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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 - CORRECT
ANSWERS-Ensure the client's weights are hanging freely from the bed.
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? - CORRECT ANSWERS-Take this
medication between meals.
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? - CORRECT ANSWERS-jackson-pratt drain
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? - CORRECT ANSWERS-lung cancer usually has metastasized before
the client presents with symptoms
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? - CORRECT
ANSWERS-Wash daily with an antibacterial soap.
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? - CORRECT ANSWERS-Avoid medications in capsule or
enteric form.
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? - CORRECT ANSWERS-"Large incisions will be made in the burned tissue to
improve circulation."
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? - CORRECT
ANSWERS-Decreased color perception
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? - CORRECT ANSWERS-Maintain the client in Fowler's position.
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.) - CORRECT ANSWERS-1) Buffalo hump 2) Purple striations 3) Moon face
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? - CORRECT ANSWERS-
Monitor intake and output hourly
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? - CORRECT ANSWERS-"You will remain NPO for 8
hours before the procedure."
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? - CORRECT ANSWERS-Postictal phase
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? - CORRECT ANSWERS-"The pain will dissipate if you
ambulate frequently."
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? - CORRECT ANSWERS-Verify that the
suction regulator is on.
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.) - CORRECT ANSWERS-Encourage fluid intake. 2) Monitor the puncture site
for hematoma.
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? - CORRECT ANSWERS-Prevent aspiration.
, A nurse is collecting data from a client who has scleroderma. Which of the
following findings should the nurse expect? - CORRECT ANSWERS-Hardened skin
A nurse is caring for an older adult client who has dysphagia and left-sided
weakness following a stroke. Which of the following actions should the nurse
take? - CORRECT ANSWERS-Add thickener to fluids.
A nurse is caring for a client who has partial-thickness and full-thickness burns
of his head, neck, and chest. The nurse should recognize which of the following
is the priority risk to the client? - CORRECT ANSWERS-Airway obstruction
A nurse is reinforcing teaching with a client who is newly diagnosed with
myasthenia gravis and is to start taking neostigmine. Which of the following
instructions should the nurse include in the teaching? - CORRECT ANSWERS-1) Take
the medication 45 minutes before eating.
A nurse is caring for a client who is 12 hours postoperative following a
transurethral resection of the prostate (TURP) and has a 3-way urinary catheter
with continuous irrigation. The nurse notes there has not been any urinary
output in the last hour. Which of the following actions should the nurse perform
first? - CORRECT ANSWERS-Notify the provider.. Determine the patency of the
tubing.
A nurse is caring for a client scheduled for a bone marrow biopsy. The client
expresses fear about the procedure and asks the nurse if the biopsy will hurt.
Which of the following responses should the nurse make? - CORRECT
ANSWERS-"The biopsy can be uncomfortable, but we will try to keep you as
comfortable as possible."