verified answers A+ Grade
What action should a nurse take first for a toddler with poor dietary intake?
- correct answer Obtain the child's dietary history.
What instruction should a nurse include about the MMR vaccine for a postpartum client?
- correct answer Avoid pregnancy for at least 28 days after receiving the vaccine.
What technique should a nurse use when performing a wet-to-dry dressing change?
- correct answer Clean the wound from the center to the outer edges.
Which statement indicates understanding of contraception teaching by a female client?
- correct answer My partner will use condoms with spermicides.
What defense mechanism is a client with bipolar disorder using when yelling at the nurse during
medication changes?
- correct answer Displacement.
What should a nurse identify as a possible source of infection for an immunocompromised client?
- correct answer Soiled linens are placed on the floor.
What action should a nurse take prior to an esophagogastroduodenoscopy for a client with peptic ulcer
disease?
- correct answer Ensure that the client gave informed consent.
What intervention should a nurse implement for a client who has been assaulted? (Select all that apply)
- correct answer Maintain a safe and private environment for the client; Provide resources for local
support services; Request a consult for case management.
,What is a key consideration for a nurse caring for a client with leukemia experiencing chronic fatigue?
- correct answer Assess the client's energy levels and provide appropriate rest periods.
What intervention should a nurse include in the care plan for a client with leukemia experiencing
chronic fatigue?
- correct answer Increase protein in the diet.
What is a common finding in a client with placenta previa?
- correct answer Bright red vaginal bleeding.
What are the responsibilities of a nurse regarding a client's advance directives?
- correct answer 1. Provide written information about advance directives. 2. Instruct the client that an
advance directive is a legal document that must be honored. 3. Communicate advance directives status
via the medical record and shift report. 4. Document discussions about do-not-resuscitate status.
Which action is an example of protecting client confidentiality?
- correct answer Giving change-of-shift report to a nurse outside the client's room.
What should a nurse do when assisting with postmortem care for a Muslim client?
- correct answer Allow a family member to stay with the client's body until burial.
What indicates understanding of breastfeeding teaching in a mother of a 5-day-old newborn?
- correct answer I should have my baby latch on to my nipple and areola during feeding.
What intervention should a nurse implement for a client with varicella zoster?
- correct answer Assign the client to a negative pressure airflow room.
How should a nurse prepare a client for testing the plantar Babinski reflex?
- correct answer Lie down and I will stroke the bottom of your foot.
What resource should a nurse recommend for a family caring for an older adult client with early onset
dementia?
- correct answer Adult day care facility.
,What is the expected intervention for a client experiencing chronic fatigue due to leukemia?
- correct answer Encourage strength-training exercise.
What should a nurse expect to find in a client with placenta previa?
- correct answer Bright red vaginal bleeding.
What is the nurse's role regarding advance directives?
- correct answer Communicate advance directives status via the medical record.
What is an appropriate action to maintain client confidentiality?
- correct answer Discarding worksheets containing client information in a secure manner.
What should a nurse do to respect the beliefs of a devout Muslim client after death?
- correct answer Position the client's head toward Mecca.
What breastfeeding practice should a mother follow for her newborn?
- correct answer My baby should breastfeed 5 to 10 minutes on each breast.
What is the correct nursing intervention for a client with varicella zoster?
- correct answer Initiate contact precautions for the client.
What is the correct instruction for testing the plantar Babinski reflex?
- correct answer Place your foot in my hand and I will tap the back of your heel.
What is a key responsibility of a nurse regarding advance directives?
- correct answer Instruct the client that an advance directive is a legal document.
What should a nurse document regarding do-not-resuscitate status?
- correct answer Document that the provider discussed do-not-resuscitate status with the client.
What is an appropriate recommendation for a family caring for an older adult with dementia?
- correct answer Suggest adult day care facility for support.
, What should a nurse avoid when discussing client information?
- correct answer Discussing a client's prognosis with assistive personnel who is not involved in their care.
What is the appropriate action for a nurse regarding a client's advance directives?
- correct answer Provide the client with written information about advance directives.
What should a nurse instruct a client to do if they experience syncope after starting enalapril?
- correct answer Rise slowly from a sitting position to a standing position.
Which food should a nurse recommend to a client with irritable bowel syndrome?
- correct answer Yogurt.
What important information should a nurse include when teaching guardians of a child with cystic
fibrosis?
- correct answer Have your child wear a medical identification wristband.
What action should a nurse take when a client requests to take a tub bath?
- correct answer Check on the client every 10 min during the bath.
What indicates a client's understanding of what to do when experiencing chest pain with stable angina
pectoris?
- correct answer I will stop what I am doing and lie down.
What supplies should a nurse ensure a client has upon discharge when prescribed oxygen at 1 to 2
L/min?
- correct answer Nasal cannula.
What is the first action a charge nurse should take upon noticing the smell of alcohol on a nurse's
breath?
- correct answer Remove the nurse from the client care area.
What is the priority action for a nurse caring for a cyanotic client with a respiratory rate of 8/min?
- correct answer Establish a patent airway for the client.