Hondros HESI PN Comprehensive Exit V5 (NEW 2026/ 2027 Update) | Questions & Answers| Grade A| 100% Correct (Accurate Solutions).

…..DLDD Hondros HESI PN Comprehensive Exit V5 (NEW 2026/ 2027 Update) | Questions & Answers| Grade A| 100% Correct (Accurate Solutions). Q. A male client is admitted for the removal of an internal fixation that was inserted for the fracture ankle. During the admission history, he tells the nurse he recently received vancomycin (vancomycin) for a methicillin-resistant Staphylococcus aureus (MRSA) wound infection. Which action should the nurse take? (Select all that apply.) ANSWERS - Collect multiple site screening culture for MRSA - Place the client on contact transmission precautions - Continue to monitor for client sign of infection. Q. A vacuum-assistive closure (VAC) device is being used to provide wound care for a client who has stage III pressure ulcer on a below-the- knee (BKA) residual limb. Which intervention should the nurse implement to ensure maximum effectiveness of the device? ANSWERS Ensure the transparent dressing has no tears that might create vacuum leak Q. The nurse is developing the plan of care for a client with pneumonia and includes the nursing diagnosis of "Ineffective airway clearance related to thick pulmonary secretions." Which intervention is most important for the nurse to include in the client's plan of care? ANSWERS Increase fluid intake to 3,000 ml/daily Q. The nurse plans to collect a 24- hour urine specimen for a creatinine clearance test. Which instruction should the nurse provide to the adult male client? ANSWERS Urinate at specific time, discard the urine, and collect all subsequent urine during the next 24 hours. Q. The nurse is preparing to administer a histamine 2-receptor antagonist to a client with peptic ulcer disease. What is the primary purpose of this drug classification? ANSWERS Decreases the amount of HCL secretion by the parietal cells in the stomach Q. The healthcare provider prescribes acarbose (Precose), an alpha-glucosidase inhibitor, for a client with Type 2 diabetes mellitus. Which information provides the best indicator of the drug's effectiveness? ANSWERS Hemoglobin A1C (HbA1C) reading less than 7% Q. The nurse assesses a client with new onset diarrhea. It is most important for the nurse to question the client about recent use of which type of medication? ANSWERS antibiotics Q. A neonate with a congenital heart defect (CHD) is demonstrating symptoms of heart failure (HF). Which interventions should the nurse include in the infant's plan of care? ANSWERS - Give O2 at 6 L/nasal canula for 3 repeated oximetry screens below 90% - Evaluate heart rate for effectiveness of cardio tonic medications - Use high energy formula 30 calories/ounce at Q3 hours feeding via soft nipples - Ensure uninterrupted and frequent rest periods between procedures. Q. The nurse is caring for a 4-year-old male child who becomes unresponsive as his heart rate decreases to 40 beats/minute. His blood pressure is 88/70 mmHg, and his oxygen saturation is 70% while receiving 100% oxygen by non-rebreather face mask. In what sequence, from first to last, should the nurse implement these actions? (Place the first action on top and last action on the bottom.) ANSWERS 1. Start chest compressions with assisted manual ventilations 2. Administer epinephrine 0.01 mg/kg intraosseous (IO) 3. Apply pads and prepare for transthoracic pacing 4. Review the possible underlying causes for bradycardia Q. An elderly male client is admitted to the mental health unit with a sudden onset of global disorientation and is continuously conversing with his mother, who died 50 years ago. The nurse reviews the multiple prescriptions he is currently taking and assesses his urine specimen, which is cloudy, dark yellow, and has foul odor. These findings suggest that his client is experiencing which condition? ANSWERS delirium Q. Following an esophagogastroduodenoscopy (EGD) a male client is drowsy and difficult to arouse, and his respirations are slow and shallow. Which action should the nurse implement? Select all that apply. ANSWERS - Prepare medication reversal agent - Check oxygen saturation level - Apply oxygen via nasal cannula Q. To help reduce the child anxiety, which action is the best for the nurse to implement? ANSWERS Provide a family tour of the preoperative unit one week before the surgery is scheduled Q. Which intervention should the nurse implement during the administration of vesicant chemotherapeutic agent via an IV site in the client's arm? ANSWERS Assess IV site frequently for signs of extravasation Q. When development a teaching plan for a client newly diagnosed type 1 diabetes, the nurse should explain that an increase thirst is an early sign of diabetes ketoacidosis (DKA), which action should the nurse instruct the client to implement if this sign of DKA occur? ANSWERS Give a dose of regular insulin per sliding scale Q. The nurse is teaching a group of clients with rheumatoid arthritis about the need to modify daily activities. Which goal should the nurse emphasize? ANSWERS Protect joint function Q. An adult client experiences a gasoline tank fire when riding a motorcycle and is admitted to the emergency department (ED) with full thickness burns to all surfaces of both lower extremities. What percentage of body surface area should the nurse document in the electronic medical record (EMR)? ANSWERS 36% Q. A client with hyperthyroidism is receiving propranolol (Inderal). Which finding indicates that the medication is having the desired effect ANSWERS Decrease in pulse rate Q. An older male client with type 2 diabetes mellitus reports that he has experienced leg pain when walking short distances, and that the pain is relieved by rest. Which client behavior indicates an understanding of healthcare teaching to promote more effective arterial circulation? ANSWERS Completely stop cigarette/ cigar smoking Q. A community health nurse is concerned about the spread of communicable diseases among migrant farm workers in a rural community. What action should the nurse take to promote the success of a healthcare program designed to address this problem? ANSWERS Establish trust with community leaders and respect cultural and family values. Q. The nurse performs a prescribed neurological check at the beginning of the shift on a client who was admitted to the hospital with a subarachnoid brain attack (stroke). The client's Glasgow Coma Scale (GCS) score is 9. What information is most important for the nurse to determine? ANSWERS The client's previous GCS score. Q. The charge nurse in a critical care unit is reviewing clients' conditions to determine who is stable enough to be transferred. Which client status report indicates readiness for transfer from the critical care unit to a medical unit? ANSWERS Chronic liver failure with a hemoglobin of 10.1 and slight bilirubin elevation Q. Based on principles of asepsis, the nurse should consider which circumstance to be sterile? ANSWERS An open sterile Foley catheter kit set up on a table at the nurse waist level Q. An unlicensed assistive personnel (UAP) reports that a client's right hand and fingers spasms when taking the blood pressure using the same arm. After confirming the presence of spams what action should the nurse take? ANSWERS Review the client's serum calcium level Q. A 56-years-old man shares with the nurse that he is having difficulty making decision about terminating life support for his wife. What is the best initial action by the nurse? ANSWERS Provide an opportunity for him to clarify his values related to the decision Q. A client is being discharged home after being treated for heart failure (HF). What instruction should the nurse include in this client's discharge teaching plan? ANSWERS Weigh