Questions and Verified Answers
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A client is comatose upon arrival to the emergency department after falling
a roof. The client flexes with painful stimuli, and the nurse determines the
client's Glasgow Coma Scale (GCS) is 6. Which intervention should the
nurse prepare to implement to maintain the client's airway? - 🧠 ANSWER
✔✔A nasopharyngeal tube
,A client is receiving a continuous half strength tube feeding at 50 ml/hr. To
prepare enough of the solution for eight hours, how many ml of full strength
feeding will the nurse need? - 🧠 ANSWER ✔✔Answer: 200
25 ml x 8hrs = 200
The alarm of a client's pulse oximeter sounds and the nurse notes that the
oxygen saturation rate is indicated at 85%. What action should the nurse
take first? - 🧠 ANSWER ✔✔Check the probe position
A client is known to have an irregular respiratory rate with periods of apnea
lasting 10 to 15 seconds. Currently, the nurse counts 22 respiratory cycles
in a 30-second interval followed by an apneic period. What intervention
should the nurse implement? - 🧠 ANSWER ✔✔Reassess the respiratory
rate, counting for one full minute
A retiree with depression complains of feeling "lonely and having no
purpose" in life.Based on Erikson's developmental theory, which questions
suggest that the nurse understands the client's most important emotional
need? - 🧠 ANSWER ✔✔"What about your life makes you proud?"
,Following a precipitous labor, a client has a continuous trickling of bright
red blood from her vagina. Her uterus is firm and her vital signs are within
normal limits. The
nurse determines that the client's symptoms may indicate which condition?
- 🧠 ANSWER ✔✔A cervical laceration
In preparing assignments for the shift, which client is best for the charge
nurse to assign to a practical nurse? - 🧠 ANSWER ✔✔An elderly client with
Alzheimer's disease complicated by dysphagia
The healthcare provider prescribes oxygen per nasal cannula at 2 L/min.
Which action has the highest priority when the nurse implements this
prescription? - 🧠 ANSWER ✔✔Set the flow meter
9. A nurse who is new to the pediatric unit is positioning a 6-month-old for
an injection of penicillin V (Pen V) in the dorsogluteal muscle. Which action
should the nurse-manager who is supervising this nurse take first? - 🧠
ANSWER ✔✔C. Instruct the nurse to select another injection site
10. After diagnosis and initial treatment of a 3-year-old child with cystic
fibrosis, the nurse provides home care instructions to the mother. Which
statement by the child's mother indicates that she understands home care
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, treatment to promote pulmonary function? - 🧠 ANSWER ✔✔"Chest
physiotherapy should be performed at least twice a day"
The nurse is preparing a community education program on osteoporosis.
Which instruction is helpful in preventing bone loss and promoting bone
formation? - 🧠 ANSWER ✔✔Encourage physical activity
The nurse reviews the signs of hypoglycemia with the parents of a child
with Type 1 diabetes mellitus. The parents correctly understands signs of
hypoglycemia if they include which symptom? - 🧠 ANSWER ✔✔Sweating
The nurse observes a 2 cm area nonblanchable erythema on the sacrum of
an immobile client. What documentation of this finding is best for the nurse
to enter into the client's record? - 🧠 ANSWER ✔✔Stage 1 pressure ulcer on
sacrum
When assessing a 7-year-old girl, the nurse notes that she has multiple
bruises on her back and upper arms. The child's aunt tells the nurse that
the child's parents abuse drugs and alcohol. What intervention is most
essential for the nurse to implement? - 🧠 ANSWER ✔✔Report assessment
findings to the proper legal authorities