A nurse is caring for an older adult who is taking acetaminophen (Tylenol) for the relief of chronic pain. Which substance is most important for the nurse to determine if the client is taking because it intensifies the most serious adverse effect of acetaminophen? |
Alcohol |
The nurse is caring for a client who is on a low carbohydrate diet. With this diet, there is decreased glucose available for energy, and fat is metabolized for energy resulting in an increased production of which substance in the urine? |
Ketones |
A nurse manager works on a unit where the nursing staff members are uncomfortable taking care of clients from cultures that are different from their own. How should the nurse manager address this situation? |
Plan a workshop that offers opportunities to learn about the cultures they might encounter while at work |
A client with Addison's disease is receiving cortisone therapy. The nurse expects what clinical indicators if the client abruptly stops the medication? (Select all that apply.) |
Tachypnea Hypotension |
A client is admitted to the hospital with a tentative diagnosis of infectious pulmonary tuberculosis. What infection control measures should the nurse take? |
Don an N95 respirator mask before entering the room. |
To minimize the side effects of the vincristine (Oncovin) that a client is receiving, what type of dietary plan does the nurse expect? |
High in fluids |
The client receives a prescription for tap water enemas until clear. The nurse is aware that no more than two enemas should be given at one time to prevent the occurrence of: |
Hypokalemia |
A client has been admitted with a urinary tract infection. The nurse receives a urine culture and sensitivity report that reveals the client has Vancomycin Resistant Enterococcus (VRE). After notifying the physician, which action should the nurse take to decrease the risk of transmission to others? |
Move the client to private room |
After abdominal surgery a client reports pain. What action should the nurse take first? |
Determine the characteristics of the pain |
A client is receiving albuterol (Proventil) to relieve severe asthma. For which clinical indicators should the nurse monitor the client? (Select all that apply.) |
Tremors and Palpitations |
The nurse performs a respiratory assessment and auscultates breath sounds that are high-pitched, creaking and accentuated on expiration. Which term best describes the findings? |
Wheezes |
When assessing a client's blood pressure, the nurse notes that the blood pressure reading in the right arm is 10 mm Hg higher than the blood pressure reading in |
is a normal occurrence. |
A client who is to receive radiation therapy for cancer says to the nurse, "My family said I will get a radiation burn." What is the nurse's best response? |
"A localized skin reaction usually occurs. |
A 90-year-old female resident of a nursing home falls and fractures the proximal end of her right femur. The surgeon plans to reduce the fracture with an internal fixation device. The general fact about the older adult that the nurse should consider when caring for this client is that: |
Physiological coping defenses are reduced |
A client is admitted to the hospital because of multiple chronic health problems. What is the priority nursing intervention at this time? |
Conducting a multidisciplinary staff conference early during the client's hospitalization |
The nurse plans care for a client with a somatoform disorder based on the understanding that the disorder is: |
An unconscious means of reducing stress. |
A client has a pressure ulcer that is full thickness with necrosis into the subcutaneous tissue down to the underlying fascia. The nurse should document the assessment finding as which stage of pressure ulcers? |
Stage 3 |
A nurse is caring for a postoperative client who had general anesthesia during surgery. What independent nursing intervention may prevent an accumulation of secretions? |
Frequent changes of position |
A nurse provides discharge teaching related to intermittent urinary self-catheterization to a client with a new spinal cord injury. Which instruction is most important for the nurse to include? |
Wash your hands before performing the procedure |
A client with hypothermia is brought to the emergency department. What treatment does the nurse anticipate when the patient is in the emergency department? |
Core rewarming with warm fluids |
To prevent footdrop in a client with a leg cast, the nurse should: |
Support the foot with 90 degrees of flexion |
A client is receiving albuterol (Proventil) to relieve severe asthma. For which clinical indicators should the nurse monitor the client? (Select all that apply.) |
Tremors Palpitations |
The nurse performs a respiratory assessment and auscultates breath sounds that are high-pitched, creaking and accentuated on expiration. Which term best describes the findings? |
Wheezes |
A client has been admitted with a diagnosis of intractable vomiting and can only tolerate sips of water. The initial blood work shows a sodium level of 122 mEq/L and a potassium level of 3.6 mEq/L. Based on the lab results and symptoms, what is the client experiencing? |
Hyponatremia |
A nurse is teaching a community group about the basics of nutrition. A participant questions why fluoride is added to drinking water. The nurse should respond that it is a necessary element added to drinking water to promote: |
Dental Health |
The intake and output of a client over an eight-hour period is: 0800: Intravenous (IV) infusing; 900 mL left in bag; 0830: 150 mL voided; From 0900-1500 time period: 200 mL gastric tube formula + 50 mL water; Repeated x 2.; 1300: 220 mL voided; 1515: 235 mL voided; 1600: IV has 550 mL left in bag. What is the difference between the client's intake and output? Record the answer using a whole number. _________ mL |
495 Intake includes 350 mL of IV fluid, 600 mL of nasogastric intubation (NGT) feeding, and 150 mL of water via NGT, for a total intake of 1100 mL; output includes voidings of 150, 220, and 235 mL, for a total output of 605 mL. Subtract 605 mL from 1100 mL for a difference of 495 mL. |
A client is scheduled for a transurethral resection of the prostate (TURP). Which statement made by the client most indicates the need for further preoperative teaching? |
"My incision will probably be painful. |
A client is in a state of uncompensated acidosis. What approximate arterial blood pH does the nurse expect the client to have? |
7.20 The pH of blood is maintained within the narrow range of 7.35 to 7.45. When there is an increase in hydrogen ions, the respiratory, buffer, and renal systems attempt to compensate to maintain the pH. If compensation is not successful, acidosis results and is reflected in a lower pH |