every morning Q. A woman just learned that she was infected with Helicobacter pylori. Based on this finding, which health promotion practice should the nurse suggest? ANSWERS Encourage screening for a peptic ulcer. Q. A child with heart failure is receiving the diuretic furosemide (Lasix) and has serum potassium level 3.0 mEq/L. Which assessment is most important for the nurse to obtain? ANSWERS Cardiac rhythm and heart rate Q. The nurse note a depressed female client has been more withdrawn and noncommunicative during the past two weeks. Which intervention is most important to include in the updated plan of care for this client? ANSWERS Engage the client in a non-threatening conversation. Q. A client with rheumatoid arthritis (RA) starts a new prescription of etanercept (Enbrel) subcutaneously once weekly. The nurse should emphasize the importance of reporting problem to the healthcare provider? ANSWERS persistent fever Q. The nurse is assessing an older adult with type 2 diabetes mellitus. Which assessment finding indicates that the client understands long-term control of diabetes? ANSWERS The hemoglobin A1C was 6.5g/100 ml last week Q. An older male client is admitted with the medical diagnosis of possible cerebral vascular accident (CVA). He has facial paralysis and cannot move his left side. When entering the room, the nurse finds the client's wife tearful and trying unsuccessfully to give him a drink of water. What action should the nurse take? ANSWERS Ask the wife to stop and assess the client's swallowing reflex. A 13 years-old client with non-union of a comminuted fracture of the tibia is admitted with osteomyelitis. The healthcare provider collects home aspirate specimens for culture and sensitivity and applies a cast to the adolescent's lower leg. What action should the nurse implement next? Begin parenteral antibiotic therapy The nurse is preparing a community education program on osteoporosis. Which instruction is helpful in preventing bone loss and promoting bone formation? Recommend weight-bearing physical activity A client with a history of chronic pain requests a nonopioid analgesic. The client is alert but has difficulty describing the exact nature and location of the pain to the nurse. What action should the nurse implement next? Administer the analgesic as requested A male client receives a thrombolytic medication following a myocardial infarction. When the client has a bowel movement, what action should the nurse implement? Send stool sample to the lab for a guaiac test The mother of a child with cerebral palsy (CP) ask the nurse if her child's impaired movements will worsen as the child grows. Which response provides the best explanation? Brain damage with CP is not progressive but does have a variable course In early septic shock states, what is the primary cause of hypotension? Peripheral vasodilation A client diagnosed with calcium kidney stones has a history of gout. A new prescription for aluminum hydroxide (Amphogel) is scheduled to begin at 0730. Which client medication should the nurse bring to the healthcare provider's attention? Allopurinol (Zyloprim) A male client's laboratory results include a platelet count of 105,000/ mm3 Based on this finding the nurse should include which action in the client's plan of care? Encourage him to use an electric razor A client is admitted to the hospital after experiencing a brain attack, commonly referred to as a stroke or cerebral vascular accident (CVA). The nurse should request a referral for speech therapy if the client exhibits which finding? Persistent coughing while drinking At 1615, prior to ambulating a postoperative client for the first time, the nurse reviews the client's medical record. Based on data contained in the record, what action should the nurse take before assisting the client with ambulation? Remove sequential compression devices. Which assessment finding for a client who is experiencing pontine myelinolysis should the nurse report to the healthcare provider? Sudden dysphagia A client is scheduled to receive an IV dose of ondansetron (Zofran) eight hours after receiving chemotherapy. The client has saline lock and is sleeping quietly without any restlessness. The nurse caring for the client is not certified in chemotherapy administration. What action should the nurse take? Administer the Zofran after flushing the saline lock with saline When providing diet teaching for a client with cholecystitis, which types of food choices the nurse recommend to the client? low fat A client with a history of cirrhosis and alcoholism is admitted with severe dyspnea and ascites. Which assessment finding warrants immediate intervention by the nurse? Muffled heart sounds When entering a client's room, the nurse discovers that the client is unresponsive and pulseless. The nurse initiate CPR and Calls for assistance. Which action should the nurse take next? Place cardiac monitor leads on the client's chest. A client with a history of dementia has become increasingly confused at night and is picking at an abdominal surgical dressing and the tape securing the intravenous (IV) line. The abdominal dressing is no longer occlusive, and the IV insertion site is pink. What intervention should the nurse implement? Redress the abdominal incision An adult male client is admitted to the emergency room following an automobile collision in which he sustained a head injury. What assessment data would provide the earliest that the client is experiencing increased intracranial pressure (ICP)? lethargy In preparing a diabetes education program, which goal should the nurse identify as the primary emphasis for a class on diabetes self-management? Enable clients to become active participating in controlling the disease process To reduce staff nurse role ambiguity, which strategy should the nurse manager implemented? Review the staff nurse job description to ensure that it is clear, accurate, and recurrent. Suicide precautions are initiated for a child admitted to the mental health unit following an intentional narcotic overdose. After a visitor leaves, the nurse finds a package of cigarettes in the client's room. Which intervention is most important for the nurse to implement? Remove cigarettes for the client's room A family member of a frail elderly adult asks the nurse about eligibility requirements for hospice care. What information should the nurse provide? (Select all that apply.) A.)A client must be willing to accept palliative care, not curative care. B.)The healthcare provider must project that the client has 6 months or less to live. C.)The client must be diagnosed with clinical depression D.)The client must be of sound mind A,B A client with atrial fibrillation receives a new prescription for dabigatran. What instruction should the nurse include in this client's teaching plan? Avoid use of nonsteroidal ant-inflammatory drugs (NSAID). An infant who is admitted for surgical repair of a ventricular septal defect (VSD) is irritable and diaphoretic with jugular vein distention. Which prescription should the nurse administer first? Digoxin The nursing staff on a medical unit includes a registered nurse (RN), practical nurse (PN), and an unlicensed assistive personnel (UAP). Which task should the charge nurse assign to the RN? Supervise a newly hired graduate nurse during an admission assessment. While teaching a young male adult to use an inhaler for his newly diagnosed asthma, the client stares into the distance and appears to be concentrating on something other than the lesson the nurse is presenting. What action should the nurse take? Ask the client what he is thinking about at his time. After several hours of non-productive coughing, a client presents to the emergency room complaining of chest tightness and shortness of