (25). Which Intervention should the nurse implement?. Which Intervention should the nurse implement?
A Space care to provide periods of rest.
B Administer PRN dose of albuterol.
C Position client for maximum comfort.
D Instruct client to purse lip breathe.
123 of 160 The nurse is caring for four clients on a medical unit. Which client is at an increased risk for candidiasis?
A An older client with chronic kidney disease who has uremic frost.
B An adolescent in the third trimester pregnancy who has persistent hyperemesis.
C An adult with acquired immunodeficiency syndrome (AIDS) who is taking antibiotics.
D A client with is admitted for preoperative surgical consult for morbid obesity.
124 of 160 A 17-year-old is brought to the Emergency Department by both parents because the adolescent has been coughing and running a fever with flu-like symptoms for the past 24 hours. Which Intervention should the nurse Implement ?
A Place a mask on the client’s face.
B Obtain a chest x-ray per protocol .
C Assess the client’s temperature .
D Determine the client’s blood pressure .
125 of 160 A client with chronic obstructive pulmonary disease (COPD) is experiencing worsening dyspnea and low oxygen levels. Vitals signs are temperature 99.0F (37.5C), heart rate beats 96 beats/minute, respirations 28 breaths/minute, blood pressure 140 / 82 mmHg and oxygen saturation 88%. Which action should the nurse implement ?
A Obtain a sputum sample for culture and sensitivity .
B Apply a non -rebreather mask at 100 % oxygen .
C Prepare client for endotracheal intubation .
D Place the client in a forward -leaning position
126 of 160 After falling, an older adult presents to the Emergency Department with shallow, labored breathing, a respiratory rate of 32 breath/minute, paradoxical chest movement, and severe rib -cage pain with inspiration and movement. The nurse applies 100% oxygen per non-rebreathing mask. Which action should the nurse take next ?
A Call for a portable chest x-ray .
B Contact the on -call respiratory therapist
C Obtain arterial blood gases (ABGs ).
D Prepare for mechanical ventilation
127 of 160 A lethargic one hour-old infant is brought to the nursery for further assessment. In which order should the nurse assess this infant? (Arrange the first item on top, and the last item on the bottom.)
A Temperature.
B Respirations.
C Heart rate.
D Heel stick.
128 of 160 A client is transferred from the operating room to the post-anesthesia care unit with the following vital signs: temperature 99.8F (37.7C) heart rate 62 beats/minute, respirations B breaths/minute, blood pressure 95/54 mm Hg, and oxygen saturation 94%.
Which medication should the nurse administer ?
A Milrinone .
B Atropine .
C Naloxone .
D Acetaminophen .
129 of 160 The nurse is ready to insert an indwelling urinary catheter as seen in the picture. At this point in the procedure, which actions should the nurse take before inserting the catheter? (Select all that apply)
A Hold the catheter 3 to 4 inches (7.5 to 10 cm) from its tip.
B Ask the client to bear down as if voiding to relax the sphincter .
C Complete perianal care with soap and water.
D Gently palpate the client’s bladder for distention.
E Secure the urinary drainage bag to the bed frame.
130 of 160 The healthcare provider prescribes 5 % Dextrose Injection , USP with 20 units of regular insulin for a client with a serum level of 6.0 mEqL (6.0 mmol/L ) and glucose level of 180 mg/dL ( 10.0 mmol/L )Which evaluation is most important for the nurse to include in this clients of care ?
A Assess the serum potassium level every 4 hours
B Monitor and document strict intake and output
C Evaluate glucose levels before and after meals
D Obtain a 12-lead electrocardiogram daily.
131 Which medication should the nurse anticipate administering to a client who is diagnosed with myxedema coma?
A Subcutaneous administration of vitamin K.
B Intravenous bolus of hydrocortisone .
C Intravenous administration of thyroid hormones .
D Oral administration of hypnotic agents .
132 of 160 The nurse is assigned to provide care for a client who scheduled for a laparoscopic cholecystectomy two hours, at 0900. What nursing action most Important?
A Review postoperative instructions with the client
B Offer to assist the client to the restroom to void.
C Determine when the client last had pain medication
D Confirm that the client has been NPO since midnight
133 of 160 Following a house fire, an adult male is admitted to the emergency department with partial and full thickness bums . He used a blanket to cover his head and face , but his is burned on the dorsal surfaces of both and hands and his anterior legs . Using the Rule Nines to assess the extent of the client’s bums , what percentage of burned body surface area should the nurse document ?
A 36%
B 27% .
C 50%
D 9%
134 of 160 A client is admitted to the mental health unit for feelings of depression secondary to a positive HIV report. To provide a safe milieu for this client, which action should the nurse take ?