An adult client presents to the Emergency Department with a nosebleed. After applying pressure, what is the next nursing action? |
Check blood pressure |
nurse assesses for hypocalcemia in a postoperative client. One of the initial signs that might be present is: |
Paresthesias. |
A nurse is caring for an elderly client with dementia who has developed dehydration as a result of vomiting and diarrhea. Which assessment best reflects the fluid balance of this client? |
Blood lab results |
A client becomes hostile when learning that amputation of a gangrenous toe is being considered. After the client's outburst, what is the best indication that the nurse-client interaction has been therapeutic? 1 |
Relaxation of tensed muscles |
The client asks the nurse to recommend foods that might be included in a diet for diverticular disease. Which foods would be appropriate to include in the teaching plan? (Select all that apply.) Whole grains Cooked fruit and vegetables Nuts and seeds Lean red meats Milk and eggs |
Whole grains Cooked fruite and vegetables Milk and eggs |
What nursing actions best promote communication when obtaining a nursing history? (Select all that apply.) |
Establishing eye contact Paraphrasing the client's message Using broad, open-ended statements |
A dying client is coping with feelings regarding impending death. The nurse bases care on the theory of death and dying by Kübler-Ross. During which stage of grieving should the nurse primarily use nonverbal interventions? |
Acceptance |
An 85-year-old client is alert and able to participate in care. The nurse understands that, according to Erikson, a person's adjustment to the period of senescence will depend largely on adjustment to which developmental stage? |
Generativity versus stagnation |
An 85-year-old client has just been admitted to a nursing home. When designing a plan of care for this older adult the nurse recalls the expected sensory losses associated with aging. (Select all that apply.) Difficulty in swallowing |
Diminished sensation of pain Impaired hearing of high-frequency sounds |
A nurse is preparing a community health program for senior citizens. The nurse teaches the group that the physical findings that are typical in older people include: |
Increased blood pressure and decreased hormone production |
When a client files a lawsuit against a nurse for malpractice, the client must prove that there is a link between the harm suffered and actions performed by the nurse that were negligent. This is known as: |
Proximate cause |
A client is receiving albuterol (Proventil) to relieve severe asthma. For which clinical indicators should the nurse monitor the client? (Select all that apply.) |
Tremors Palpitations |
The nurse is providing information about blood pressure to Unlicensed Assistive Personnel (UAP) and recalls that the factor that has the greatest influence on diastolic blood pressure is: |
Peripheral Vascular resistance |
A client comes to the clinic complaining of a productive cough with copious yellow sputum, fever, and chills for the past two days. The first thing the nurse should do when caring for this client is to: |
Take the temperature |
A nurse speaking in support of the best interest of a vulnerable client reflects the nurse's duty of: |
Advocacy |
A physician orders guaifenesin (Humibid) 300 mg four times a day. The dosage strength is 200 milligrams/5 milliliters. To ensure the patient's safety, how many milliliters should the nurse administer for each dose? Record your answer using one decimal place. ____ mL |
7.5 |
The nurse is providing restraint education to a group of nursing students. The nurse should include that it is inappropriate to use a restraint device to: |
Prevent an adult client from getting up at night when there is insufficient staffing on the unit. |
An adolescent is taken to the emergency department of the local hospital after stepping on a nail. The puncture wound is cleansed and a sterile dressing applied. The nurse asks about having had a tetanus immunization. The adolescent responds that all immunizations are up to date. Penicillin is administered, and the client is sent home with instructions to return if there is any change in the wound area. A few days later, the client is admitted to the hospital with a diagnosis of tetanus. Legally, what is the nurse's responsibility in this situation? |
Data collection by the nurse was incomplete, and as a result the treatment was insufficient. |
A client experiences a muscle sprain of the ankle. When assessing the injury, the nurse discovers that a hematoma is developing, edema is present and that the client reports tenderness when the ankle is palpated. The nurse anticipates that the plan of care will include the applying of a/an: Binder |
Ice bag |
A nurse provides crutch-walking instructions to a client that has a left-leg cast. The nurse should explain that weight must be placed: |
On the hands |
Which task is most appropriate for a nurse to delegate to unlicensed assistive personnel? |
Assessing the blood pressure of a client before physical therapy |
Nurses are held responsible for the commission of a tort. The nurse understands that a tort is: |
An illegality committed by one person against the property or person of another |
Health promotion efforts within the health care system should include efforts related to secondary prevention. Which activities reflect secondary prevention interventions in relation to health promotion? (Select all that apply.) |
Encouraging regular dental checkups Teaching the procedure for breast-self-examination |
A client diagnosed with tuberculosis is taking isoniazid (INH). To prevent a food and drug interaction, the nurse should advise the client to avoid: |
Red wine |
When assessing an obese client, a nurse observes dehiscence of the abdominal surgical wound with evisceration. The nurse places the client in the low-Fowler position with the knees slightly bent and encourages the client to lie still. What is the next nursing action? 1 |
Cover the wound with a sterile towel moistened with normal saline |
The nurse is caring for an older adult client who is aphasic. The client's family reports to the nurse manager that the primary nurse failed to obtain a signed consent form before inserting an indwelling catheter to measure intake and output. What should the nurse manager consider before responding? |
A separate signed informed consent for routine treatments is unnecessary |
The nurse is preparing discharge instructions for a client that acquired a nosocomial infection, Clostridium difficile. What should the nurse include in the instructions? |
The infection causes diarrhea accompanied by flatus and abdominal discomfort |