breath. History includes end stage chronic obstructive pulmonary disease (COPD) and diabetes mellitus. While completing the pulmonary assessment, the nurse hears wheezing and poor air movement bilaterally. Which actions should the nurse implement? (Select all that apply.) A.)Administer PRN nebulizer treatment. B.)Obtain 12 lead electrocardiogram. C.)Monitor continuous oxygen saturation. D.) Lay the client in the prone position A,B,C The nurse caring for a 3-month-old boy one day after a pylorotomy notices that the infant is restless, is exhibiting facial grimaces, and is drawing his knees to his chest. What action should the nurse take? Administer a prescribed analgesia for pain. A 4-year-old with acute lymphocytic leukemia (ALL) is receiving a chemotherapy (CT) protocol that includes methotrexate (Mexate, Trexal, MIX), an antimetabolite. Which information should the nurse provide the parents about caring for their child? Use sunblock or protective clothing when outdoors. Two days after admission a male client remembers that he is allergic to eggs, and informs the nurse of the allergy. Which actions should the nurse implement? SATA A.) Tell the client that its a mild reaction B.)Notify the food services department of the allergy. C.)Enter the allergy information in the client's record. D.)Add egg allergy to the client's allergy arm band. B,C,D The rapid response team's detects return of spontaneous circulation (ROSC) after 2 min of continuous chest compressions. The client has a weak, fast pulse and no respiratory effort, so the healthcare provider performs a successful oral, intubation. What action should the nurse implement? Perform bilateral chest auscultation. After administering an antipyretic medication. Which intervention should the nurse implement? Encouraging liberal fluid intake A client with hyperthyroidism is being treated with radioactive iodine (I-131). Which explanation should be included in preparing this client for this treatment? Describe radioactive iodine as a tasteless, colorless medication administered by the healthcare provider After a colon resection for colon cancer, a male client is moaning while being transferred to the Postanesthesia Care Unit (PACU). Which intervention should the nurse implement first? Determine client's pulse, blood pressure, and respirations The nurse is caring for a group of clients with the help of a licensed practical nurse (LPN) and an experienced unlicensed assistive personnel (UAP). Which procedures can the nurse delegate to the UAP? (Select all that apply) A.)Take postoperative vital signs for a client who has an epidual following knee arthroplasty B.)Collect a sputum specimen for a client with a fever of unknown origin C.)Ambulate a client who had a femoral-popliteal bypass graft yesterday A,B,C A male client with cirrhosis has ascites and reports feeling short of breath. The client is in semi Fowler position with his arms at his side. What action should the nurse implement? Raise the head of the bed to a Fowler's position and support his arms with a pillow A client with a history of chronic pain requests a nonopioid analgesic. The client is alert but has difficulty describing the exact nature and location of the pain to the nurse. Which action should the nurse implement next? Administer the analgesic as requested The nurse uses the parkland formula (4ml x kg x total body surface area = 24 hours fluid replacement) to calculate the 24-hours IV fluid replacement for a client with 40% burns who weighs 76kg. How many ml should the client receive? (Enter numeric value only.) 12160 A client with leukemia undergoes a bone marrow biopsy. The client's laboratory values indicate the client has thrombocytopenia. Based on this data, which nursing assessment is most important following the procedure? A.)Observe aspiration site. B.)Assess body temperature C.)Monitor skin elasticity D.)Measure urinary output A An 18-year-old female client is seen at the health department for treatment of condylomata acuminate (perineal warts) caused by the human papillomavirus (HPV). Which intervention should the nurse implement? Reinforce the importance of annual papanicolaou (Pap) smears. A client admitted to the psychiatric unit diagnosed with major depression wants to sleep during the day, refuses to take a bath, and refuses to eat. Which nursing intervention should the nurse implement first? Establish a structured routine for the client to follow. A client with history of bilateral adrenalectomy is admitted with a week, irregular pulse, and hypotension. Which assessment finding warrants immediate intervention by the nurse? Ventricular arrhythmias. The mother of a 7-month-old brings the infant to the clinic because the skin in the diaper area is excoriated and red, but there are no blisters or bleeding. The mother reports no evidence of watery stools. Which nursing intervention should the nurse implement? Instruct the mother to change the child's diaper more often. A resident of a long-term care facility, who has moderate dementia, is having difficulty eating in the dining room. The client becomes frustrated when dropping utensils on the floor and then refuses to eat. What action should the nurse implement? Encourage the client to eat finger foods. A client is receiving mesalamine 800 mg PO TID. Which assessment is most important for the nurse to perform to assess the effectiveness of the medication? Bowel patterns While in the medical records department, the nurse observes several old medical records with names visible in waste container. What action should the nurse implement? Contact the medical records department supervisor. A 16-year-old adolescent with meningococcal meningitis is receiving a continuous IV infusion of penicillin G, which is prescribed as 20 million units in a total volume of 2 liters of normal saline every 24 hr. The pharmacy delivers 10 million units/ liters of normal saline. How many ml/hr should the nurse program the infusion pump? (Enter numeric value only. If rounding is required, round to the nearest whole number.) 83 While visiting a female client who has heart failure (HF) and osteoarthritis, the home health nurse determines that the client is having more difficulty getting in and out of the bed than she did previously. Which action should the nurse implement first? Submit a referral for an evaluation by a physical therapist. A client has an intravenous fluid infusing in the right forearm. To determine the client's distal pulse rate most accurately, which action should the nurse implement? Submit a referral for an evaluation by a physical therapist. A child is admitted to the pediatric unit diagnosed with sickle cell crisis. When the nurse walks into the room, the unlicensed assistive personnel (UAP) is encouraging the child to stay in bed in the supine position. Which action should the nurse implement? Reposition the client with the head of the bed elevated. 