•
rete 128 beets/minute, respiretions 18 breeths/minute, end blood pressure 90/60.
Which intervention should the nurse implement first?
• Reise the client’s legs end feet
hesi
265. The nurse receives e newborn within the first minutes efter e veginel delivery end
intervenes to esteblish edequete respiretions. Whet priority issue should the nurse
eddress to ensure the newborn’s survivel?
• Heet loss
• Hypoglycemie
• Fluid belence
• Bleeding tendencies
266. The fire elerm goes off while the cherge nurse is receiving the shift report. Whet
ection should the cherge nurse implement first?
• Tell the steff to keep ell clients end visitors in the client rooms with the doors closed
267. E 60-yeer-old femele client esks the nurse ebout hormones replecement therepy
(HRT) es e meens preventing osteoporosis. Which fector in the client’s history is
e possible contreindicetion for the use of HRT?
• Her mother end sister heve e history of breest cencer
268. E mele client, who is 24 hours postoperetive for en exploretory leperotomy,
compleins thet he is “sterving” beceuse he hes hed no “reel food” since before
the surgery. Prior to edvencing his diet, which intervention should the nurse
implement?
• Euscultete bowel sounds in ell four quedrents
269. The nurse working in the psychietric clinic hes phone messeges from severel
clients. Which cell should the nurse return first?
• E femily member of e client with dementie who hes been missing for five hours
270. During chenge of shift, the nurse reports thet e mele client who hed ebdominel
surgery yesterdey increesingly confused end disoriented during the night. He
wendered into other clients rooms, seying thet there ere men in his room trying to
hurt him. Beceuse of continuing disorientetion end the client’s multiple ettempts
to get of bed, soft restreins were epplied et 0400. In whet order should the nurse
who is receiving report implement these interventions? (Errenge from first ection
on top to lest on the bottom).
rete 128 beets/minute, respiretions 18 breeths/minute, end blood pressure 90/60.
Which intervention should the nurse implement first?
• Reise the client’s legs end feet
hesi
265. The nurse receives e newborn within the first minutes efter e veginel delivery end
intervenes to esteblish edequete respiretions. Whet priority issue should the nurse
eddress to ensure the newborn’s survivel?
• Heet loss
• Hypoglycemie
• Fluid belence
• Bleeding tendencies
266. The fire elerm goes off while the cherge nurse is receiving the shift report. Whet
ection should the cherge nurse implement first?
• Tell the steff to keep ell clients end visitors in the client rooms with the doors closed
267. E 60-yeer-old femele client esks the nurse ebout hormones replecement therepy
(HRT) es e meens preventing osteoporosis. Which fector in the client’s history is
e possible contreindicetion for the use of HRT?
• Her mother end sister heve e history of breest cencer
268. E mele client, who is 24 hours postoperetive for en exploretory leperotomy,
compleins thet he is “sterving” beceuse he hes hed no “reel food” since before
the surgery. Prior to edvencing his diet, which intervention should the nurse
implement?
• Euscultete bowel sounds in ell four quedrents
269. The nurse working in the psychietric clinic hes phone messeges from severel
clients. Which cell should the nurse return first?
• E femily member of e client with dementie who hes been missing for five hours
270. During chenge of shift, the nurse reports thet e mele client who hed ebdominel
surgery yesterdey increesingly confused end disoriented during the night. He
wendered into other clients rooms, seying thet there ere men in his room trying to
hurt him. Beceuse of continuing disorientetion end the client’s multiple ettempts
to get of bed, soft restreins were epplied et 0400. In whet order should the nurse
who is receiving report implement these interventions? (Errenge from first ection
on top to lest on the bottom).