A health care provider prescribes an antibiotic intravenous piggyback (IVPB) twice a day for a client with an infection. The health care provider prescribes peak and trough levels 48 and 72 hours after initiation of the therapy. The client asks the nurse why there is a need for so many blood tests. The nurse's best response is, "These tests will: |
Determine adequate dosage levels of the drug |
The nurse providing post-procedure care to a client who had a cardiac catheterization through the femoral artery discovers a large amount of blood under the client's buttocks. After donning gloves, which action should the nurse take first? |
Assess the catheterization site |
When monitoring a client 24 to 48 hours after surgery, the nurse should assess for which problem associated with anesthetic agents? |
Paralytic ileus |
A nurse is preparing to administer an oil-retention enema and understands that it works primarily by: |
Lubricating the sigmoid colon and rectum |
A nurse is evaluating the appropriateness of a family member's initial response to grief. What is the most important factor for the nurse to consider? |
Cultural background |
What should the nurse include in dietary teaching for a client with a colostomy? |
The diet should be adjusted to include foods that result in manageable stools |
A client with respiratory difficulties asks why the percussion procedure is being performed. The nurse explains that the primary purpose of percussion is to: |
Loosen pulmonary secretions |
The nurse recognizes that which are important components of a neurovascular assessment? (Select all that apply.) 2 |
capillary refill, pulses, warmth and paresthesias, and movement and sensation |
Which age-related change should the nurse consider when formulating a plan of care for an older adult? (Select all that apply.) |
Increased sensitivity to glare Diminished sensation to pain |
A client has a right above-the-knee amputation after trauma sustained in a work-related accident. Upon awakening from surgery, the client states, "What happened to me? I don't remember a thing." What is the nurse's best initial response? |
You were in a work-related accident this morning |
An arterial blood gas report indicates the client's pH is 7.25, PCO2 is 35 mm Hg, and HCO3 is 20 mEq/L. Which disturbance should the nurse identify based on these results? |
Metabolic acidosis |
A client who is to have brain surgery has a signed advance directive in the medical record. In what situation should this document be used? |
Client cannot consent to his or her own surgery |
A nurse is providing colostomy care to a client with a nosocomial infection caused by methicillin-resistant Staphylococcus aureus (MRSA). Which personal protective equipment (PPE) should the nurse use? (Select all that apply.) |
Gloves Gown Goggles |
What physiological changes that occur with aging must be taken into consideration when the nurse provides care for the older adult? (Select all that apply.) |
Urinary urgency Loss of skin elasticity Swallowing difficulties Elevated blood pressure |
The nurse recognizes that a common conflict experienced by the older adult is the conflict between: |
Independence and dependence |
A client has a paracentesis, and the health care provider removes 1500 mL of fluid. To monitor for a serious postprocedure complication, the nurse should assess for: |
Tachycardia |
When performing a postoperative assessment, which parameter would alert the nurse to a common side effect of epidural anesthesia? |
Decreased blood pressure |
A nurse is teaching a group of parents about child abuse. What definition of assault should the nurse include in the teaching plan? |
Assault is a threat to do bodily harm to another person |
A client receiving steroid therapy states, "I have difficulty controlling my temper, which is so unlike me, and I don't know why this is happening." What is the nurse's best response? |
Interview the client to determine whether other mood swings are being experienced |
A nurse is teaching a group of parents about child abuse. What definition of assault should the nurse include in the teaching plan? |
Assault is a threat to do bodily harm to another person |
The intake and output of a client over an eight-hour period is: 0800: Intravenous (IV) infusing; 900 mL left in bag; 0830: 150 mL voided; From 0900-1500 time period: 200 mL gastric tube formula + 50 mL water; Repeated x 2.; 1300: 220 mL voided; 1515: 235 mL voided; 1600: IV has 550 mL left in bag. What is the difference between the client's intake and output? Record the answer using a whole number. _________ mL |
495 Intake includes 350 mL of IV fluid, 600 mL of nasogastric intubation (NGT) feeding, and 150 mL of water via NGT, for a total intake of 1100 mL; output includes voidings of 150, 220, and 235 mL, for a total output of 605 mL. Subtract 605 mL from 1100 mL for a difference of 495 mL. |
A client with limited mobility is being discharged. To prevent urinary stasis and formation of renal calculi, the nurse should instruct the client to: |
Increase oral fluid intake to 2 to 3 L per day |
Immediately after receiving spinal anesthesia a client develops hypotension. To what physiological change does the nurse attribute the decreased blood pressure? |
Dilation of blood vessels |
A nurse is providing preoperative teaching for a client regarding use of an incentive spirometer and should include what instructions? |
Inhale deeply through the spirometer, hold it as long as possible, and slowly exhale |
A client with Type I Diabetes complains of hunger, thirst, tiredness, and frequent urination. Based on these findings, the nurse should take what action? |
Determine the client's blood glucose level |
What is a nurse's responsibility when administering prescribed opioid analgesics? (Select all that apply.) |
Count the client's respirations Document the intensity of the client's pain Verify the number of doses in the locked cabinet before administering the prescribed dose |
A client undergoes a bowel resection. When assessing the client 4 hours postoperatively, the nurse identifies which finding as an early sign of shock? |
Restlessness |
What are the clinical indicators that a nurse expects when an intravenous (IV) line has infiltrated? (Select all that apply.) |
Pallor Edema Decreased flow rate |
The health care provider prescribes a low-fat, 2-gram sodium diet for a client with hypertension. The nurse should explain that the purpose of restricting sodium is to: |
Prevent reabsorption of water in the distal tubules |
An 89-year-old client with osteoporosis is admitted to the hospital with a compression fracture of the spine. The nurse identifies that a factor of special concern when caring for this client is the client's: |
