1. A client has an automatic blood stress cuff on the proper arm where an IV is infusing. In
the left arm, a saline lock is present. The PN notes the presence of blood within the IV
infusion line. What movement ought to the PN implement? - ANS-flow the blood
pressure cuff to the left arm
2. A patron is admitted with bacterial meningitis. Which intervention is maximum essential
for the PN? - ANS-put into effect droplet precautions.
3. A purchaser is receiving supplemental oxygen. The sensible nurse walks within the room
and sees a fireplace in the bedside wastebasket. Which movement need to the PN take
first? - ANS-take patron out of the room
4. A consumer presents to the emergent care middle reporting chest ache and feeling
"lightheaded" as if he is "going to faint." What is the most essential movement the PN
need to enforce? - ANS-area customer in a chair or upright on a stretcher
5. A patron who had abdominal surgery the day prior to this is receiving morphine thru a
PCA. The purchaser reviews a ache degree of 6 based on a scale of one-10. What
actions need to the PN put into effect first? - ANS-ask for a description of the pain
6. A purchaser who has a tunneled Hickman catheter for hemodialysis gets a prescription
for IV an antibiotic. Which movement should the realistic nurse take? - ANS-make use of
a peripheral IV access to administer IV antibiotics
7. A purchaser who is 8 hours postoperative starts the use of the inducement spirometer
with 750 ml inspiratory volume and coughs up a massive thick mild yellow white mucous
plug. What motion must the sensible nurse take - ANS-document the findings
8. A purchaser who is demonstrating violent conduct is constrained by way of employees
using a four guy maneuver. Two days later, the practice nurse sees that the customers
arm is ecchimotic and mottled. What locating is maximum vital for the PN to file. -
ANS-radial pulse
9. A purchaser who is located in wrist protective gadgets starts to bitch of ache and
swelling in one hand. That PN notes that both palms are cool and pale. Which action
must the PN take? - ANS-take away both gadgets and notify the healthcare provider.
10. A customer who's postoperative is receiving an infusion at eighty mL/hour. At the cease
of eight postoperative hours, the PN documents that the customer tolerated one hundred
mL oral intake of ice chips and urinary output is 1100 mL. What movement ought to the
PN take - ANS-file the consumption and output findings.
11. A client who's three days postoperative complains of getting "actually horrific ache" and
wants remedy now. What movement must the sensible nurse put into effect? -
ANS-decide the location of the pain
, 12. A client who is two days postoperative for a colectomy and brief colostomy tells the PN
that the drainage bag is complete of fuel. What action need to the PN take? - ANS-open
the bag's clamp to launch the flatus
13. A client with a forearm laceration arrives inside the medical institution making use of
direct pressure with a smooth washcloth. The PN notes that the washcloth is saturated
with blood. What motion need to the PN put in force? - ANS-follow digital strain to arm
above the harm
14. A patron with a likely mumps infection is admitted to an acute care facility. Which
contamination control precaution should the PN put in force - ANS-put on a mask or
respirator inside 3 toes of the customer.
15. A patron with Clostridium difficile is placed on isolation precautions. Which transmission
primarily based precaution have to the sensible nurse put in force? - ANS-wear robe and
gloves when rendering direct care.
16. A client's serum potassium level is two.9 mEq/L. Which is the most critical locating that
the PN must report to the price nurse? - ANS-pulse rate weak and abnormal
17. A male customer who walks inside the clinic starts offevolved speaking to the practical
nurse with slurred speech. Which movement have to the PN put in force first? - ANS-ask
the consumer how he is feeling today
18. A male patron with espresso ground emesis is admitted with a hemoglobin of 10.2 grams
this is now 7.5 grams/dl in view that admission. The patron's blood is type and
crossmatched for 2 gadgets of blood, and the healthcare company prescribes STAT
administration of 1 unit. The client suggests to the PN that he wants to bathe first. Which
intervention should the PN enforce? - ANS-provide an explanation for the want for
starting the transfusion right now.
19. An older patron arrives a the outpatient health facility complaining of burning and severe
right sided chest ache. The pN observes vesicular eruptions in a line across the anterior
and posterior chest wall. What action must the PN enforce? - ANS-put on gloves
throughout palpation
20. An older consumer is receiving normal saline at eighty three ml/hour in step with gravity.
At the cease of shift checks, the PN calculates the clients intake and output and
determines that the infusion added 500 ml in the final hour. Which movement should the
PN take first? - ANS-ascultate the lungs for crackles
21. An UAP tells the PN that any other nurse on the unit is appearing disrespectfully. What
action ought to the PN enforce? - ANS-Tell the UAP to share feelings with the nurse
22. At 0900, a client's blood strain is one hundred twenty/70. At noon, the unlicensed
assisitive personnel reports that the patron's blood stress is 2 hundred/a hundred. Which
motion ought to the PN put in force first? - ANS-take customers blood strain
23. For several days after her husband's demise, a customer who is admitted with acute
melancholy repeats time and again, "I have to have made him go to the medical doctor
whilst he stated he didn't sense properly. Which descriptor have to the practical nurse
use to record the client's feelings? - ANS-guilt
24. The circle of relatives of a male client with terminal cancer comes to a decision now not
to inform the client about his diagnosis. The client has asked the PN several instances if
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