A nurse is caring for a client who is 3 days postoperative following a total right hip arthroplasty.
Which of the following actions should the nurse take? - ANS Maintain abduction of the client's
right leg while in bed.
A nurse is caring for a client who has terminal pancreatic cancer. The client states, "I don't think
I can go on any longer." Which of the following responses should the nurse make? - ANS "You
feel like you want to discontinue treatment?"
A nurse is contributing to the plan of care for a client who is having difficulty eating following a
stroke. Which of the following actions should the nurse take first? - ANS Implement
recommendations from the speech-language pathologist.
A nurse is contributing to the plan of care for a client who was admitted to the neurological unit
following a stroke 3 hr ago. Which of the following interventions should the nurse identify as the
priority? - ANS Keep the client in a side-lying position.
A nurse is participating in a health fair for older adult clients. Which of the following vaccines
should the nurse recommend for this age group? - ANS Herpes zoster
A nurse is contributing to the plan of care for a client who has a new prescription for nystatin
suspension for oral candidiasis. Which of the following interventions should the nurse include in
the plan? - ANS Instruct the client to swish the medication in their mouth.
A nurse is preparing to perform intermittent urinary catheterization for a female client who has
been unable to void following surgery 6 hr ago. Which of the following catheters should the
nurse use to perform this procedure? - ANS intermittent straight catheter (clear tube with blue
top)
A nurse is preparing to auscultate the bowel sounds of a client who has a mechanical bowel
obstruction in the descending colon. When listening in the left upper quadrant, the nurse should
identify this sound as which of the following? - ANS Hyperactive bowel sounds
A nurse is contributing to the plan of care for a client who has multiple sclerosis and is taking
dantrolene to manage muscle spasms. Which of the following interventions should the nurse
include? - ANS Encourage the client to complete ADLs.
, A nurse is assisting with the care of a client who had a cardiac catheterization via the right
femoral artery. Which of the following actions should the nurse take to prevent postprocedure
complications? - ANS Monitor the insertion site for bleeding is
Maintain the pressure dressing
Check the client's peripheral pulses
A home health nurse is reinforcing teaching about preventing asthma attacks with a client who
has asthma. Which of the following instructions should the nurse include in the teaching? - ANS
"Do not allow visitors to smoke cigarettes in your home."
A nurse is caring for a client who has a prescription for phenazopyridine. Which of the following
findings should the nurse identify as a therapeutic effect of the medication? - ANS Decreases
pain during urination
A nurse is monitoring a client who is taking acarbose. Which of the following findings should the
nurse identify as an adverse effect of the medication? - ANS Abdominal cramps
A nurse is caring for a client who has a new cast on their left forearm and reports severe pain in
the affected arm with numbness in the ngers. The nurse nds the skin is pale and cold with
sluggish capillary refill. Which of the following fracture complications should the nurse suspect? -
ANS Compartment Syndrome
A nurse is assisting with the discharge planning for a client who is postoperative following a total
hip arthroplasty. Which of the following instructions should the nurse include in the discharge
plan? - ANS Obtain a raised toilet seat.
A nurse is assisting in the care of a client who has manifestations of sepsis. Which of the
following provider prescriptions should the nurse implement first? - ANS Initiate oxygen at 4
L/min via nasal cannula
A nurse is reviewing the laboratory results of a client who has type 2 diabetes mellitus. The
nurse should identify that which of the following laboratory values indicates the client is at risk
for delayed wound healing? - ANS Prealbumin 12 mg/dL
A nurse is contributing to the plan of care for a client who has a methicillin-resistant
Staphylococcus aureus (MRSA) infection and is on contact isolation precautions. Which of the
following actions should the nurse take? - ANS Have a designated stethoscope in the client's
room.
A nurse is caring for a client who has a compound fracture of the femur and was placed in
balanced suspension skeletal traction 4 days ago. Which of the following actions should the
nurse take? - ANS Perform pin site care daily.
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