A home health nurse is caring for a child who has Lyme disease. Which of the following is an
appropriate action for the nurse to take? - ANS Ensure the state health department has been
notified
A nurse is caring for a client who has a vented NG tube set to low intermittent suction and has
vomited. Which of the following actions should the nurse perform first? - ANS Evaluate
functioning of the suction device
While performing a routine assessment, a nurse notices fraying on the electrical cord of a
client's continuous passive motion device. Which of the following actions should the nurse take
first? - ANS Remove the device from the room
A nurse is setting up a sterile field to perform wound irrigation for a client. Which of the following
actions should the nurse take when pouring the sterile solution? - ANS Remove the cap and
place it sterile side up on a CLEAN surface
A nurse is creating a plan of care for a female client who has recurrent UTIs. Which of the
following interventions should the nurse include in the plan? - ANS Wear loose fitting underwear
A nurse is caring for an infant who has gastroenteritis. Which of the following assessment
findings should the nurse report to the provider? - ANS Sunken fontanels and dry mucous
membranes
A nurse is conducting health promotion education regarding contraindications to combination
oral contraceptives use to a group of women. Which of the following conditions should the nurse
include in the teaching? - ANS Hypertension
A nurse is providing teaching to a client who has a depressive disorder and a new prescription
for amitriptyline. Which of the following statements by the client indicates an understanding of
the teaching? - ANS "I know it will be a couple of weeks before the medication helps me feel
better."
A nurse is caring for a client who is immobile. Which of the following interventions is appropriate
to prevent contracture? - ANS Apply an orthotic to the client's foot.
A nurse is assessing a client who is postoperative following abdominal surgery and has an
indwelling urinary catheter that is draining dark yellow urine at 25mL/hr. Which of the following
interventions should the nurse anticipate? - ANS Obtain a urine specimen for culture and
sensitivity
, A nurse is reporting a client's laboratory tests to the provider to obtain a prescription for the
client's daily warfarin. Which of the following laboratory tests should the nurse plan to report to
obtain the prescriptions for the warfarin? - ANS INR
A nurse is assessing a client who is taking haloperidol and is experiencing pseudo
parkinsonism. Which of the following findings should the nurse document as a manifestation of
pseudo parkinsonism? - ANS Shuffling gait
A nurse is caring for a client who is experiencing expressive aphasia and right hemiparesis
following a stroke. Which of the following actions by the nurse best promotes communication
among staff caring for the client? - ANS Having interdisciplinary team meetings for the client on
a regular basis.
A nurse is caring for a 2 year old toddler. Which of the following food choices should the nurse
recommend to promote independence in eating? - ANS Banana slices
A nurse on a medical-surgical unit is notified that a mass casualty event has occurred in the
community. Which of the following actions should the nurse plan to take? - ANS Determine the
medical needs of incoming clients through the emergency department
A nurse has just received change-of-shift report for four clients. Which of the following clients
should the nurse assess first? - ANS A client who was just given a glass of orange juice for a
low glucose level
A nurse is performing postmortem care for a recently deceased client prior to the client's family
visit. Which of the following actions should the nurse plan to take? - ANS Hold the client's eyes
shut for a few seconds.
A nurse is admitting a client who has schizophrenia. The client states, I'm hearing voices. Which
of the following responses is the priority for the nurse to state? - ANS What are the voices telling
you?
A nurse is administering furosemide IV bolus to a client who has fluid volume excess. The nurse
should recognize which of the following findings as an indication that the medication has been
effective? - ANS Weight loss
A nurse is caring for a client who is in a coma and is scheduled for a surgical procedure. Which
of the following actions should the nurse take? - ANS Determine if the client's health care
surrogate is aware of the risks and benefits of the procedure
A nurse is preparing to administer vancomycin IV to a adult client. The client asks the nurse if
the medication can be given 2 hours earlier. Which of the following statements should the nurse
make? - ANS I can start the medication 30 minutes earlier.
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