Inability to maintain an optimal level of functioning |
Health promotion efforts with the chronically ill client should include interventions related to primary prevention. What should this include? |
Encouraging daily physical excercise |
Several recently licensed practical nurses are discussing whether they should purchase personal professional liability insurance. Which statement indicates the most accurate information about professional liability insurance? |
"Personal liability insurance offers representation if the State Board of Nursing files charges against you." |
A nurse assesses a client's serum electrolyte levels in the laboratory report. What electrolyte in intracellular fluid should the nurse consider most important? |
Potassium |
While caring for a client with a Hemovac portable wound drainage system, the nurse observes that the collection container is half full. The nurse empties the container. What is the next nursing intervention? |
Compress the container before closing the port |
An 80-year-old female is admitted to the hospital because of complications associated with severe dehydration. The client's daughter asks the nurse how her mother could have become dehydrated because she is alert and able to care for herself. The nurse's best response is: |
The thirst reflex diminishes with age, and therefore the recognition of the need for fluid is decreased |
What is a basic concept associated with rehabilitation that the nurse should consider when formulating discharge plans for clients? |
Immediate or potential rehabilitation needs are exhibited by clients with health problems. |
A nurse educator is presenting information about the nursing process to a class of nursing students. What definition of the nursing process should be included in the presentation? |
Sequence of steps used to meet the client's needs. |
Which nursing action is confidential and protected from legal action? |
Reporting incidents of suspected child abuse to the appropriate authorities. |
A nurse is evaluating the appropriateness of a family member's initial response to grief. What is the most important factor for the nurse to consider? |
Cultural background |
What clinical finding indicates to the nurse that a client may have hypokalemia? |
Abdominal distention |
A client is being discharged from the hospital with an indwelling urinary catheter. The client asks about the best way to prevent infection and keep the catheter clean. Which would be appropriate for the nurse to include in the client teaching? |
Change the drainage bag at least once a week as needed |
A nurse assesses drainage on a surgical dressing and documents the findings. Which documentation is most informative? |
A 10-mm-diameter area of drainage at 1900 hours." |
A nurse is preparing to administer an ophthalmic medication to a client. What techniques should the nurse use for this procedure? (Select all that apply.) |
Clean the eyelid and eyelashes. Apply clean gloves before beginning of procedure. Press on the nasolacrimal duct after instilling the solution. |
A client is being treated for Influenza A (H1N1). The nurse has provided instructions to the client about how to decrease the risk of transmission to others. Which patient statement indicates a need for further instruction/clarification? |
I should obtain a pneumococcal vaccination each year. |
After gastric surgery a client has a nasogastric tube in place. What should the nurse do when caring for this client? |
Monitor for signs of electrolyte imbalance. |
A nurse is supportive of a child receiving long-term rehabilitation in the home rather than in a health care facility. Why is living with the family so important to a child's emotional development? |
It is where child's identity and roles are learned |
The nurse is having difficulty understanding a client's decision to have hospice care rather than an extensive surgical procedure. Which ethical principle does the client's behavior illustrate? |
Autonomy |
A client receiving intravenous vancomycin (Vancocin) reports ringing in both ears. Which initial action should the nurse take? |
Stop the infusion |
A client with a diagnosis of uncontrolled diabetes began receiving Lasix (Furosemide) two days ago. The nurse reviews the morning lab results and discovers that the client's potassium level is 2.8 mEq/L. What is the most appropriate action for the nurse to take? |
Notify the primary healthcare provider of the result, which is critically low |
The nurse is discussing discharge plans with a client who had a myocardial infarction. The client states, "I'm worried about going home." The nurse responds, "Tell me more about this." What interviewing technique did the nurse use? |
Exploring |
A nurse takes into consideration that the key factor in accurately assessing how a client will cope with body image changes is the: |
Perception of the body changes |
The nurse receives a report on a newly admitted client who is positive for Clostridium difficile. Which category of isolation would the nurse implement for this client? |
Contact precautions |
The nurse manager is planning to assign unlicensed assistive personnel (UAP) to care for clients. What care can be delegated on a medical-surgical unit to UAP? (Select all that apply.) |
Performing a bed bath for a client on bed rest Assisting a client who has patient-controlled analgesia (PCA) to the bathroom. |
When caring for a client with pneumonia, which nursing intervention is the highest priority? |
Employ breathing exercises and controlled coughing |
After changing a dressing that was used to cover a draining wound on a client with Vancomycin Resistant Enterococcus (VRE), the nurse should take which step to ensure proper disposal of soiled dressing? |
Place the dressing in a red bag/hazardous materials bag. |
The unlicensed assistive person (UAP) assigned to the 7 am shift has not been coming to work until 8 am. Nursing care is delayed and assignments are started late. What is the most appropriate action by the charge nurse/team leader? |
Document the information before discussing it with the UAP |
A nurse applies a heating pad to a client's buttocks. Upon removal of the heating pad, the nurse discovers that the client has received burns due to incorrect settings when use of the heating pad was initiated. Which principle would legally apply? |
The nurse could be held liable for the injury that occurred. |
The nurse caring for a client with a systemic infection is aware that the assessment finding that is most indicative of a systemic infection is: |
Oral temperature of 101.3º F |
A client with a fractured tibia and fibula is to be discharged from the emergency department with a right leg cast and crutches. In addition to the technical aspects of crutch walking, the nurse should teach the client to: |