155. After six days on a mechanical ventilator, a male client is extubated and place on 40% oxygen via face mask. He is awake and cooperative, but complaining of a severe sore throat. While sipping water to swallow a medication, the client begins coughing, as if strangled. What intervention is most important for the nurse to implement? Hold oral intake until swallow evaluation is done. The nurse is interacting with a female client who is diagnosed with postpartum depression. Which finding should the nurse document as an objective signs of depression? (Select all that apply) A.)Interacts with a flat affect. B.)Avoids eye contact. C.)Makes dull eye contact D.)Has a disheveled appearance. A,B,D A client in the postanesthesia care unit (PACU) has an eight (8) on the Aldrete postanesthesia scoring system. What intervention should nurse implement? Transfer the client to the surgical floor. In caring for the body of a client who just died, which tasks can be delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.) A.)Place personal religious artifacts on the body. B.)Attach identifying name tags to the body. C.)Follow cultural beliefs in preparing the body. D.) Inform the family A,B,C An adult male reports the last time he received penicillin he developed a severe maculopapular rash all over his chest. What information should the nurse provide the client about future antibiotic prescriptions? Be alert for possible cross-sensitivity to cephalosporin agents. A client with a prescription for "do not resuscitate" (DNR) begins to manifest signs of impending death. After notifying the family of the client's status, what priority action should the nurse implement? The client's need for pain medication should be determined. A client with cirrhosis of the liver is admitted with complications related to end stage liver disease. Which intervention should the nurse implement? (Select all that apply.) A.)Monitor abdominal girth. B.)Increase oral fluid intake to 1500 ml daily. C.)Report serum albumin and globulin levels. D.)Provide diet low in phosphorous. E.)Note signs of swelling and edema. A,C,E During discharge teaching, the nurse discusses the parameters for weight monitoring with a client who was recently diagnosed with heart failure (HF). Which information is most important for the client to acknowledge? Report weight gain of 2 pounds (0.9kg) in 24 hours Which problem, noted in the client's history, is important for the nurse to be aware of prior to administration of a newly prescribed selective serotonin reuptake inhibitor (SSRI)? Aural migraine headaches. When implementing a disaster intervention plan, which intervention should the nurse implement first? A.)Initiate the discharge of stable clients from hospital units B.)Identify a command center where activities are coordinated C.)Assess community safety needs impacted by the disaster D.)Instruct all essential off-duty personnel to report to the facility B The nurse is evaluating a client's symptoms, and formulates the nursing diagnosis, "high risk for injury due to possible urinary tract infection." Which symptoms indicate the need for this diagnosis? Fever and dysuria. A client is admitted with metastatic carcinoma of the liver, ascites, and bilateral 4+ pitting edema of both lower extremities. When the client complains that the antiembolic stocking are too constricting, which intervention should the nurse implement? Maintain both lower extremities elevated on pillows. A client with muscular dystrophy is concerned about becoming totally dependent and is reluctant to call the nurse to assist with activities of daily living (ADLs). To achieve maximum mobility and independence, which intervention is most important for the nurse to include in the client's plan of care? Teach family proper range of motion exercises. The nurse is teaching a postmenopausal client about osteoporosis prevention. The client reports that she smokes 2 packs of cigarettes a day and takes 750 mg calcium supplements daily. What information should the nurse include when teaching this client about osteoporosis prevention? Postmenopausal women need an intake of at least 1,500 mg of calcium daily. When evaluating a client's rectal bleeding, which findings should the nurse document? Color characteristics of each stool. The nurse is auscultating a client's lung sounds. Which description should the nurse use to document this sound? A.)High pitched or fine crackles. B.)Rhonchi C.)High pitched wheeze D.)Stridor A An adult male is admitted to the emergency department after falling from a ladder. While waiting to have a computed tomography (CT) scan, he requests something for a severe headache. When the nurse offers him a prescribed does of acetaminophen, he asks for something stronger. Which intervention should the nurse implement? Explain the reason for using only non-narcotics. The nurse is managing the care of a client with Cushing's syndrome. Which interventions should the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply) Weigh the client and report any weight gain. Report any client complaint of pain or discomfort. Note and report the client's food and liquid intake during meals and snacks. Ten years after a female client was diagnosed with multiple sclerosis (MS), she is admitted to a community palliative care unit. Which intervention is most important for the nurse to include in the client's plan of care? Medicate as needed for pain and anxiety. An increased number of elderly persons are electing to undergo a new surgical procedure which cures glaucoma. What effect is the nurse likely to note as a result of this increases in glaucoma surgeries? Decrease prevalence of glaucoma in the population. The nurse is caring for a client who is entering the second stage of labor. Which action should the nurse implement first? Convey to the client that birth is imminent. To evaluate the effectiveness of male client's new prescription for ezetimibe, which action should the clinic nurse implement? Remind the client to keep his appointments to have his cholesterol level checked. Diagnostic studies indicate that the elderly client has decreased bone density. In providing client teaching, which area of instruction is most important for the nurse to include? Fall prevention measures. A young adult client is admitted to the emergency room following a motor vehicle collision. The client's head hit the dashboard. Admission assessment include: Blood pressure 85/45 mm Hg, temperature 98.6 F, pulse 124 beat/minute and respirations 22 breath/minute. Based on these data, the nurse formulates the first portion of nursing diagnosis as " Risk of injury" What term best expresses the "related to" portion of nursing diagnosis? A.)Infection B.)Increase intracranial pressure C.)Shock D.)Head Injury. C An older male client with history of diabetes mellitus, chronic gout, and osteoarthritis comes to the clinic with a bag of medication bottles. Which intervention should the nurse implement first? Identify pills in the bag. A male client who was diagnosed with viral hepatitis A 4 weeks ago returns to the clinic complaining of weakness and fatigue. Which finding is most important for the nurse to report to the healthcare provider? New onset of purple skin lesions. In assessing a client twelve hours following transurethral resection of the prostate (TURP), the nurse observes that the urinary drainage tubing contains a large amount of clear pale pink urine and the continuous bladder irrigation is infusing slowly. What action should the nurse implement? Ensure that no dependent loops are present in the tubing. The healthcare provider prescribes the antibiotic Cefdinir (cephalosporin) 300mg PO every 12 h for a client with postoperative wound infections. Which feeds should the nurse encourage this client to eat? A.)Yogurt and/or buttermilk. B.)Avocados and cheese C.)Green leafy vegetables D.)Fresh fruits A The charge nurse is making assignment on a psychiatric unit for a practical nurse (PN) and newly license register nurse (RN). Which client should be assigned to the RN? A.)An adult female who has been depress for the past several month and denies suicidal ideations. B.)A middle-age male who is in depressive phase on bipolar disease and is receiving Lithium. C.)A young male with schizophrenia who said voices is telling him to kill his psychiatric. D.)An elderly male who tell the staff and other client that he is superman and he can fly. C In assessing an older female client with complication associated with chronic obstructive pulmonary disease (COPD), the nurse notices a change in the client's appearance. Her face appears tense and she begs the nurse not to leave her