BSN 366 WK 2 Sherpath Heart Failure
Simulation|Latest 2025 Update with complete
solutions.
. When walking past a client's room, the nurse hears 1 unlicensed assistive
personnel (UAP) talking to another UAP. Which statement requires follow-up
intervention? - answer-"Since I am late for lunch, would you do this one client's
glucose test?"
A 1 year-old child is receiving temporary total parental nutrition (TPN) through
a central venous line. This is the first day of TPN therapy. Although all of the
following nursing actions must be included in the plan of care of this child,
which one would be a priority at this time? - answer-Monitor serum glucose
levels
A 24 year-old male is admitted with a diagnosis of testicular cancer. The nurse
would expect the client to have - answer-Heaviness in the affected testicle
A 25 year-old client, unresponsive after a motor vehicle accident, is being
transferred from the hospital to a long term care facility. To which o staff
members should the charge nurse assign the client? - answer-RN
A 52 year-old client is being transfused with one unit of packed cells. A half
hour after the transfusion was initiated, the client complains of chills and
headache. Which action should the nurse implement first? - answer-Stop the
transfusion
,A 6 year-old child diagnosed with acute glomerulonephritis (AGN) is
experiencing anorexia, moderate edema and elevated blood urea nitrogen
(BUN) levels. The child requests a peanut butter sandwich for lunch. What
would the nurse's best response to this request? - answer-"I know that is your
favorite, but let me help you pick another lunch."
A 64 year-old client scheduled for surgery with a general anesthetic refuses to
remove a set of dentures prior to leaving the unit for the operating room.
What would be the most appropriate intervention by the nurse? - answer-Ask
the client if the preference would be to remove the dentures in the operating
room receiving area
A 9 year-old is taken to the emergency room with right lower quadrant pain
and vomiting. When preparing the child for an emergency appendectomy,
what must the nurse expect to be the child's greatest fear? - answer-Perceived
loss of control
A charge nurse working in a long term care facility is making out assignments.
Which assignment to an unlicensed assistive personnel (UAP), if made by the
nurse, requires intervention by the supervisor? - answer-Teaching a family
intermittent (bolus) feedings via G-tube before discharge
A child is sent to the school nurse by a teacher who has a written note that
Fifth's disease is suspected. Which characteristic would the nurse expect to
find? - answer-Erythema on the face, primarily on cheeks giving a "slapped
face" appearance
, A child is treated with edetate calcium disodium (Calcium EDTA) for lead
poisoning. Which of these should the nurse assess first ? - answer-Urinary
output
A client admits to benzodiazepine dependence for several years. She is now in
an outpatient detoxification program. The nurse must understand that a
priority during withdrawal is - answer-Avoid alcohol use during this time
A client being treated for hypertension returns to the community clinic for
follow up. The client says, "I know these pills are important, but I just can't take
these water pills anymore. I drive a truck for a living, and I can't be stopping
every 20 minutes to go to the bathroom." Which of these is the best nursing
diagnosis? - answer-Noncompliance related to medication side effects
A client calls the nurse with a complaint of sudden deep throbbing leg pain.
What is the appropriate first action by the nurse? - answer-Maintain the client
on bed rest
A client experiences intense anxiety after the home was destroyed by a fire.
The client escaped from the fire with only minor injuries. The nurse knows that
the most important initial intervention would be to: - answer-Determine
available community and personal resources
A client has been admitted with complaints of lower abdominal pain, difficulty
swallowing, nausea, dizziness, headache and fatigue. The client is agitated,
fearful, tachycardic and complains of being "too sick to return to work." The
client is diagnosed as having somatoform disorder. In formulating a plan of
care, the nurse must consider that the client's behavior - answer-Is controlled
by their subconscious mind
Simulation|Latest 2025 Update with complete
solutions.
. When walking past a client's room, the nurse hears 1 unlicensed assistive
personnel (UAP) talking to another UAP. Which statement requires follow-up
intervention? - answer-"Since I am late for lunch, would you do this one client's
glucose test?"
A 1 year-old child is receiving temporary total parental nutrition (TPN) through
a central venous line. This is the first day of TPN therapy. Although all of the
following nursing actions must be included in the plan of care of this child,
which one would be a priority at this time? - answer-Monitor serum glucose
levels
A 24 year-old male is admitted with a diagnosis of testicular cancer. The nurse
would expect the client to have - answer-Heaviness in the affected testicle
A 25 year-old client, unresponsive after a motor vehicle accident, is being
transferred from the hospital to a long term care facility. To which o staff
members should the charge nurse assign the client? - answer-RN
A 52 year-old client is being transfused with one unit of packed cells. A half
hour after the transfusion was initiated, the client complains of chills and
headache. Which action should the nurse implement first? - answer-Stop the
transfusion
,A 6 year-old child diagnosed with acute glomerulonephritis (AGN) is
experiencing anorexia, moderate edema and elevated blood urea nitrogen
(BUN) levels. The child requests a peanut butter sandwich for lunch. What
would the nurse's best response to this request? - answer-"I know that is your
favorite, but let me help you pick another lunch."
A 64 year-old client scheduled for surgery with a general anesthetic refuses to
remove a set of dentures prior to leaving the unit for the operating room.
What would be the most appropriate intervention by the nurse? - answer-Ask
the client if the preference would be to remove the dentures in the operating
room receiving area
A 9 year-old is taken to the emergency room with right lower quadrant pain
and vomiting. When preparing the child for an emergency appendectomy,
what must the nurse expect to be the child's greatest fear? - answer-Perceived
loss of control
A charge nurse working in a long term care facility is making out assignments.
Which assignment to an unlicensed assistive personnel (UAP), if made by the
nurse, requires intervention by the supervisor? - answer-Teaching a family
intermittent (bolus) feedings via G-tube before discharge
A child is sent to the school nurse by a teacher who has a written note that
Fifth's disease is suspected. Which characteristic would the nurse expect to
find? - answer-Erythema on the face, primarily on cheeks giving a "slapped
face" appearance
, A child is treated with edetate calcium disodium (Calcium EDTA) for lead
poisoning. Which of these should the nurse assess first ? - answer-Urinary
output
A client admits to benzodiazepine dependence for several years. She is now in
an outpatient detoxification program. The nurse must understand that a
priority during withdrawal is - answer-Avoid alcohol use during this time
A client being treated for hypertension returns to the community clinic for
follow up. The client says, "I know these pills are important, but I just can't take
these water pills anymore. I drive a truck for a living, and I can't be stopping
every 20 minutes to go to the bathroom." Which of these is the best nursing
diagnosis? - answer-Noncompliance related to medication side effects
A client calls the nurse with a complaint of sudden deep throbbing leg pain.
What is the appropriate first action by the nurse? - answer-Maintain the client
on bed rest
A client experiences intense anxiety after the home was destroyed by a fire.
The client escaped from the fire with only minor injuries. The nurse knows that
the most important initial intervention would be to: - answer-Determine
available community and personal resources
A client has been admitted with complaints of lower abdominal pain, difficulty
swallowing, nausea, dizziness, headache and fatigue. The client is agitated,
fearful, tachycardic and complains of being "too sick to return to work." The
client is diagnosed as having somatoform disorder. In formulating a plan of
care, the nurse must consider that the client's behavior - answer-Is controlled
by their subconscious mind