A Take the client’s cellular telephone and provide a telephone in the room .
B Ensure that prescribed medications are kept in a safe place in the room .
C Remove soft drink cans from the nurse’s desk and patient lounge .
D Replace paper trash bags with plastic biohazard bags .
135 of 160 A client who is admitted to the intensive care unit with syndrome of inappropriate antidiuretic hormone (SIADH) has developed osmotic demyelination, Which intervention should the nurse implement first?
A Patch one eye .
B Evaluate swallow .
C Reorient often .
D Range of motion.
136 of 160 When should intimate partner violence (IPV) screening occur ?
A Only when a client presents with an unexplained injury.
B Once the clinician confirms a history of abuse.
C As a routine part of each health care encounter.
D As soon as the clinician suspects a problem.
137 of 160 A client who had bariatric 2 months ago is admitted because of vomiting and inability to tolerate food and Equids. The client is pain free. Which Intervention should the nurse Include In the plan of care ?
A Administer daily vitamin supplements
B Determine if the client is over -hydrating to feel satiated
C Maintain the client on an NPO status .
D Encourage positive self accolades for dietary adherence .
138 of 160 A client with a history of chronic obstructive pulmonary (COPD) in admitted with pneumonia. Vital signs include: Heart rate 122 beats/minute. Respiratory rate 28 breaths/ minute, and blood pressure 170/90 mmHg. Which assessment finding warrants the most immediate intervention by the nurse?
A Bilateral diffuse wheezing .
B Shortness of breath on exertion .
C Yellow expectorated sputum .
D Temperature of 100.5 F (38.1 C ).
139 of 160 Following a motor vehicle collision (MVC ), an unrestrained client is admitted to the intensive care unit with altered mental status . The client has multiple rib fractures and bruising across the lower abdomen . Which assessment finding warrants immediate intervention by the nurse ?( Please scroll and view each tab’s information in the client’s medical record before selecting the answer .)
A large amount of gross hematuria .
B Several apnea episodes lasting ten seconds .
C Delayed peripheral capillary refill .
D Numbness of the left lower extremity .
140 of 160 An older is being admitted to a short -term rehabilitation facility after a long hospitalization The nurse is performing a functional assessment with the client . Which action should the nurse implement ?
A Ask the client how often episodes of sundowning are experienced .
B Question the client about the frequency of falls in recent months .
C Assist the client with values clarification about end -of -life care options
D Encourage the client to lie as still as possible during the assessment
141 of 160 The nurse is caring for a client with the sexually transmitted infection (STI) chlamydia . The client reports having sex with multiple partners. Which response should the nurse provide?
A Urge the client to have regular STI screening every two years.
B Provide counseling that most contraceptives protect against infection.
C Explain that reporting the infection to health agencies is required .
D Discuss that partners without similar symptoms may not be infected .
142 of 160 A mother brings 3-weeks old son to the clinic because he is vomiting “all the time”. In performing a physical assessment , the nurse notes that the infant has poor skin turgor, has lost 20% of his birth weight, and has a palpable oval-in abdomen. Which should the nurse Implement ?
A Give the infant 5% dextrose in water orally .
B Insert a nasogastric tube for feeding .
C Initiate a prescribed IV for parenteral fluid .
D Feed the infant 3 ounces of Isomil.
143 of 160 A client receives a prescription for itraconazole, Which information provided by the client requires additional instruction by the nurse?
A Avoid the consumption of grapefruit juice .
B Take the medication with antacids .
C Report any difficulty with breathing .
D Monitor for changes in stool color .
144 of 160 In evaluating a client at 29-weeks’ gestation, which finding should the nurse report to the healthcare provider immediately?
A Urinary frequency .
B Whitish , odorless , mucoid vaginal discharge .
C Edema of ankles , face , and hands .
D Temperature of 100F ( 37.8 C).
145 of 160 When planning care for an adolescent with anorexia nervosa, which nursing problem has the highest priority?
A Interrupted Family Processes
B Disturbed Body Image .
C Noncompliance with treatment regimen .
D Imbalanced Nutrition : less than body requirements .
146 of 160 When the parents of a 6-year-old boy with a brain tumor are told that his condition is terminal, the mother shouts at the father, “This is your fault It never would have happened if we had sought treatment sooner”. Which intervention is best for the nurse to implement?
A Assure the parents that a terminal diagnosis was inevitable .
B Refer the parents to the chaplain to provide grief counseling .
C Tell the parents that blaming each other will not change the situation .
D Explain to the parents that anger is a common response to grief .