alone. Her pulse rate is 100, and respirations are 26 per min. What is the primary nursing diagnosis? Anxiety related to fear of suffocation. A client with a cervical spinal cord injury (SCI) has Crutchfield tongs and skeletal traction applied as a method of closed reduction. Which intervention is most important for the nurse to include in the client's a plan of care? Provide daily care of tong insertion sites using saline and antibiotic ointment A client arrives on the surgical floor after major abdominal surgery. What intervention should the nurse perform first? Determine the client's vital sign. A client is admitted to the emergency department with a respiratory rate of 34 breaths per minute and high pitched wheezing on inspiration and expiration, the medical diagnosis is severe exacerbation of asthma. Which assessment finding, obtained 10 min after the admission assessment, should the nurse report immediately to the emergency department healthcare provider? No wheezing upon auscultation of the chest. The nurse is planning a class for a group of clients with diabetes mellitus about blood glucose monitoring. In teaching the class as a whole, the nurse should emphasize the need to check glucose levels in which situation? During acute illness A 350-bed acute care hospital declares an internal disaster because the emergency generators malfunctioned during a city-wide power failure. The UAPs working on a general medical unit ask the charge nurse what they should do first. What instruction should the charge nurse provide to these UAPs? Tell all their assigned clients to stay in their rooms. The healthcare provider changes a client's medication prescription from IV to PO administration and double the dose. The nurse notes in the drug guide that the prescribed medication, when given orally, has a high first-pass effect and reduce bioavailability. What action should the nurse implement? Administer the medication via the oral route as prescribed A client refuses to ambulate, reporting abdominal discomfort and bloating caused by "too much gas buildup" the client's abdomen is distended. Which prescribed PRN medication should the nurse administer? Simethicone (Mylicon) The public nurse health received funding to initiate primary prevention program in the community. Which program the best fits the nurse's proposal? A.)Lead screening for children in low-income housing. B.)Case management and screening for clients with HIV C.)Regional relocation center for earthquake victims D.)Vitamin supplements for high-risk pregnant women. D When assessing and adult male who presents as the community health clinic with a history of hypertension, the nurse note that he has 2+ pitting edema in both ankles. He also has a history of gastroesophageal reflex disease (GERD) and depression. Which intervention is the most important for the nurse to implement? A.)Arrange to transport the client to the hospital B.)Instruct the client to keep a food journal, including portions size. C.)Review the client's use of over the counter (OTC) medications. D.)Reinforce the importance of keeping the feet elevated. C An older client is admitted to the intensive care unit with severe abdominal pain, abdominal distention, and absent bowel sound. The client has a history of smoking 2 packs of cigarettes daily for 50 years and is currently restless and confused. Vital signs are: temperature 96`F, heart rate 122 beats/minute, respiratory rate 36 breaths/minute, mean arterial pressure(MAP) 64 mmHg and central venous pressure (CVP) 7 mmHg. Serum laboratory findings include: hemoglobin 6.5 grams/dl, platelets 6o, 000, and white blood cell count (WBC) 3,000/mm3. Based on these findings this client is at greatest risk for which pathophysiological condition? A.)Multiple organ dysfunction syndrome (MODS) B.)Disseminated intravascular coagulation (DIC) C.)Chronic obstructive disease. D.)Acquired immunodeficiency syndrome (AIDS) A A man expresses concern to the nurse about the care his mother is receiving while hospitalized. He believes that her care is not based on any ethical standards and ask what type of care he should expect from a public hospital. What action should the nurse take? Provide the man and his mother with a copy of the Patient's Bill of Rights A client experiencing withdrawal from the benzodiazepines alprazolam (Xanax) is demonstrating severe agitation and tremors. What is the best initial nursing action? A.)Administer naloxone (Narcan) per PNR protocol B.)Initiate seizure precautions C.)Obtain a serum drug screen D.)Instruct the family about withdrawal symptoms. B The nurse is caring for a client who is taking a macrolide to treat a bacterial infection. Which finding should the nurse report to the healthcare provider before administering the next dose? A.)Jaundice B.)Nausea C.)Fever D.)Fatigue A A client with Alzheimer's disease (AD) is receiving trazodone (Desyrel), a recently prescribed atypical antidepressant. The caregiver tells the home health nurse that the client's mood and sleep patterns are improved, but there is no change in cognitive ability. How should the nurse respond to this information? A.)Explain that it may take several weeks for the medication to be effective B.)Confirm the desired effect of the medication has been achieved. C.)Notify the health care provider than a change may be needed. D.)Evaluate when and how the medication is being administered to the client. B A client with diabetic peripheral neuropathy has been taking pregabalin (Lyrica) for 4 days. Which finding indicates to the nurse that the medication is effective? A.)Reduced level of pain B.)Full volume of pedal pulses C.)Granulating tissue in foot ulcer D.)Improved visual acuity A A group of nurse-managers is asked to engage in a needs assessment for a piece of equipment that will be expensed to the organization's budget. Which question is most important to consider when analyzing the cost-benefit for this piece of equipment? A.)How many departments can use this equipment? B.)Will the equipment require annual repair? C.)Is the cost of the equipment reasonable? D.)Can the equipment be updated each year? A While receiving a male postoperative client's staples de nurse observe that the client's eyes are closed and his face and hands are clenched. The client states, "I just hate having staples removed". After acknowledgement the client's anxiety, what action should the nurse implement? A.)Encourage the client to continue verbalize his anxiety B.)Attempt to distract the client with general conversation C.)Explain the procedure in detail while removing the staples D.)Reassure the client that this is a simple nursing procedure. B A male client is admitted for the removal of an internal fixation that was inserted for the fracture ankle. During the admission history, he tells the nurse he recently received vancomycin (vancomycin) for a methicillin-resistant Staphylococcus aureus (MRSA) wound infection. Which action should the nurse take? (Select all that apply.) A.)Collect multiple site screening culture for MRSA B.)Call healthcare provider for a prescription for linezolid (Zyrovix) C.)Place the client on contact transmission precautions D.)Obtain sputum specimen for culture and sensitivity E.)Continue to monitor for client sign of infection. A,C,E A vacuum-assistive closure (VAC) device is being use to provide wound care for a client who has stage III pressure ulcer on a below-the- knee (BKA) residual limb. Which intervention should the nurse implement to ensure maximum effectiveness of the device? Ensure the transparent dressing has no tears that might create vacuum leaks The nurse is developing the plan of care for a client with pneumonia and includes the nursing diagnosis of "Ineffective airway clearance related to thick pulmonary secretions." Which