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◉ A nurse is caring for a client who is at risk for developing pressure
ulcers. Which of the following actions should the nurse take?
Answer: Position pillows between the bony prominences
◉ A nurse is caring for a client who is postoperative and is receiving
an IV infusion of cefazolin. Ten minutes after beginning the infusion,
the client reports intense itching. Which of the following actions
should the nurse take first? Answer: Stop the medication infusion
◉ A nurse is reinforcing teaching with a client who has gonorrhea.
Which of the following information should the nurse include?
Answer: You are at risk for infertility with this infection, regardless
of treatment
◉ A nurse is examining a clients IV site and notes a red line up his
arm. The client reliant a throbbing, burning pain at the IV site. The
nurse should identify that the clients manifestations indicate which
of the following complications? Answer: Thrombophlebitis
,◉ A nurse is reinforcing teaching with an adolescent client regarding
testicular self examination. Which of the following statements by the
client demonstrates an undertsmdibg of the teaching? Answer: I
understand that testicular cancer is painless
◉ A nurse in a long term care facility is collecting data from a client
who reports fullness in the rectum and abdominal cramping. Which
of the following findings should indicate to the nurse that the client
might have a fecal impaction? Answer: Small liquid stools
◉ A nurse in an oncology is reinforcing teaching about Mohs surgery
with a client who has skin cancer. Which of the following
information should the nurse include in the teaching? Answer: Mohs
surgery is a horizontal shaving of thin layers of the tumor
◉ A nurse is reinforcing teaching about GERd with a client. Which of
the following statements by the client indicates an understanding of
the teaching? Answer: I should wait at least 2 hours after eating
before going to bed
◉ A nurse is assisting with the care of a care who is reconciled 0.9 %
sodium chloride by continuous IV infusion. The client report pain
and swelling at the IV site. In which order should the nurse perform
that following steps? Answer: Check the IV site, stop the infusion,
withdraw the IV catheter, elevate the affected arm, notify the charge
nurse
,◉ A nurse is contributing to the plan of care for an older adult client
who is at risk for osteoporosis. Which of the following interventions
should the nurse include to prevent bone loss? Answer: Encourage
weight bearing exercises
◉ A nurse is assisting with the care of a client who has a cardiac
catheterization via the right femoral artery. Which of the following
actions should the nurse take to prevent lost procedure
complications? Answer: Monitor the insertion site for bleeding is
correct, maintain the pressure dressing, check the clients peripheral
pulses
◉ A nurse is caring for a client who is 1 day postoperative following
a hip arthroplasty. The client is exhibiting hypotension,tachycardia,
and tachypnea. The nurse should recognize these findings indicate
which of the following complications? Answer: Pulmonary embolism
◉ A nurse is reinforcing discharge teaching with a client who has
hearing loss. Which of the following actions should the nurse take
when communication with the client? Answer: Rephrase client
instructions when not understood
◉ A nurse is caring for a client who is postoperative and has an
epidural infusion. Which of the following findings should the nurse
recognize as the priority? Answer: Dyspnea
, ◉ A nurse is preparing to administer phytonadione 7 mg
subcutaneously to a client who has an INR of 4. Available is
phytonadione 10 mg/ml. How many ml should the nurse
administer? Answer: 0.7
◉ A nurse is reinforcing teaching with a client who has multiple
sclerosis and a new prescription for baclofen. Which of the following
instructions should the nurse include in the teaching? Answer: Avoid
stopping this medication suddenly
◉ A nurse is planning to implement droplet precautions for a client
who has manifestation of pertussis. Which of the following
interventions should the nurse include when contributing? Answer:
Apply a mask on the client of transport is needed
◉ A nurse is caring for an older adult client who has a reddened area
over the sacrum. Which of the following actions should the nurse
take? Answer: Minimize the time the head of the bed is elevated
◉ A nurse is collecting data from a client and noticed several skin
lesions. Which of the following findings should the nurse report as
possible melanoma? Answer: Irregular borders