147 of 160 A female client is taking alendronate, a bisphosphonate, for postmenopausal osteoporosis. The client tells the nurse that she is experiencing jaw pain. How should the nurse respond?
A Report the client’s jaw pain to the healthcare provider .
B Advise the client to gargle with warm salt water twice daily .
C Confirm that this is a common symptom of osteoporosis .
D Determine how the client is administering the medication .
148 of 160 The nurse is evaluating a tertiary prevention program for clients with cardiovascular disease implemented in a rural health clinic. Which outcome indicates the program is effective?
A Client relapse rate of 30% in a 5-year community-wide anti-smoking campaign.
B Clients reported having new confidence in making healthy food choices.
C Clients who incurred disease complications promptly received rehabilitation.
D At-risk clients received an increased number of routine health screenings.
149 of 160 The nurse is developing a plan of care for a client who reports chest pain on exertion and who is newly diagnosed with cardiovascular disease Which outcome should the nurse include in the plan of care for this client ?
A The nurse will encourage the client to walk thirty minutes every day.
B The client will monitor blood glucose and blood pressure after each meal .
C The client’s blood pressure readings will be less than 160/90 mmHg .
D The client’s daily blood pressure will be less than 140/80 mmHg this month .
150 of 160 A client with end stage Alzheimer’s disease is brought to the clinic by the caregiver for an appointment with the healthcare provider. The caregiver speaks privately to the nurse about not sleeping well at night and experiencing frequent periods of crying. Which intervention should the nurse implement ?
A Advise to have a case management evaluation of the client’s home environment .
B Suggest social services be contacted to find a respite care facility for the client
C Propose the extended family could return to the area to help provide assistance .
D Tell the caregiver to consider hiring a private duty nurse for time to be away .
151 of 160 The nurse delegates hygiene care to unlicensed assistive personnel (UAP) for a client who experienced an episode of incontinence. The client is on droplet precautions for a viral pneumonia infection. The UAP requests a change in assignment, stating she has not yet been fitted for a particulate mask Which action should the nurse take?
A Advise the UAP to wear a standard face mask to obtain vital signs , and then get fitted for a filter mask before providing personal care .
B Send the UAP to be fitted for a particulate filter mask immediately so she can provide care to this client
C Before changing assignments , determine which staff members have fitted particulate filter masks .
D Instruct the UAP that a standard face mask is sufficient to be able to provide care for the assigned client
152 of 160 The nurse walks into a client’s room and notices bright red blood on the sheets and on the floor by the IV pole. Which action should the nurse take first?
A Notify the healthcare provider that the client appears to be bleeding .
B Clean up the spilled blood to reduce infection transmission .
C Identify the source and amount of bleeding .
D Apply direct pressure to the client’s IV site.
153 of 160 A client is receiving intravenous (IV) fluids by gravity infusion and exhibits signs of fluid volume overload. When assessing the clients IV delivery system, where should the nurse assess ?
154 of 160 The nurse reviews the arterial blood gas (ABG) results of a client admitted with increasing dyspnea. Which interpretation should the nurse make from the findings ? ( Select all that apply .)
A Compensation for underlying pH problem .
B Respiratory alkalosis .
C Respiratory acidosis.
D Metabolic acidosis .
E Hypoxemia .
155 of 160 The nurse is a admitting a client from the post anesthesia unit to the postoperative surgical care unit. Which prescription should the nurse implement first?
A Advance from clear liquids as tolerated .
B Straight catheterization if unable to void.
C Complete blood cell count (CBC) in AM.
D Cefazolin 1 gram IVPB q6 hours .
156 of 160 The mother of a child recently diagnosed with asthma asks the nurse how to help protect her child from having asthmatic attacks. To avoid triggers for asthmatic attacks, which Instructions should the nurse provide the mother? (Select all that apply)
A Stay indoors when grass is being cut
B Keep away from pets with long hair.
C Avoid sudden changes in temperature.
D Close car windows and use air conditioner.
E Decrease the raw sugars in the diet
157 of 160 A male client with stomach cancer returns to the unit following a total gastrectomy. He has a nasogastric tube to suction and is receiving Lactated Ringer’s solution at 75 hour . One hour after admission to the unit, the nurse notes 300 ml of blood in the suction canister, the client’s heart rate is 155 beats/minute, and his blood pressure is 78/48 mmHg. In addition to reporting the findings to the surgeon, which action should the nurse implement ?
A Measure and document the client’s urinary output .
B Increase the infusion rate of Lactated Ringer’s solution .
C Request the client’s reserved unit of packed red blood cells .
D Prepare for placement of a centr
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