Remove loose rugs from the environment |
The nurse is caring for a client admitted with chronic obstructive pulmonary disease (COPD). The nurse should monitor the results of which laboratory test to evaluate the client for hypoxia? |
Arterial blood gas |
The nurse is having difficulty understanding a client's decision to have hospice care rather than an extensive surgical procedure. Which ethical principle does the client's behavior illustrate? |
Autonomy |
A nurse who promotes freedom of choice for clients in decision-making best supports which principle? |
Autonomy |
A client spends several minutes making negative comments to the nurse about numerous aspects of the hospital stay. What is the nurse's best initial response? |
Refocus the conversation on the client's fears, frustrations, and anger about the condition. |
What should the nurse consider when obtaining an informed consent from a 17-year-old adolescent? |
If the client is allowed to give consent. |
When changing the soiled bed linens of a client with a wound that is draining seropurulent material, what personal protective equipment (PPE) is most essential for the nurse to wear? |
Sterile gloves |
A client with a history of chronic obstructive pulmonary disease (COPD) is admitted with acute bronchopneumonia. The client is in moderate respiratory distress. The nurse should place the client in what position to enhance comfort? |
High-Fowler's position using the bedside table as an arm rest |
A nurse is caring for a client diagnosed with Methicillin-Resistant Staphylococcus Aureus (MRSA) in the urine. The health care provider orders an indwelling urinary catheter to be inserted. Which precaution should the nurse take during this procedure? |
Surgical asepsis |
When changing the soiled bed linens of a client with a wound that is draining seropurulent material, what personal protective equipment (PPE) is most essential for the nurse to wear? |
Clean gloves |
The nurse is preparing discharge instructions for a client who was prescribed enalapril maleate (Vasotec) for treatment of hypertension. Which is appropriate for the nurse to include in the client's teaching? |
Do not change positions suddenly |
A 50-year-old client being seen for a routine physical asks why a stool specimen for occult blood testing has been prescribed when there is no history of health problems. What is an appropriate nursing response? |
It is performed routinely starting at your age as part of an assessment for colon cancer |
An adolescent that had an inguinal hernia repair is being prepared for discharge home. The nurse provides instructions about resumption of physical activities. Which statement by the adolescent indicates that the client understands the instructions? |
I can't perform any weightlifting for at least 3 weeks |
A client has received instructions to take 650 mg aspirin (ASA) every 6 hours as needed for arthritic pain. What should the nurse include in the client's medication teaching? (Select all that apply.) |
Take the aspirin with meals or a snack Do not chew enteric-coated tablets Report persistent abdominal pain |
A client is admitted to the hospital for an elective surgical procedure. The client tells a nurse about the emotional stress of recently disclosing being a homosexual to family and friends. What is the nurse's first consideration when planning care? |
Identifying personal feelings toward this client. |
Following a surgery on the neck, the client asks the nurse why the head of the bed is up so high. The nurse should tell the client that the high-Fowler position is preferred for what reason? |
To reduce edema at the operative site |
A client that is scheduled for a surgical resection of the colon and creation of a colostomy for a bowel malignancy asks why preoperative antibiotics have been prescribed. The nurse explains that the primary purpose is to: |
Decrease bacteria in the intestinves |
The nurse is preparing discharge instructions for a client who has begun to demonstrate signs of early Alzheimer's dementia. The client lives alone. The client's adult children live nearby. According to the prescribed medication regimen the client is to take medications six times throughout the day. What is priority nursing intervention to assist the client with compliance with medication-taking? |
Contact the primary healthcare provider and discuss the possibility of simplifying the medication regimen |
Which nursing intervention is most appropriate for a client in skeletal traction? |
Assess the pin sites at least every shift and as needed |
What is a nurse's responsibility when administering prescribed opioid analgesics? (Select all that apply.) |
Count the client's respirations Document the intensity of the client's pain Verify the number of doses in the locked cabinet before administering the prescribed dose |
When providing preoperative teaching, the nurse should focus primarily on: |
Providing general information to reduce client and family anxiety |
Based on the client's reported pain level, the nurse administers 8 mg of the prescribed morphine. The medication is available in a 10 mg syringe. Wasting of the remaining 2 mg of morphine should be done by the nurse and a witness. It is most appropriate for the nurse to ask which member of the health care team to be the witness? |
Licensed practical nurse (LPN) |
The nurse is caring for a client that is hyperventilating. The nurse recalls that the client is at risk for: |
Respiratory alkalosis |
When caring for a client with varicella and disseminated herpes zoster, the nurse should implement which types of precautions? (Select all that apply.) |
Airborne Contact Standard ACS |
A client admitted to the hospital with a diagnosis of malabsorption syndrome exhibits signs of tetany. The nurse concludes that the tetany was precipitated by the inadequate absorption of which electrolyte? |
Calcium |
A client with arthritis increases the dose of ibuprofen (Motrin, Advil) to abate joint discomfort. After several weeks the client becomes increasingly weak. The client is admitted to the hospital and is diagnosed with severe anemia. What clinical indicators does the nurse expect to identify when performing an admission assessment? (Select all that apply.) |
Melena Tachycardia |
A pain scale of 1 to 10 is used by a nurse to assess a client's degree of pain. The client rates the pain as an 8 before receiving an analgesic and a 7 after being medicated. What conclusion should the nurse make regarding the client's response to pain medication? |
Medication is not adequately effective |
The nurse has provided instructions about back safety to a client. Which client statement indicates understanding of the instructions? |
