Guide
A nurse is planning care for a client who is receiving heparin to treat a L leg DVT.
Nursing intervention? - Correct Answer elevate the leg
A nurse is teaching about child safety measures. What statement indicates
understanding? - Correct Answer avoid sun exposure 10am-2pm
A home health nurse is teaching about infection prevention to a cancer pt on chemo.
Which statement indicates understanding? - Correct Answer "I'll walk short distances
throughout the day"
A nurse is providing dietary teaching to the parents of a 6 month old. What instructions
should the nurse give? - Correct Answer introduce new foods over 5-7 days
A charge nurse is planning care for a client in mechanical restraints. What
interventions? - Correct Answer provide a staff member to stay with the client
continuously
A community health nurse is assisting with the development of a disaster management
plan. What nursing responsibility should be included in the disaster response stage? -
Correct Answer perform a rapid needs assessment
A nurse manager is assisting with the orientation of a newly licensed nurse. Which of
the following requires manager intervention? - Correct Answer tells the hospital chaplain
a client's diagnosis
A nurse is caring for a client that is in labor at 39 weeks gestation. During the second
stage of labor, the nurse observes early decelerations on the monitor. What action
should the nurse take? - Correct Answer continue observing the fetal heart rate
A nurse manager is planning to make changes to the current scheduling system on the
unit. To facilitate staff acceptance, what should the nurse manager do first? - Correct
Answer provide information about scheduling issues to staff
A nurse is planning teaching about allowable foods for a client with uric acid-based
urinary calculi formation. What foods should the nurse recommend? - Correct Answer
oranges
A charge nurse is teaching a newly licensed nurse how to identify true labor. What
should the nurse include in the teaching? - Correct Answer the cervix transitions to an
anterior position
, A nurse on a med-surg unit is caring for a client prior to a surgical procedure. Which of
the following findings should indicate to the nurse that the client can sign the informed
consent? - Correct Answer the client an accurately describe the procedure
A charge nurse assigns a new nurse to a client with a chest tube. The new nurse
expresses concern d/t limited experience with monitoring drainage. What should the
charge do to teach about chest tubes? - Correct Answer ask the nurse about their
knowledge of the procedure
A nurse is teaching a client about a new prescription for estradiol. For which of the
following adverse effects should the nurse tell the client to monitor and contact the
provider? - Correct Answer headaches
A nurse is preparing to administer diazepam 0.3mg/kg IV bolus to a 22lb toddler who is
experiencing a grand mal seizure. Available is 5mg/mL. How many mls should the
nurse administer? - Correct Answer 0.6mL
A nurse is caring for a 12 hour post op on a PCA for pain control and requires a blood
pressure check in 10 min. Which of the following staff members should the nurse assign
to collect this information. - Correct Answer an Ap who is assisting a client to bed
A nurse is creating a plan of care for a child who has acute lymphoid leukemia and an
absolute neutrophil count of 400/mm3. What intervention should the nurse include in the
plan? - Correct Answer withhold the varicella vaccine
A nurse is providing teaching about improving nutrition for a client who has MS. Which
instructions should the nurse include? - Correct Answer -a speech pathologist
-rest before eating
-thicken beverages before eating
A nurse is assessing a client who has schizophrenia and is taking chlorpromazine.
Which finding is the priority for the nurse to provide to the provider? - Correct Answer
temp 102.9f
A client is receiving lorazepam IV for panic attacks and develops a RR of 6/min and a
BP of 90/44mm Hg. What med should the nurse anticipate administering? - Correct
Answer Flumazenil
A nurse is caring for an older adult client in the PACU following general anesthesia.
What finding should the nurse report to the provider - Correct Answer audible stridor
A nurse is preparing a sterile field in order to insert an indwelling urinary catheter on a
male client. Which technique should the nurse use to maintain aseptic technique? -
Correct Answer set the tray on the table at waist height