intervention is most important for the nurse to include in the client's plan of care? Increase fluid intake to 3,000 ml/daily The nurse plans to collect a 24- hour urine specimen for a creatinine clearance test. Which instruction should the nurse provide to the adult male client? A.)Clearance around the meatus, discard first portion of voiding, and collect the rest in a sterile bottle B.)Urinate at specific time, discard the urine, and collect all subsequent urine during the next 24 hours. C.)For the next 24 hours, notify the nurse when the bladder is full, and the nurse will collect catheterized specimens. D.)Urinate immediately into a urinal, and the lab will collect specimen every 6 hours, for the next 24 hours. D The nurse is preparing to administer a histamine 2-receptor antagonist to a client with peptic ulcer disease. What is the primary purpose of this drug classification? Decreases the amount of HCL secretion by the parietal cells in the stomach The healthcare provider prescribes acarbose (Precose), an alpha-glucosidase inhibitor, for a client with Type 2 diabetes mellitus. Which information provides the best indicator of the drug's effectiveness? Hemoglobin A1C (HbA1C) reading less than 7% The nurse assesses a client with new onset diarrhea. It is most important for the nurse to question the client about recent use of which type of medication? A.)Antibiotics B.)Anticoagulants C.)Antihypertensive D)Anticholinergics A A neonate with a congenital heart defect (CHD) is demonstrating symptoms of heart failure (HF). Which interventions should the nurse include in the infant's plan of care? A.)Give O2 at 6 L/nasal cannula for 3 repeated oximetry screens below 90% B.)Administer diuretics via secondary infusion in the morning only C.)Evaluate heart rate for effectiveness of cardio tonic medications D.)Use high energy formula 30 calories/ounce at Q3 hours feeding via softnipples E.)Ensure Interrupted and frequent rest periods between procedures. A,C,D,E The nurse is caring for a 4-year-old male child who becomes unresponsive as his heart rate decreases to 40 beats/minute. His blood pressure is 88/70 mmHg, and his oxygen saturation is 70% while receiving 100% oxygen by non-rebreather face mask. In what sequence, from first to last, should the nurse implement these actions? (Place the first action on top and last action on the bottom.) Administer epinephrine 0.01 mg/kg intraosseous (IO) Start chest compressions with assisted manual ventilations Review the possible underlying causes for bradycardia Apply pads and prepare for transthoracic pacing 1. Start chest compressions with assisted manual ventilations 2. Administer epinephrine 0.01 mg/kg intraosseous (IO) 3. Apply pads and prepare for transthoracic pacing 4. Review the possible underlying causes for bradycardia An elderly male client is admitted to the mental health unit with a sudden onset of global disorientation and is continuously conversing with his mother, who died 50 years ago. The nurse reviews the multiple prescriptions he is currently taking and assesses his urine specimen, which is cloudy, dark yellow, and has foul odor. These findings suggest that his client is experiencing which condition? A.)Psychotic episode B.)Depression C.)Dementia D.)Delirium D A preschool-aged boy is admitted to the pediatric unit following successful resuscitation from a near-drowning incident. While providing care to child, the nurse begins talking with his preadolescent brother who rescued the child from the swimming pool and initiated resuscitation. The nurse notices the older boy becomes withdrawn when asked about what happened. What action should the nurse take? Ask the older brother how he felt during the incident. Following an esophagogastroduodenoscopy (EGD) a male client is drowsy and difficult to arouse, and his respiration are slow and shallow. Which action should the nurse implement? Select all that apply. A.)Prepare medication reversal agent B.)Check oxygen saturation level C.)Apply oxygen via nasal cannula D.)Initiate bag- valve mask ventilation. E.)Begin cardiopulmonary resuscitation A,B,C The nurse is planning preoperative teaching plan of a 12-years old child who is scheduled for surgery. To help reduce the child anxiety, which action is the best for the nurse to implement? A.)Give the child syringes or hospital mask to play it at home prior to hospitalization. B.)Include the child in pay therapy with children who are hospitalized for similarsurgery. C.)Provide a family tour of the preoperative unit one week before the surgery is scheduled. D.)Provide doll an equipment to re-enact feeling associated with painful procedures. C Which intervention should the nurse implement during the administration of vesicant chemotherapeutic agent via an IV site in the client's arm? Assess IV site frequently for signs of extravasation When development a teaching plan for a client newly diagnosed type 1 diabetes, the nurse should explain that an increase thirst is an early sing of diabetes ketoacidosis (DKA), which action should the nurse instruct the client to implement if this sign of DKA occur A.)Resume normal physical activity B.)Drink electrolyte fluid replacement C.)Give a dose of regular insulin per sliding scale D.)Measure urinary output over 24 hours. C The nurse is teaching a group of clients with rheumatoid arthritis about the need to modify daily activities. Which goal should the nurse emphasize? A.)Protect joint function B.)Improve circulation C.)Control tremors D.)Increase weight bearing A An adult client experiences a gasoline tank fire when riding a motorcycle and is admitted to the emergency department (ED) with full thickness burns to all surfaces of both lower extremities. What percentage of body surface area should the nurse document in the electronic medical record (EMR)? A.)9 % B.)18 % C.)36 % D.)45 % C A client with hyperthyroidism is receiving propranolol (Inderal). Which finding indicates that the medication is having the desired effect? A.)Decrease in serum T4 levels B.)Increase in blood pressure C.)Decrease in pulse rate D.)Goiter no longer palpable C An older male client with type 2 diabetes mellitus reports that has experiences legs pain when walking short distances, and that the pain is relieved by rest. Which client behavior indicates an understanding of healthcare teaching to promote more effective arterial circulation? A.)Consistently applies TED hose before getting dressed in the morning. B.)Frequently elevated legs thorough the day. C.)Inspect the leg frequently for any irritation or skin breakdown D.)Completely stop cigarette/ cigar smoking. D A community health nurse is concerned about the spread of communicable diseases among migrant farm workers in a rural community. What action should the nurse take to promote the success of a healthcare program designed to address this problem? Establish trust with community leaders and respect cultural and family values The nurse performs a prescribed neurological check at the beginning of the shift on a client who was admitted to the hospital with a subarachnoid brain attack (stroke). The client's Glasgow Coma Scale (GCS) score is 9. What information is most important for the nurse to determine? A.)The client's previous GCS score B.)When the client's stroke symptoms started C.)If the client is oriented to time D.)The client's blood pressure and respiration rate A The charge nurse in a critical care unit is reviewing clients' conditions to determine who is stable enough to be transferred. Which client status report indicates readiness for transfer from the critical care unit to a medical unit? Chronic liver failure with a hemoglobin of 10.1 and slight bilirubin elevation Based on principles of asepsis, the nurse should consider which circumstance to be