I should carry objects close to my body |
What are the clinical indicators that a nurse expects when an intravenous (IV) line has infiltrated? (Select all that apply.) |
Pallor Edema Decreased flow rate |
A nurse provides discharge teaching related to intermittent urinary self-catheterization to a client with a new spinal cord injury. Which instruction is most important for the nurse to include? |
Wash your hands before performing the procedure |
To prevent thrombophlebitis in the immediate postoperative period, which action is most important for a nurse to include in the client's plan of care? |
Encourage early mobility |
A nurse is caring for a client with hemiplegia who is frustrated. How can the nurse motivate the client toward independence? |
Reinforce success in tasks accomplished |
The nurse creates a plan of care for a client with a risk of infection. Which is the most desirable expected outcome for the client? |
The client will be free of signs and symptoms of infection by discharge |
When assessing an obese client, a nurse observes dehiscence of the abdominal surgical wound with evisceration. The nurse places the client in the low-Fowler position with the knees slightly bent and encourages the client to lie still. What is the next nursing action? |
Cover the wound with a sterile towel moistened with normal saline |
A health care provider prescribes famotidine (Pepcid) and magnesium hydroxide/aluminum hydroxide (Maalox) for a client with a peptic ulcer. The nurse should teach the client to take the Maalox at what time? |
One hour before or two hours after famotidine |
What is a nurse's responsibility when administering prescribed opioid analgesics? (Select all that apply.) |
Count the client's respirations Document the intensity of the client's pain Verify the number of doses in the locked cabinet before administering the prescribed dose |
A client's serum potassium level has increased to 5.8 mEq/L. What action should the nurse implement first? |
Take vital signs and notify the charge nurse or health care provider |
As a nurse prepares an older adult client for sleep, actions are taken to help reduce the likelihood of a fall during the night. What nursing action is most appropriate when targeting older adults' most frequent cause of falls? |
Instructing the client to call the nurse before going to the bathroom |
A nurse assesses a client with dry and brittle hair, flaky skin, a beefy-red tongue and bleeding gums. The nurse recognizes that these clinical manifestations are most likely a result of: |
A nutritional deficiency |
The nurse reviews a medical record and is concerned that the client may develop hyperkalemia. Which disease increases the risk of hyperkalemia? |
End-stage renal |
A client's intravenous (IV) infusion infiltrates. The nurse concludes that what is most likely the cause of the infiltration? |
Failure to secure the catheter adequately |
The nurse providing post-procedure care to a client who had a cardiac catheterization through the femoral artery discovers a large amount of blood under the client's buttocks. After donning gloves, which action should the nurse take first? |
Assess the catheterization site |
The hospital's policy requires two nurses to supervise the wasting of excess opioid solutions. The nurse draws up the prescribed dose and then requests that another nurse witness wasting of the remaining medication. The second nurse states that there is no time to observe the wasting of the medication, enters the identification to serve as the witness, and leaves the area. What is the appropriate action for the first nurse to take? |
Cancel the process and ask another nurse to serve as the witness and to observe the wasting of the medication. |
What does a nurse consider the most significant influence on many clients' perception of pain when interpreting findings from a pain assessment? |
Previous experience and cultural values |
A health care provider prescribes simvastatin (Zocor) 20 mg daily for elevated cholesterol and triglyceride levels for a female client. Which is most important for the nurse to teach when the client initially takes the medication? |
Inform the health care provider if the client wishes to become pregnant |
A client is admitted with metabolic acidosis. The nurse considers that two body systems interact with the bicarbonate buffer system to preserve healthy body fluid pH. What two body systems should the nurse assess for compensatory changes? |
Respiratory and urinary |
The nurse manager of the unit comes to work obviously intoxicated. The staff nurse's ethical obligation is to: |
Have the supervisor validate the observation |
A nurse is reviewing a plan of care for a client who was admitted with dehydration as a result of prolonged watery diarrhea. Which prescription should the nurse question? |
Parenteral albumin (Albuminar) |
A nurse is providing colostomy care to a client with a nosocomial infection caused by methicillin-resistant Staphylococcus aureus (MRSA). Which personal protective equipment (PPE) should the nurse use? (Select all that apply.) |
Gloves Gown Goggles |
A physician orders a urinalysis for a client with an indwelling catheter. To ensure that an appropriate specimen is obtained, the nurse would obtain the specimen from which site? |
tubing injection port |
A nurse reviews a medical record of a client with ascites. What does the nurse identify that may be causing the ascites? |
Decreased liver function |
A nurse instructs a client to breathe deeply to open collapsed alveoli. What should the nurse include in the explanation of the relationship between alveoli and improved oxygenation? |
Oxygen is exchanged for carbon dioxide in the alveolar membrane |
A health care provider prescribes a standard walker (pick-up walker with rubber tips on all four legs). The nurse identifies what clinical findings that indicate the client is capable of using a standard walker? |
Strong upper arm strength and non-weight bearing on the affected extermity |
A nurse is caring for a client with diarrhea. The nurse anticipates a decrease in which clinical indicator? |
Tissue Turgor |
A client's chest tube has accidentally dislodged. What is the nursing action of highest priority? |
Apply a petroleum gauze dressing over the site |
A client has received instructions to take 650 mg aspirin (ASA) every 6 hours as needed for arthritic pain. What should the nurse include in the client's medication teaching? (Select all that apply.) |
Take the aspirin with meals or snack Do not chew enteric-coated tablets Report persistent abdominal pain |
A client is receiving albuterol (Proventil) to relieve severe asthma. For which clinical indicators should the nurse monitor the client? (Select all that apply.) |
