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1. A nurse is assisting with the care of a client who has a femur fracture and is
in skeletal traction. Which of the following actions should the nurse take: Ensure
the client's weights are hanging freely from the bed.
2. A nurse in a provider's office is reinforcing teaching with a client who has
anemia and has been taking ferrous gluconate for several weeks. Which of
the following instructions should the nurse include?: Take this medication between meals.
3. A nurse is preparing a plan of care for a client who is postoperative following
a modified radical mastectomy. Which of the following invasive devices should
the nurse expect this client to have?: jackson-pratt drain
4. A nurse is caring for a client who had a left lower lobectomy to treat lung
cancer. Which of the following factors will have a significant impact on the plan
of care for this client?: lung cancer usually has metastasized before the client presents with symptoms
5. A nurse is reviewing the plan of care for a client who has cellulitis of the leg.
Which of the following interventions should the nurse recommend?: Wash daily
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, with an antibacterial soap.
6. A nurse is reinforcing teaching with a client who is postoperative after
having an ileostomy established. Which of the following instructions should
the nurse include in the teaching?: Avoid medications in capsule or enteric form.
7. A nurse is caring for a client with severe burns to both lower extremities. The
client is scheduled for an escharotomy and wants to know what the procedure
involves. Which of the following statements is appropriate for the nurse to
make?: "Large incisions will be made in the burned tissue to improve circulation."
8. A nurse is collecting data from a client who has a possible cataract. Which
of the following manifestations should the nurse expect the client to report?-
: Decreased color perception
9. A nurse is contributing to the plan of care for a client who has an intestinal
obstruction and is receiving continuous gastrointestinal decompression using
a nasogastric tube. Which of the following interventions should the nurse
include in the plan of care?: Maintain the client in Fowler's position.
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, 10. A nurse is caring for a client who has Cushing's syndrome. Which of the
following clinical manifestations should the nurse expect to observe? (Select
all that apply.): 1) Buttalo hump 2) Purple striations 3) Moon face
11. A nurse is caring for a client who is in the oliguric phase of acute kidney
injury. Which of the following actions should the nurse take?: Monitor intake and
output hourly
12. A nurse is reinforcing teaching about an esophagogastroduodenoscopy
with a client who has upper gastric pain. Which of the following statements
should the nurse include in the teaching?: "You will remain NPO for 8 hours before the
procedure."
13. A nurse is caring for a client who is difficult to arouse and very sleepy
for several hours following a generalized tonic-clonic seizure. Which of the
following descriptions should the nurse use when documenting this finding
in the medical record?: Postictal phase
14. A nurse is reinforcing teaching with a client who reports right shoulder pain
following a laparoscopic cholecystectomy. Which of the following statements
should the nurse make?: "The pain will dissipate if you ambulate frequently."
15. A nurse is checking the suction control chamber of a client's chest tube and
notes that there is no bubbling in the suction control chamber. Which of the
following actions should the nurse take?: Verify that the suction regulator is on.
16. A nurse is assisting with the care of a client immediately following a lumbar
puncture. Which of the following actions should the nurse take? (Select all that
apply.): Encourage fluid intake. 2) Monitor the puncture site for hematoma.
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, 17. A nurse is assisting with the care of a client who is postoperative following
surgical repair of a fractured mandible. The client's jaw is wired shut to repair
and stabilize the fracture. The nurse should recognize which of the following
is the priority action?: Prevent aspiration.
18. A nurse is collecting data from a client who has scleroderma. Which of the
following findings should the nurse expect?: Hardened skin
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