sterile? A.)One inch- border around the edge of the sterile field set up in the operating room B.)A wrapped unopened, sterile 4x4 gauze placed on a damp table top. C.)An open sterile Foley catheter kit set up on a table at the nurse waist level D.)Sterile syringe is placed on sterile area as the nurse riches over the sterile field. C An unlicensed assistive personnel (UAP) reports that a client's right hand and fingers spasms when taking the blood pressure using the same arm. After confirming the presence of spams what action should the nurse take? A.)Ask the UAP to take the blood pressure in the other arm B.)Tell the UAP to use a different sphygmomanometer. C.)Review the client's serum calcium level D.)Administer PRN antianxiety medication. C A 56-years-old man shares with the nurse that he is having difficulty making decision about terminating life support for his wife. What is the best initial action by the nurse? A.)Provide an opportunity for him to clarify his values related to the decision B.)Encourage him to share memories about his life with his wife and family C.)Advise him to seek several opinions before making decision D.)Offer to contact the hospital chaplain or social worker to offer support. A A client is being discharged home after being treated for heart failure (HF). What instruction should the nurse include in this client's discharge teaching plan? A.)Weigh every morning B.)Eat a high protein diet C.)Perform range of motion exercises D.)Limit fluid intake to 1,500 ml daily A A woman just learned that she was infected with Heliobacter pylori. Based on this finding, which health promotion practice should the nurse suggest? Encourage screening for a peptic ulcer A client who recently underwear a tracheostomy is being prepared for discharge to home. Which instructions is most important for the nurse to include in the discharge plan? Teach tracheal suctioning techniques A child with heart failure is receiving the diuretic furosemide (Lasix) and has serum potassium level 3.0 mEq/L. Which assessment is most important for the nurse to obtain? A.)Daily intake of foods rich in potassium. B.)Cardiac rhythm and heart rate. C.)Hourly urinary output D.)Thirst ad skin turgor. B The nurse note a depressed female client has been more withdrawn and non-communicative during the past two weeks. Which intervention is most important to include in the updated plan of care for this client? A.)Encourage the client's family to visit more often B.)Schedule a daily conference with the social worker C.)Encourage the client to participate in group activities D.)Engage the client in a non-threatening conversation. D A client with rheumatoid arthritis (RA) starts a new prescription of etanercept (Enbrel) subcutaneously once weekly. The nurse should emphasize the importance of reporting problem to the healthcare provider? A.)Headache B.)Joint stiffness C.)Persistent fever D.)Increase hunger and thirst C The nurse is assessing an older adult with type 2 diabetes mellitus. Which assessment finding indicates that the client understands long- term control of diabetes? A.)The fating blood sugar was 120 mg/dl this morning. B.)Urine ketones have been negative for the past 6 months C.)The hemoglobin A1C was 6.5g/100 ml last week D.)No diabetic ketoacidosis has occurred in 6 months. C An older male client is admitted with the medical diagnosis of possible cerebral vascular accident (CVA). He has facial paralysis and cannot move his left side. When entering the room, the nurse finds the client's wife tearful and trying unsuccessfully to give him a drink of water. What action should the nurse take? Ask the wife to stop and assess the client's swallowing reflex A 13 years-old client with non-union of a comminuted fracture of the tibia is admitted with osteomyelitis. The healthcare provider collects home aspirate specimens for culture and sensitivity and applies a cast to the adolescent's lower leg. What action should the nurse implement next? A.)Administer antiemetic agents B.) Bivalve the cast for distal compromise C.)Provide high- calorie, high-protein diet D.)Begin parenteral antibiotic therapy D The nurse is preparing a community education program on osteoporosis. Which instruction is helpful in preventing bone loss and promoting bone formation? Recommend weigh bearing physical activity A client with a history of chronic pain requests a nonopioid analgesic. The client is alert but has difficulty describing the exact nature and location of the pain to the nurse. What action should the nurse implement next? Administer the analgesic as requested A male client receives a thrombolytic medication following a myocardial infarction. When the client has a bowel movement, what action should the nurse implement? A.)Send stool sample to the lab for a guaiac test B.)Observe stool for a day-colored appearance. C.)Obtain specimen for culture and sensitivity analysis D.)Asses for fatty yellow streaks in the client's stool. A The mother of a child with cerebral palsy (CP) ask the nurse if her child's impaired movements will worsen as the child grows. Which response provides the best explanation? Brain damage with CP is not progressive but does have a variable course During shift report, the central electrocardiogram (EKG) monitoring system alarms. Which client alarm should the nurse investigate first? Respiratory apnea of 30 seconds In early septic shock states, what is the primary cause of hypotension? A.)Peripheral vasoconstriction B.)Peripheral vasodilation C.)Cardiac failure D.)A vagal response B A client diagnosed with calcium kidney stones has a history of gout. A new prescription for aluminum hydroxide (Amphogel) is scheduled to begin at 0730. Which client medication should the nurse bring to the healthcare provider's attention? A.)Aspirin, low dose B.)Furosemide (lasix) C.)Enalapril (vasote) D.)Allopurinol (Zyloprim) D A male client's laboratory results include a platelet count of 105,000/ mm3 Based on this finding the nurse should include which action in the client's plan of care? A.)Cluster care to conserve energy B.)Initiate contact isolation C.)Encourage him to use an electric razor D.)Asses him for adventitious lung sounds C A client is admitted to the hospital after experiencing a brain attack, commonly referred to as a stroke or cerebral vascular accident (CVA). The nurse should request a referral for speech therapy if the client exhibits which finding? A.)Abnormal responses for cranial nerves I and II B.)Persistent coughing while drinking C.)Unilateral facial drooping D.)Inappropriate or exaggerated mood swings B At 1615, prior to ambulating a postoperative client for the first time, the nurse reviews the client's medical record. Based on date contained in the record, what action should the nurse take before assisting the client with ambulation: A.)Remove sequential compression devices. B.)Apply PRN oxygen per nasal cannula. C.)Administer a PRN dose of an antipyretic. D.)Reinforce the surgical wound dressing. A Which assessment finding for a client who is experiencing pontine myelinolysis should the nurse report to the healthcare provider? A.)Sudden dysphagia B.)Blurred visual field C.)Gradual weakness D.)Profuse diarrhea A A client is scheduled to receive an IW dose of ondansetron (Zofran) eight hours after receiving chemotherapy. The client has saline lock and is sleeping quietly without any restlessness. The nurse caring for the client is not certified in chemotherapy administration. What action should the nurse take? A.)Ask a chemotherapy-certified nurse to administer the Zofran B.)Administer the Zofran after flushing the saline lock with saline C.)Hold the scheduled dose of Zofran until the client awakens D.)Awaken the client to assess the need for administration of the Zofran. B When providing diet