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c. Advice to sit up slowly from a reclining position
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The nurse is caring for a client withdrawing from a fentanyl citrate addiction.
The client receives a prescription for Clonidine 0.2 milligrams PO taken twice
daily. Which action should the nurse take?
a. Monitor for signs of bleeding or hemorrhage
b. Compare daily electrolyte levels prior to each morning dose
c. Advice to sit up slowly from a reclining position
d. Administer the medication on an empty stomach
b. Acute anginal pain
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, A client with a history of heart failure and type one diabetes mellitus is
admitted with unstable angina. Which problem requires the most immediate
intervention by the nurse?
a. Fluid volume excess
b. Acute anginal pain
c. Activity intolerance
d. Fatigue
b. Offer effective time management strategies
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The nurse is caring for a child newly diagnosed with attention deficit
hyperactive disorder (ADHD). The child's mother asked about information of
the treatment options. Which information is most helpful for the nurse to
provide?
a. Emphasize the addictive nature of popular medications
b. Offer effective time management strategies
c. Explore the combination of medication and behavioral therapies
d. Discuss dietary changes such as increasing protein intake
b. Intention tremor
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While interviewing an elderly client, the nurse observes that the clients hands
tremble uncontrollably while reaching for a glass of water. How should the
nurse document this finding?
a. Muscle flaccidity
b. Intention tremor
, c. Transient ischemic attack
d. Sensory dysfunction
c. Peritonitis
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A client with chronic kidney disease on peritoneal dialysis exhibits redness,
tenderness, and drainage around the catheter site on the abdominal wall.
While planning care, the nurse is most concerned about preventing which
complication related to these findings?
a. Atelectasis
b. Exit site infection
c. Peritonitis
d. Outflow obstruction
C. Document the statement in the client's spiritual assessment.
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During the admission assessment of a terminally ill client, the client expresses
being agnostic. Which is the best nursing action in response to this statement?
a. Invite the client to a healing service for people of all religions
b. Provide information about the hours and location of the Chapel
c. Document the statement in the client spiritual assessment
d. Offer to contact the spiritual advisor at the client's choice
b. Oral mucosa is cyanotic
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, In observing a client's face, which assessment finding requires the most
immediate intervention by the nurse?
a. Cornea are jaundiced
b. Oral mucosa is cyanotic
c. Face is flushed and diaphoretic
d. Eyelids are matted and crusted
d. Document the assessment data
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The nurse assesses an adult client with a partial rebreather mask and notes
that the oxygen reservoir bag does not deflate completely during inspiration
and the client's respiratory rate is 14 breaths/minute. Which action should the
nurse implement?
a. Encourage the client to take deep breaths
b. Increase the liter flow of oxygen
c. Remove the mask to deflate the bag
d. Document the assessment data
a. Ankle brachial index
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c. Advice to sit up slowly from a reclining position
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The nurse is caring for a client withdrawing from a fentanyl citrate addiction.
The client receives a prescription for Clonidine 0.2 milligrams PO taken twice
daily. Which action should the nurse take?
a. Monitor for signs of bleeding or hemorrhage
b. Compare daily electrolyte levels prior to each morning dose
c. Advice to sit up slowly from a reclining position
d. Administer the medication on an empty stomach
b. Acute anginal pain
Give this one a try later!
, A client with a history of heart failure and type one diabetes mellitus is
admitted with unstable angina. Which problem requires the most immediate
intervention by the nurse?
a. Fluid volume excess
b. Acute anginal pain
c. Activity intolerance
d. Fatigue
b. Offer effective time management strategies
Give this one a try later!
The nurse is caring for a child newly diagnosed with attention deficit
hyperactive disorder (ADHD). The child's mother asked about information of
the treatment options. Which information is most helpful for the nurse to
provide?
a. Emphasize the addictive nature of popular medications
b. Offer effective time management strategies
c. Explore the combination of medication and behavioral therapies
d. Discuss dietary changes such as increasing protein intake
b. Intention tremor
Give this one a try later!
While interviewing an elderly client, the nurse observes that the clients hands
tremble uncontrollably while reaching for a glass of water. How should the
nurse document this finding?
a. Muscle flaccidity
b. Intention tremor
, c. Transient ischemic attack
d. Sensory dysfunction
c. Peritonitis
Give this one a try later!
A client with chronic kidney disease on peritoneal dialysis exhibits redness,
tenderness, and drainage around the catheter site on the abdominal wall.
While planning care, the nurse is most concerned about preventing which
complication related to these findings?
a. Atelectasis
b. Exit site infection
c. Peritonitis
d. Outflow obstruction
C. Document the statement in the client's spiritual assessment.
Give this one a try later!
During the admission assessment of a terminally ill client, the client expresses
being agnostic. Which is the best nursing action in response to this statement?
a. Invite the client to a healing service for people of all religions
b. Provide information about the hours and location of the Chapel
c. Document the statement in the client spiritual assessment
d. Offer to contact the spiritual advisor at the client's choice
b. Oral mucosa is cyanotic
Give this one a try later!
, In observing a client's face, which assessment finding requires the most
immediate intervention by the nurse?
a. Cornea are jaundiced
b. Oral mucosa is cyanotic
c. Face is flushed and diaphoretic
d. Eyelids are matted and crusted
d. Document the assessment data
Give this one a try later!
The nurse assesses an adult client with a partial rebreather mask and notes
that the oxygen reservoir bag does not deflate completely during inspiration
and the client's respiratory rate is 14 breaths/minute. Which action should the
nurse implement?
a. Encourage the client to take deep breaths
b. Increase the liter flow of oxygen
c. Remove the mask to deflate the bag
d. Document the assessment data
a. Ankle brachial index
Give this one a try later!
