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A nurse is caring for a client who has an aggressive form of prostate cancer. The
provider briefly discusses treatment options and leaves the client's room. When the
nurse asks if the client would like to discuss any concerns, the client declines. Which of
the following statements should the nurse make? -CORRECT ANSWER "I am available
to talk if you should change your mind."
A nurse is planning strategies to manage time effectively for client care. Which of the
following strategies should the nurse implement? -CORRECT ANSWER Use the
planning step of the nursing process to prioritize client care delivery.
A nurse is preparing to administer enoxaparin subcutaneously to a client. Which of the
following actions should the nurse take? -CORRECT ANSWER Administer the
medication with the needle at a 45° angle.
A nurse is responding to a call light and finds a client lying on the bathroom floor. Which
of the following actions should the nurse take first? -CORRECT ANSWER Check the
client for injuries.
A nurse is using an open irrigation technique to irrigate a client's indwelling urinary
catheter. Which of the following actions should the nurse take? -CORRECT ANSWER
Subtract the amount of irrigant used from the client's urine output.
A nurse is providing discharge instructions to a client who will be using a walker. Which
of the following client statements indicates an understanding of the teaching? -
CORRECT ANSWER "I will hire someone to trim the tree that hangs low over the stairs
of my front porch."
A nurse is caring for a client who is postoperative and refuses to use an incentive
spirometer following major abdominal surgery. Which of the following actions is the
nurse's priority? -CORRECT ANSWER Determine the reasons why the client is refusing
to use the incentive spirometer.
A nurse is preparing a change-of-shift report. Which of the following tools or documents
should the nurse use to communicate continuity of care? -CORRECT ANSWER
Situation, background, assessment, and recommendation (SBAR)
A nurse is talking with an older adult client who is contemplating retirement. The client
states, "I keep thinking about how much I enjoy my job. I'm not sure I want to retire."
, Which of the following responses should the nurse make? -CORRECT ANSWER "Let's
talk about how the change in your job status will affect you."
A nurse is caring for a client who is postoperative following a knee arthroplasty and
requires the use of thigh-length sequential compression sleeves. Which of the following
actions should the nurse take? -CORRECT ANSWER Make sure two fingers can fit
under the sleeves.
Select the 3 tasks the nurse should delegate to an assistive personnel (AP).
A nurse is caring for a client who has pancreatitis.
Exhibit 1:
Nurses' Notes: 1000: Client states, "I am unable to eat anything without vomiting." Client
reports pain in left upper quadrant of abdomen that radiates to their back. States that
pain is a "7" on a 0 to 10 pain scale. Bruising noted on client's abdomen. Client is pale
and diaphoretic. Provider prescribed blood work, abdominal CT, and NG tube insertion
with low-intermittent decompression. IV fluids started and infusing in left peripheral IV
site.
Exhibit 2:
Vital Signs: 1000: BP 96/52 mm Hg, Heart rate 110/min, Respirations 22/min,
Temperature 38.4° C (101.1° F), Oxygen saturation 92% on room air
Exhibit 3:
Prescriptions: 1100: CT of abdomen, NG tube to low wall suction, Serum amylase level
-CORRECT ANSWER - Document the client's vital signs
- Measure the client's intake and output
- Transfer the client from wheelchair to bed
A nurse is preparing to administer 0.9% sodium chloride 750 mL IV to infuse over 7 hr.
The nurse should set the infusion pump to deliver how many mL/hr? (Round the
CORRECT ANSWER to the nearest whole number. Use a leading zero if it applies. Do
not use a trailing zero.) -CORRECT ANSWER 107 mL/hr
A nurse is caring for a client who is expressing anger about his diagnosis of colorectal
cancer. Which of the following actions should the nurse take? -CORRECT ANSWER
Reassure the client that this is an expected response to grief.
A nurse is educating a client who has a terminal illness about declining resuscitation in
a living will. The client asks, "What would happen if I arrived at the emergency
department and I had difficulty breathing?" Which of the following responses should the
nurse make? -CORRECT ANSWER "We would give you oxygen through a tube in your
nose."