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 - Answer- 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? - Answer- Take this medication between meals
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? - Answer- Take this medication between meals.
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? - Answer- 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? - Answer- 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? - Answer- "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? - Answer-
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? -
Answer- 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.) -
Answer- 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? - Answer- 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? - Answer- "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? - Answer- 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? - Answer- "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? - Answer- 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.) - Answer-
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? -
Answer- Prevent aspiration.
A nurse is collecting data from a client who has scleroderma. Which of the following
findings should the nurse expect? - Answer- 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? - Answer- 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? - Answer- 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? - Answer- 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