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• A nurse is caring for a client who is 4 hr postoperative ff a total thyroidectomy.
Which ofthe ff manifestations should the nurse report to the provider as
indicating possible hypocalcemia?
ANS: Tingling of fingers
• A nurse in a long-term care facility is assisting with an in-service for newly
hired assistive personnel about legal issues within the facility. Which of the
ff should thenurseinclude as an example of assault?
ANS: Informing a client the nurse is going to administer an
injection even thoughthe client refuses
.
• A nurse is collecting data from who is severe pain. Which of the ff questions
shouldthenurse ask first?
ANS: "Where is your pain located?"
• A nurse is reviewing the laboratory results for a client who is at 29 weeks
gestation.Forwhich of the ff results should the nurse notify the provider?
ANS: Platelet count 95,000 mm3
,• A nurse is performing a dressing change for a client who had abdominal surgery
5 daysago. The nurse notes organs protruding from the incision. Which of the ff
actions shouldthe nurse take?
ANS: Cover the exposed area with sterile, saline-soaked dressings.
• A nurse is speaking with the adult daughter of a client who has Alzheimer's
disease. Thedaughter states, "I love my dad, but caring for him is wearing me
out." Which ofthe ff response should the nurse make?
ANS: "Let's discuss how caring for your father is affecting your health.
• A nurse is contributing to the plan of care for a care for a client who has
chest tubeconnected to a closed drainage system. Which of the ff actions
should the nurse includein the plan of care?
ANS: Maintain the drainage system below the level of the client's
chest.
• A nurse in an acute mental health facility is caring for a client who has
borderline personality disorder and reports. "I am going to kill my
girlfriend when I get out ofhere."Which of the ff actions should the nurse
take?
ANS: Notify the client's care team of the threats against the partner
• A nurse is admitting a client who is at high risk for suicide. Which
of the ffactions is thenurse's priority?
ANS: Search the client's personal belongings
,• A nurse is caring for a client who is 1 day postoperative and is unable
to ambulate. Whichof the ff actions should the nurse take to promote
the client'svenous return?
ANS: Maintain the sequential compression device.
• A nurse in a pediatric clinic is collecting the data from a school-age
child whoseinjuriesare inconsistent with the parent's stated cause.
Which of the ff actions should the nurse take?
ANS: Report the suspected abuse to a appropriate agency.
• A nurse is collecting data from a middle adult female client who is
takingmelatonin.Which of the ff responses to the med should the
nurse expect?
ANS: Improved sleep
• A nurse on a pediatric unit is collecting data from four newly admitted
clients.Which ofthe ff clients should the nurse identify as being at risk
for urinary retention?
ANS: A school-age child who has allergic rhinitis and is taking
diphenhydramine.
• A nurse is preparing to administer purified protein derivative (PPD) to
a clientwho hassuspected TB. Which of the ff actions should the nurse
plan to take?
ANS: Ensure the injection produces a wheal on the skin
, • A client who is diagnosed with Parkinson's disease verbalizes frustration
due toincreasedifficulty with ambulation. Which of the ff responses
should the nurse take?
ANS: Perform active ROM with your arms and legs two times a day.
• a Nurse is collecting data from a client who has multiple fractures
following amotor-vehicle crash. For which of the following client
statements
ANS: "I am so frustrated. I cannot even open my milk carton for
breakfast."
• A nurse on an acute care unity is collecting data from a school-age
Child who has cysticfibrosis. Which of the following findings is the
priority for the nurse?
ANS: Reports lack of appetite
• a nurse working in a provider's office receives a phone call from the
parent of aschool-age child who has varicella. The parent asked the
nurse when the child can return to school. Which of the following
responses should the nurse make?
ANS: "When the lesions have scabbed over."
• A nurse is caring for a client who has a Penrose drain. To ensure
proper placement andfunctioning of the drain, which of the
following should thenurse expect to observe?
ANS: The safety pin is present at the distal end of the drain.