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An adult female client is admitted to the psychiatric unit with
diagnosis of major depression. After 2 weeks of antidepressant
medication therapy, the nurse notices the client has more energy, is
giving her belongings away to her visitors, and is in an overall better
mood. Which intervention is best for the nurse to implement? -
Answer -ask the client if she has had any recent thoughts of harming
herself.
an adult male client tells the nurse that he believes someone is trying
to obtain his cpu records, which his wife reports are recreational in
nature. the client insist that an elaborate alarm system needs to be
installed in his home. the nurse knows that this client is exhibiting
which signs or symptoms? - Answer -delusions of persecution
After a change of shift report, the nurse makes rounds on a
postoperative unit. Which client finding necessitates the immediate
attention of the nurse? - Answer - A client who is having bright red
drainage from the rectum following a colonoscopy with a polyp
removal
After a client returns from Hemodialysis, the nurse measures the
client's weight and notes a 3-poundweight loss from the pre-dialysis
weight. The client reports feeling weak and fatigued. What action
should the nurse take next? - Answer - Measure the client's blood
pressure
After morning dressing changes are completed, a male client who has
paraplegia contaminates his ischial decubiti dressing with a diarrheal
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,stool. What activity is best for the nurse to assign to the unlicensed
assistive personnel? - Answer - Provide perianal care and collect clean
linens for the dressing change
After report, the nurse receives the laboratory values for 4 clients.
Which client requires the nurse's immediate intervention? The client
who is..... - Answer - Trembling and has a glucose level of 50 mg/dL
An ambulatory client with an indwelling urinary catheter (Foley) is
requesting to take a shower for the first time. What is the best
intervention for the nurse to implement? - Answer - Keep the catheter
intact and assist the client with a shower
At 7AM, a Diabetic client is conscious with a serum glucose level of
50mg/dL. To manage this client's care effectively, what should the
nurse administer? - Answer - Orange juice
Augmentin (amoxicillin/clavulante) 500mg suspension is prescribed
for an older adult client who has trouble swallowing . The suspension
is available in 125mg/5mL solution. How many ml should the client
receive? (enter the numberic value only) - Answer -20
Based on the documentation in the medical record, which action
should the nurse implement next? - Answer - Give the rubella vaccine
subcutaneously
Based on the Nursing diagnosis of "Potential for infection related to
second and third degree burns," which intervention has the highest
priority? - Answer -Use of careful hand washing technique
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, Based on the Nursing diagnosis of, "Risk for Infection," which
intervention should the nurse implement when providing care for an
elderly client with Urinary incontinence? - Answer -Maintain standard
precautions
The care plan for a male client with amyotrophic lateral sclerosis
includes the Nursing diagnosis, "Decisional conflict related to
concerns about mechanical ventilation." When assigned to care for
this client, what intervention should the nurse implement based on
this diagnosis ? - Answer - Encourage the client to discuss his feelings
and concerns related to the use of mechanical ventilation
The cervix is the opening into the uterine cavity. What is its function
in reproduction? - Answer -Secretes mucus to facilitate sperm
transport
The charge nurse brings a #18fr urinary catheter (Foley) with a 30 mL
balloon to the nurse who is preparing to insert a catheter in a female
client who weighs 50 kg. What action should the nurse take first? -
Answer -Consult with the charge nurse about the catheter
A child with Chronic Asthma is scheduled for Chest Physiotherapy.
When should the nurse administer the meter-dosed inhaler (MDI) puff
of bronchodilator relative to postural drainage treatments? - Answer -
After postural drainage
A client asks the nurse to explain the location of the prostate gland.
What is the best response? - Answer -Close the rectal wall the prostate
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