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A young male client is admitted to rehabilitation following a right above-knee amputation
(AKA) for a severe traumatic injury. He is in the commons room and anxiously calls out to the
nurse, stating that his "right foot is aching". The nurse offers reassurance and support. Which
additional intervention is most important for the nurse to implement?
A. Encourage discussion of feelings about the loss of his limb
B. Administer a prescription for gabapentin, a neuroleptic agent
C. Tech the client how to wrap the stump with an elastic bandage
D. Offer to assist the client to a quieter location so he can relax - Answer>>> A. Encourage
discussion of feelings about the loss of his limb
The nurse assesses a client one hour after starting a transfusion of packed red blood cells and
determines that there are no indications of a transfusion reaction. What instruction should the
nurse provide the unlicensed assistive personnel (UAP) who is working with the nurse?
A. Notify the nurse when the transfusion has finished, so further client assessment can be done
B. Continue to measure the client's vital signs every thirty minutes until the transfusion is
complete
C. Monitor the client carefully for the next three hours and report the onset of a reaction
immediately
D. Since a reaction did not occur, the priority is to maintain client comfort during the transfusion
- Answer>>> B. Continue to measure the client's vital signs every thirty minutes until the
transfusion is complete
A preschool aged boy is admitted to the pediatric unit following successful resuscitation from a
near drowning incident. While providing care to the child, the nurse begins with the brother who
rescued the child from the swimming pool and initiated resuscitation. The nurse notices the older
,boy becomes withdrawn when asked about what happened. Which action should the nurse take?
- Answer>>> Ask the older brother how he felt during the incident.
A preschool-aged boy is admitted to the pediatric unit following successful resuscitation from a
near-drowning incident. While providing care to the child, the nurse begins talking with his
preadolescent brother who rescued the child from the swimming pool and initiated resuscitation.
The nurse notices the older boy becomes withdrawn when asked about what happened. Which
action should the nurse take?
A. Develop a water safety teaching plan for the family
B. Ask the older brother how he felt during the incident
C. Tell the older brother that he seems depressed
D. Commend the older brother for his heroic actions - Answer>>> B. Ask the older brother how
he felt during the incident
The nurse is feeding an older adult who was admitted with aspiration pneumonia. The pt is weak
and begins coughing while attempting to drink through a straw. Which intervention should the
nurse implement? - Answer>>> Teach coughing and deep breathing exercises
The nurse is providing care for a client with severe peripheral arterial disease (PAD). The client
reports a history of rest ischemia, with leg pain that occurs during the night. Which action should
the nurse take in response to this finding?
A. Elevate the legs to assess for color changes
B. Provide a heating pad for PRN use
C. Offer cold packs when the pain occurs
D. Suggest dangling the legs when pain occurs - Answer>>> C. Offer cold packs when the pain
occurs
The nurse is teaching the pt about home care after surgery for an ileal conduit placement. When
reviewing the information, which statement should the nurse recognize as needing additional
education? - Answer>>> Empty the pouch when it is half full.
,A male client with cirrhosis has jaundice and pruritus. He tells the nurse that he has been soaking
in hot baths at night with no relief of his discomfort. Which action should the nurse take?
A. Encourage the client to use cooler water and apply calamine lotion after soaking
B. Obtain a PRN prescription for an analgesic that the client can use for symptom relief
C. Suggest that the client take brief showers and apply oil-based lotion after showering
D. Explain that the symptoms are caused by liver damage and cannot be relieved - Answer>>>
A. Encourage the client to use cooler water and apply calamine lotion after soaking
An older client with a long history of coronary artery disease (CAD), hypertension (HTN), and
heart failure (HF) arrives in the Emergency Department (ED) in respiratory distress. The
healthcare provider prescribes furosemide IV. Which therapeutic response to furosemide should
the nurse expected in the client with acute HF?
A. Increased cardiac contractility
B. Reduced preload
C. Relaxed vascular tone
D. Decreased afterload - Answer>>> B. Reduced preload
A 12 week gestation is admitted to the antepartum unit with a dx of hyperemesis gravidarum.
Which action is most important for the nurse to implement? - Answer>>> initiate prescribed IV
fluids
A pt with dyspnea is being admitted to the medical unit. To best prepare for the pt arrival, the
nurse should ensure that the pt bed is in which position? - Answer>>> Picture with the bed
sitting up
The nurse leading a care team on a medical surgical unit is assigning client care to a practical
nurse (PN) and an unlicensed assistive personnel (UAP). Which task should the nurse delegate to
the UAP?
A. Evaluate a client's mobility progress toward the plan of care
B. Assess for side effects of administered pain medications
, C. Turn and reposition a client with a total hip replacement
D. Monitor an intravenous infusion rate on an established schedule - Answer>>> C. Turn and
reposition a client with a total hip replacement
After an older client receives treatment for drug toxicity, the healthcare provider prescribes a 24-
hour creatinine clearance test. Prior to starting the urine collection, the nurse notes that the
client's serum creatinine is 0.3 mg/dL. Which action should the nurse implement?
A. Evaluate the client's serum BUN level
B. Initiate the urine collection as prescribed
C. Notify the healthcare provider of the results
D. Assess the client for signs of hypokalemia - Answer>>> C. Notify the healthcare provider of
the results
The nurse is developing a plan of care for a client who reports tingling of the feet and who is
newly diagnosed with peripheral vascular disease. Which outcome should the nurse include in
the plan of care for this client?
A. The client's skin on the lower legs will be intact at the next clinic visit
B. The client will express acceptance of their newly diagnosed health status
C. The client's blood pressure readings will be less than 160/90 mmHg
D. The nurse will encourage the client to walk thirty minutes every day - Answer>>> C. The
client's blood pressure readings will be less than 160/90 mmHg
A pt who is scheduled for a bronchoscopy in the morning is anxious and asking the nurse
numerous questions about the procedure. In preparing the pt for the procedure, which
intervention has the highest priority? - Answer>>> Instruct pt to write down questions
While caring for a pt post operative dressing, the nurse observes purulent drainage at the wound.
Before reporting this finding to the provider, the nurse should review which of the pt lab values?
- Answer>>> culture for sensitive organisms