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?
- 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....
ATI Comprehensive Predictor with NGN 2023 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? - 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? - Evaluate functioning of the suction device. While performing a routine assessment, a nurse notices fraying onto the electrical cord of a client's continuous passive motion (CPM)device. Which of the following actions should the nurse take first? - 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? - 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 urinary tract infections. Which of the following interventions should the nurse include in the plan? - Wear loose fitting underwear. A nurse is caring for an infant who has gastroenteritis. Which of the following assessments findings should the nurse report to the provider? - Sunken fontanels and dry mucous membranes. A nurse is conducting health promotion education regarding contraindications to combination oral contraceptive use to a group of women. Which of the following conditions should the nurse include in the teaching? - 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 understanding of the teaching? - "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? - Align a trochanter wedge between the client's legs. 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 25 mL/hr. Which of the following interventions should the nurse anticipate? - 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 prescription for the warfarin? - 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 ? - 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? - 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? - 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? - Recommend to the provider specific acute care clients for discharge. A nurse is receiving change -of-shift report for four clients. Which of the following clients should the nurse assess first? - A client who was just given a glass of orange juice for low blood 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? - 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? - "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 as an indication that the medication has been effective? - Weight loss A nurse is caring for a client who requires nasotracheal suctioning. Identify the sequence the nurse should follow to perform suctioning. – 1. Turn on the suction and set the pressure. 2. Don sterile gloves. 3. Insert the catheter during the client's inspiration. 4. Apply suction while rotating the catheter. 5. Rinse the catheter to remove secretions. 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? - 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 an 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? - "I can start the medication 30 minutes earlier." A nurse is caring for a client who requires seclusion to prevent harm to others on the unit. Which of the following is an appropriate action for the nurse to take? - Offer fluids every 2 hours. A nurse is caring for an adolescent who has hyperthermia. Which of the following actions should the nurse take? - Initiate seizure precautions. A nurse is caring for a client who asks for information regarding organ donation. Which of the following responses should the nurse make? - "Your desire to be an organ donor must be documented in writing."
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