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The nurse has been made aware of the following client situations. It is
necessary for the nurse to intially assess the client who has: - Answer:
Diabetes mellitus (type 1) is difficult to arouse, and has a blood glucose
of 38 mg/dL
The nurse has recieved handoff report and is assigning tasks to the
unlicensed assistive personnel (UAP). Which of the following tasks
should the nurse instruct the UAP to perform first? - Answer: Obtain a
,capillary blood glucose on a client who had a hypoglycemic episode 30
minutes ago and recieved dextrose IV.
The nurse working on a pediatric unit has received the handoff report
and is reviewing client data and orders. Which of the following clients
should the nurse plan to see first? - Answer: The infant who has a
diagnosis of pertussis or RSV and is recieving oxygen via nasal cannula.
The nurses is assisting with discharge planning for assigned clients.
Which of the following referrals is appropriate for the nurse to make? -
Answer: A physical therapist (PT) referral for a client who has a total
knee replacement (TKR) and needs instruction on the use of a walker.
The nurse who normally works on the maternity unit has been floated
to work on an adult medical surgical unit for the shift. It is appropriate
to assign the float nurse the client who? - Answer: 24 hours post-op
from having an appendectomy
The nurse preceptor is observing a newly hired nurse teach a client who
has pelvic inflammatoy disease about self-care. The client does not
speak english. Which of the following actions by the newly hired nurse
requires intervention by the nurse preceptor? - Answer: Having a
family member who speaks English and the clients language interpret
the instructions.
, The nurse working in the labor and delivery (L&D) unit is caring for a
client in labor whose membranes just spontaneously ruptured. Which
of the following findings is priority for the nurse to report to the health
care provider (PHCP)? - Answer: New appearance of late decelerations
The nurse preceptor is observing a newly hired nurse care for assigned
clients. Which of the following actions by the newly hired nurse
indicates correct care? - Answer: Using 23 gauge, 1 inch needle when
administering a medication in the deltoid muscle.
The nurse working in an outpatient care clinic is assessing clients who
are waiting to be seen. Which of the following clients should the nurse
have the primary health care provider (PHCP) see first? - Answer: 45
year-old who has pleurisy and is reporting worsening shortness of
breath.
The nurse is caring for a male client who has full-thickness burns to 50%
of the lower body. It is a priority for the nurse to notify the primary
health care provider (PHCP if the client has: - Answer: Temperature of
104.2 F
The nurse working in the emergency department (ED) is assisting with
triage clients following an explosion at a local factory. Which of the