2023 with question and answer100%gradedA+
Request an interpreter during the initial assessment - A client who is deaf and communicates
using sign language is being admitted by a nurse who does not know sign language.
Daytime oliguria - A nurse is caring for a client who has left-sided heart failure.
Turn the client on their side - A nurse enters a client's room and observes the client having a
tonic-clonic seizure.
Decreased anxiety - A nurse is caring for a client who has acute heart failure and received
morphine IV 30 min ago.
Alopecia - A nurse is assessing a client who has anorexia.
The elastic bandage will prevent excessive edema. - A nurse is caring for a client who is 2
days postoperative following a below-the-knee amputation.
Obtain an ECG - A nurse in the emergency department is managing the care of a client who
has an electrical shock injury.
Initiate IV fluid replacement - A nurse is caring for a client who has a new onset of
hyperglycemic hyperosmolar state (HHS).
,Strawberries - A nurse is reviewing the health history of a client who is scheduled for
exploratory surgery.
You will need to return in 48 hours for re-evaluation. - A nurse is assessing a client who
received a purified protein derivative (PPD) skin test 48 hr ago.
Place a paper towel around the ampule's neck to break off the top with both hands - A nurse
is planning to withdraw medication from an ampule to prepare for an injection.
Consider respite care services - A nurse is caring for a client who has moderate Alzheimer's
disease.
Pain assessment - A nurse is assessing a client who is postoperative following an open
reduction and internal fixation (ORIF) of the femur.
Encourage the client to perform circumduction of the feet - A nurse is caring for a client who
is 3 hr postoperative following a total knee arthroplasty.
Stool for occult blood - A nurse is admitting a client who has arthritic pain and reports taking
ibuprofen several times daily for 3 years.
Assist the client with ambulation. - A nurse is caring for a client who is 16 hr postoperative
and is experiencing abdominal gas pains.
Stop the infusion - A nurse is administering packed RBCs to a client who reports chills, lower
back pain, and nausea 10 min. after the infusion begins.
, Triiodothyronine 3 - A nurse is reviewing the laboratory findings of a client who has a new
diagnosis of Graves' disease.
Administer the plasma immediately after thawing - A nurse is preparing to administer fresh
frozen plasma to a client.
Burn injury - A nurse working in the emergency department is caring for a client who has a
burn injury.
Airway intervention - Start an IV with a large-bore needle
Peripheral nerve block concerns - "Let's discuss your concerns about this procedure."
Warfarin food interactions - Kale
Bilateral orchiectomy discharge symptoms - Hot flashes
Isoniazid (INH) understanding - "I will have my liver function tested while I am taking this
medication."
Raynaud's disease triggers - Using a nicotine transdermal patch
Post-extubation intervention - Stridor
Postoperative endoscopy priority assessment - Gag reflex