Tremors Palpitations |
female client explains to the nurse that she sleeps until noon every day and takes frequent naps during the rest of the day. What should the nurse do initially? |
Arrange a referral for a thorough medical evaluation |
A client is scheduled to receive phenytoin (Dilantin) 100 mg orally at 6 PM but is having difficulty swallowing capsules. What method should the nurse use to help the client take the medication? |
Contact the prescriber to determine if a change to a suspension form would be possible |
A client with Type I Diabetes complains of hunger, thirst, tiredness, and frequent urination. Based on these findings, the nurse should take what action? |
Determine the client's blood glucose level |
A nurse is transcribing a practitioner's orders for a group of clients. Which order should the nurse clarify with the practitioner? |
Erythropoietin (Procrit) 6000 units subcutaneously TIW |
The nurse is providing post-procedure care for a client that had a liver biopsy. To prevent hemorrhage, it is the nurse's highest priority to place the client in what position? |
On the right side |
A client has been admitted with a diagnosis of intractable vomiting and can only tolerate sips of water. The initial blood work shows a sodium level of 122 mEq/L and a potassium level of 3.6 mEq/L. Based on the lab results and symptoms, what is the client experiencing? |
Hyponatremia |
A client is scheduled to receive conscious sedation during a colonoscopy. The client asks the nurse, "How will they 'knock me out' for this procedure?" Which answer by the nurse correctly describes the route of administration for conscious sedation? |
You will receive medication through an intravenous catheter |
The nurse teaching a health awareness class identifies which situation as being the highest risk factor for the development of a deep vein thrombosis (DVT)? |
Inactivity |
A client with an abdominal wound infected with methicillin-resistant Staphylococcus aureus (MRSA) is scheduled for a computed tomography (CT) scan of the abdomen. To ensure client and visitor safety during transport, the nurse should implement which precaution? |
Cover the infected site with a dressing |
A client is being treated for Influenza A (H1N1). The nurse has provided instructions to the client about how to decrease the risk of transmission to others. Which patient statement indicates a need for further instruction/clarification? |
I should obtain pneumococcal vaccination each year |
A client that is scheduled for a surgical resection of the colon and creation of a colostomy for a bowel malignancy asks why preoperative antibiotics have been prescribed. The nurse explains that the primary purpose is to: |
Decrease bacteria in the intestines |
A client with rheumatoid arthritis does not want the prescribed cortisone and informs the nurse. Later, the nurse attempts to administer cortisone. When the client asks what the medication is, the nurse gives an evasive answer. The client takes the medication and later discovers that it was cortisone. The client states an intent to sue. What factors in this situation must be considered in a legal action? (Select all that apply.) |
Clients have a right to refuse treatment Nurses are required to answer clients truthfully The health care provider should have been notified |
A client is admitted to the hospital and benazepril hydrochloride (Lotensin) is prescribed for hypertension. Which is an appropriate nursing action for clients taking this medication? |
Assess for dizziness |
A health care provider prescribes digoxin (Lanoxin) for a client. The nurse teaches the client to be alert for which common early indication of digoxin toxicity? |
Nausea |
At the conclusion of visiting hours, the parent of a 14-year-old adolescent scheduled for orthopedic surgery the next day hands the nurse a bottle of capsules and says, "These are for my child's allergy. Will you be sure my child takes one about 9 PM tonight?" What is the nurse's best response? |
"I will get a prescription so that the medicine can be taken." |
A nurse is providing morning hygiene to a bedridden client who was admitted for exacerbation of chronic obstructive pulmonary disease (COPD). What is the priority nursing intervention when the client becomes short of breath during the care? |
Put the client in a high-Fowler's position. |
A nurse applies a cold pack to treat an acute musculoskeletal injury. Cold therapy decreases pain by: |
Causing local vasoconstriction, preventing edema and muscle spasm |
When reviewing a drug to be administered, the nurse identifies that the package insert indicates that the Z-track injection technique should be used. Under what circumstance does the nurse expect that this technique will be necessary? |
Medication is irritating to subcutaneous tissue and skin |
When monitoring fluids and electrolytes, the nurse recalls that the major cation-regulating intracellular osmolarity is: |
Potassium |
What clinical finding does a nurse anticipate when admitting a client with an extracellular fluid volume excess? |
Distended jugular veins |
A nurse administers an intravenous solution of 0.45% sodium chloride. In what category of fluids does this solution belong? |
Hypotonic |
A nurse who is working on a medical-surgical unit receives a phone call requesting information about a client who has undergone surgery. The nurse observes that the client requested a do not publish ("DNP") order on any information regarding condition or presence in the hospital. What is the best response by the nurse? |
We have no record of that client on our unit. Thank you for calling." 2 |
A nurse is assigned to take care of a group of clients. Which client should the nurse see first? |
A 2-yr-old male with diarrhea |
A nurse is taking care of a client who has severe back pain as a result of a work injury. What nursing considerations should be made when determining the client's plan of care? (Select all that apply.) |
Ask the client what is the client's acceptable level of pain. Administer the pain medications regularly around the clock. |
What are the desired outcomes that the nurse expects when administering a nonsteroidal antiinflammatory drug (NSAID)? (Select all that apply.) |
Pain reief Antipyresis Reduced inflammation |
A nurse provides teaching for a client who is scheduled for a cholecystectomy. In the initial postoperative period, the nurse explains that the most important part of the treatment plan is: |
Coughing and deep breathing |
A primary nurse receives prescriptions for a newly admitted client and has difficulty reading the health care provider's writing. Who should the nurse ask for clarification of this prescription? |