teaching for a client with cholecystitis, which types of food choices the nurse recommend to the client? A.)High protein B.)Low fat C.)Low sodium D.)High carbohydrate. B A client with a history of cirrhosis and alcoholism is admitted with severe dyspnea and ascites. Which assessment finding warrants immediate intervention by the nurse? A.) Jaundice skin tone B.)Muffled heart sounds C.)Pitting peripheral edema D.)Bilateral scleral edema B When entering a client's room, the nurse discovers that the client is unresponsive and pulseless. The nurse initiate CPR and Calls for assistance. Which action should the nurse take next? A.)Prepare to administer atropine 0.4 mg IVP B.)Gather emergency tracheostomy equipment C.)Prepare to administer lidocaine at 100 mg IVP D.)Place cardiac monitor leads on the client's chest. D A client with a history of dementia has become increasingly confused at night and is picking at an abdominal surgical dressing and the tape securing the intravenous (IV) line. The abdominal dressing is no longer occlusive, and the IV insertion site is pink. What intervention should the nurse implement? A.)Replace the IV site with a smaller gauge. B.)Redress the abdominal incision C.)Leave the lights on in the room at night. D.)Apply soft bilateral wrist restraints. B An adult male client is admitted to the emergency room following an automobile collision in which he sustained a head injury. What assessment data would provide the earliest that the client is experiencing increased intracranial pressure (ICP)? A.)Lethargy B.)Decorticate posturing C.)Fixed dilated pupil D.)Clear drainage from the ear. A In preparing a diabetes education program, which goal should the nurse identify as the primary emphasis for a class on diabetes self-management? A.)Prepare the client to independently treat their disease process B.)Reduce healthcare costs related to diabetic complications C.)Enable clients to become active participating in controlling the disease process D.)Increase client's knowledge of the diabetic disease process and treatment options. C To reduce staff nurse role ambiguity, which strategy should the nurse manager implemented? A.)Confirm that all the staff nurses are being assigned to equal number of clients. B.)Review the staff nurse job description to ensure that it is clear, accurate, and recurrent. C.)Assign each staff nurse a turn unit charge nurse on a regular, rotating basis. D.)Analyze the amount of overtime needed by the nursing staff to complete assignments. B The nurse is assisting a new mother with infant feeding. Which information should the nurse provide that is most likely to result in a decrease milk supply for the mother who is breastfeeding? A.)Supplemental feedings with formula B.)Maternal diet high in protein C.)Maternal intake of increased oral fluid D.)Breastfeeding every 2 or 3 hours. A Which assessment is more important for the nurse to include in the daily plan of care for a client with a burned extremity? A.)Range of Motion B.)Distal pulse intensity C.)Extremity sensation D.)Presence of exudate B An elderly client with degenerative joint disease asks if she should use the rubber jar openers that are available. The nurse's response should be based on which information about assistive devices? When assessing a 6-month old infant, the nurse determines that the anterior fontanel is bulging. In which situation would this finding be most significant? A.)Crying B.)Straining on stool C.)Vomiting D.)Sitting upright. D A client with angina pectoris is being discharge from the hospital. What instruction should the nurse plan to include in this discharge teaching? A.)Engage in physical exercise immediately after eating to help decrease cholesterol levels. B.)Walk briskly in cold weather to increase cardiac output C.)Keep nitroglycerin in a light-colored plastic bottle and readily available. D.)Avoid all isometric exercises, but walk regularly. D What is the priority nursing action when initiating morphine therapy via an intravenous patient-controlled analgesia (PCA) pump? A.)Initiate the dosage lockout mechanism on the PCA pump B.)Instruct the client to use the medication before the pain becomes severe C.)Assess the abdomen for bowel sounds. D.)Assess the client ability to use a numeric pain scale A While undergoing hemodialysis, a male client suddenly complains of dizziness. He is alert and oriented, but his skin is cool and clammy. His vital signs are: heart rate 128 beats/minute, respirations 18 breaths/minute, and blood pressure 90/60. Which intervention should the nurse implement first? The nurse receives a newborn within the first minutes after a vaginal delivery and intervenes to establish adequate respirations. What priority issue should the nurse address to ensure the newborn's survival? A.)Heat loss B.)Hypoglycemia C.)Fluid balance D.)Bleeding tendencies A The fire alarm goes off while the charge nurse is receiving the shift report. What action should the charge nurse implement first? A 60-year-old female client asks the nurse about hormones replacement therapy (HRT) as a means preventing osteoporosis. Which factor in the client's history is a possible contraindication for the use of HRT? A male client, who is 24 hours postoperative for an exploratory laparotomy, complains that he is "starving" because he has had no "real food" since before the surgery. Prior to advancing his diet, which intervention should the nurse implement? The nurse working in the psychiatric clinic has phone messages from several clients. Which call should the nurse return first? During change of shift, the nurse reports that a male client who had abdominal surgery yesterday increasingly confused and disoriented during the night. He wandered into other clients rooms, saying that there are men in his room trying to hurt him. Because of continuing disorientation and the client's multiple attempts to get of bed, soft restrains were applied at 0400. In what order should the nurse who is receiving report implement these interventions? (Arrange from first action on top to last on the bottom). Assign unlicensed assistive personnel to remove restrains and remain with client Assess the client's skin and circulation for impairment related to the restrains Contact the client's surgeon and primary healthcare provider Evaluate the client's mentation to determine need to continue the restrains A mother brings her 3-year-old son to the emergency room and tells the nurse the he has had an upper respiratory infection for the past two days. Assessment of the child reveals a rectal temperature of 102 F. he is drooling and becoming increasingly more restless. What action should the nurse take first? After receiving the first dose of penicillin, the client begins wheezing and has trouble breathing. The nurse notifies the healthcare provider immediately and received several prescriptions. Which medication prescription should the nurse administer first? Two clients ring their call bells simultaneously requesting pain medication. What action should the nurse implement first? A client receives a new prescription for simvastatin (Zocor) 5 mg PO daily at bedtime. What action should the nurse take? Which client should the nurse assess frequently because of the risk for overflow incontinence? A client Who is confused and frequently forgets to go to the bathroom While monitoring a client during a seizure, which interventions should the nurse implement? (Select all that apply) A.)Move obstacle away from client B.)Monitor physical movements C.)Observe for a patent airway D.)Record the duration of the seizure A,B,C,D A male client with a long history of alcoholism is admitted because of mild confusion and fine motor tremors. He reports that he quit drinking alcohol and stopped smoking cigarettes one month ago a