1. A nurse is obtaining health hx from a client who is scheduled to undergo cardiac catheterization in 2 days. Which questions is the priority for the nurse to ask? ANS: “Do you know if you’re allergic to iodine?”
- The greatest risk to the client is an allergic reaction to the contrast agen...
1. A nurse is obtaining health hx from a client who is scheduled to undergo cardiac
catheterization in 2 days. Which questions is the priority for the nurse to ask?
ANS: “Do you know if you’re allergic to iodine?”
- The greatest risk to the client is an allergic reaction to the contrast agent, which contains
iodine.
2. A nurse is planning to administer nystatin oral suspension to a client who has oral
candidiasis. Which instructions should the nurse give?
ANS: “Hold the medication in your mouth for several minutes prior to swallowing”
- The client should swish & hold the liquid in the mouth for at least 2 min to facilitate contact
of the medication with the organism. The client should then swallow or spit out the
medication.
3. A nurse is preparing to care for the assigned clients on her upcoming shift. Which time
management strategies should the nurse plan to use?
ANS: Prepare a priority list of client needs for the shift.
- The nurse should prepare a client priority-to-do list, which could include administering time-
critical medications. This will allow the nurse to determine which clients should receive care
first.
4. After witnessing the consent, what action should the nurse take next?
ANS: Ask client what he understands about the procedure.
5. Which task should the nurse assign to an AP for a pt 2 days post-op ff Total knee
arthroplasty?
ANS: Reapply antiembolitic stockings to the client ff a shower.
6. A nurse is reinforcing teaching with a client who is receiving radiation therapy for cancer of
the larynx. Which statement made by the client indicates understanding of the teaching?
ANS: “I will wear a soft scarf around my neck when I am outside”
- Wash it with plain water without soap. NO heat source therapy. Only use electric razor if
necessary, for shaving.
7. A nurse is using FLACC scale to determine the level of pain for an 11-months-old infant who
sis port-op. Which factor should the nurse consider when using this pain scale?
ANS: Level Of Activity
- The nurse should consider the infants level of activity when using FLACC pain scale. The
FLACC is determined by five categories of behavior: Facial Expression, Leg Movement,
Activity, and Consolability.
8. A nurse is collecting data from a 5YO child at a well-child visit. Parent reports that the child is
having frequent nightmares. Which statements by the parents indicates to the nurse that the
child Is experiencing sleep terrors rather than nightmares?
ANS: “My child goes back to sleep right away.”
- The nurse should realize that going back to sleep quickly is an indication of sleep terrors,
rather than nightmares. A child who is experiencing nightmare has difficulty returning to
sleep because of continued fear.
9. A nurse is assisting with the care of a school-age child immediately ff surgery. The child
weighs 21.8 kg (48 lb) & has a chest tube applied to suction. Which finding should the nurse
report to PCP?
ANS: 250 mL of sanguineous drainage over the last 3 hr
- More than 3 mL/kg/hr of sanguineous drainage occurs for more than 2-3 consecutive hr ff
surgery. It indicates active hemorrhaging.
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