Health care provider who wrote the prescription |
A client has a paracentesis, and the health care provider removes 1500 mL of fluid. To monitor for a serious postprocedure complication, the nurse should assess for: |
Tachycardia |
A nurse is providing morning hygiene to a bedridden client who was admitted for exacerbation of chronic obstructive pulmonary disease (COPD). What is the priority nursing intervention when the client becomes short of breath during the care? |
Put the client in a high-Fowler's position |
A client reports severe pain two days after surgery. After assessing the characteristics of the pain, which initial action should the nurse take next? |
Obtain the vital signs |
What clinical indicators should the nurse expect a client with hyperkalemia to exhibit? (Select all that apply.) |
Diarrhea Weakness Dysrhythmias |
A client is receiving albuterol (Proventil) to relieve severe asthma. For which clinical indicators should the nurse monitor the client? (Select all that apply.) |
Tremors Palpitations |
A nurse is caring for an elderly client with dementia who has developed dehydration as a result of vomiting and diarrhea. Which assessment best reflects the fluid balance of this client? |
Blood lab results |
A client with Addison's disease is receiving cortisone therapy. The nurse expects what clinical indicators if the client abruptly stops the medication? (Select all that apply.) |
Tachypnea Hypotension |
What response should a nurse be particularly alert for when assessing a client for side effects of long-term cortisone therapy? |
Behavioral changes |
A client with arthritis increases the dose of ibuprofen (Motrin, Advil) to abate joint discomfort. After several weeks the client becomes increasingly weak. The client is admitted to the hospital and is diagnosed with severe anemia. What clinical indicators does the nurse expect to identify when performing an admission assessment? (Select all that apply.) |
Melena Tachycardia |
Neomycin, 1 gram, is prescribed preoperatively for a client with cancer of the colon. The client asks why this is necessary. How should the nurse respond? |
"It will kill the bacteria in your bowel and decrease the risk for infection after surgery." |
A nurse is assisting a client to transfer from the bed to a chair. What should the nurse do to widen the client's base of support during the transfer? |
Spread the client's feet away from each other. |
A client has Clostridium difficile. The nurse is providing discharge instructions related to decreasing the risk of transmission to family members. What would be appropriate to include in the client's teaching? |
Wash hands with soap and water. |
The nurse assesses an elderly client with a diagnosis of dehydration and recognizes which finding as an early sign of dehydration? |
Change in mental status |
he nurse administers a pneumococcal vaccine to a 70-year-old client. The client asks "Will I have to get this every year like I do with the flu shot?" How should the nurse respond? |
It is unnecessary to have any follow-up injections of the pneumococcal vaccine after this dose |
A nurse assesses for hypocalcemia in a postoperative client. One of the initial signs that might be present is: |
Parasthesias |
The nurse is caring for a client who is receiving therapy for vitamin B12 deficiency. Which finding indicates that the therapy is having the desired effect? |
Improved hemoglobin and hematocrit levels |
What clinical finding does a nurse anticipate when admitting a client with an extracellular fluid volume excess? |
Distended jugular veins |
A visitor from a room adjacent to a client asks the nurse what disease the client has. The nurse responds, "I cannot discuss any client's illness with you." What legal issue supports the nurse's response? |
Invasion of privacy |
A client has been admitted with a urinary tract infection. The nurse receives a urine culture and sensitivity report that reveals the client has Vancomycin Resistant Enterococcus (VRE). After notifying the physician, which action should the nurse take to decrease the risk of transmission to others? |
Move the client to a private room |
The nurse is monitoring a client's hemoglobin level. The nurse recalls that the amount of hemoglobin in the blood has what effect on oxygenation status? |
A low hemoglobin level causes reduced oxygen-carrying capacity |
A nurse addresses the needs of a client who is hyperventilating to prevent what complication? |
Carbonic acide deficit |
A client with an abdominal wound infected with methicillin-resistant Staphylococcus aureus (MRSA) is scheduled for a computed tomography (CT) scan of the abdomen. To ensure client and visitor safety during transport, the nurse should implement which precaution? |
Cover the infected site with a dressing |
A nurse manager is evaluating the performance of the LPN/LVN who is supervising Unlicensed Assistive Personnel (UAP). What action indicates to the nurse manager that the LPN/LVN needs further instruction? |
Ask the UAP to assess the client's response to a respiratory treatment |
A nurse is taking care of a client who has severe back pain as a result of a work injury. What nursing considerations should be made when determining the client's plan of care? (Select all that apply.) |
Ask the client what is the client's acceptable level of pain. Administer the pain medications regularly around the clock. |
When caring for a client with pneumonia, which nursing intervention is the highest priority? |
Employ breathing exercises and controlled coughing. |
A nurse is caring for a client for whom segmental postural drainage treatments are prescribed. The nurse should avoid scheduling the treatment at what time? |
After a meal |
A child is being treated with oral ampicillin (Omnipen) for otitis media. What should be included in the discharge instructions that the nurse provides to the parents of the client? |
Complete the entire course of antibiotic therapy. |
A health care provider prescribes transdermal fentanyl (Duragesic) 25 mcg/hr every 72 hours. During the first 24 hours after starting the fentanyl, what is the most important nursing intervention? |
Manage pain with oral pain medication |
When suctioning a client with a tracheostomy, an important safety measure for the nurse is to: |
Apply suction only as the catheter is being withdrawn |
A client has undergone a subtotal thyroidectomy. The client is being transferred from the post anesthesia care unit/recovery area to the inpatient nursing unit. What emergency equipment is most important for the nurse to have available for this client? |
A tracheostomy tray |
A nurse is obtaining a health history from the newly admitted client who has chronic pain in the knee. What should the nurse include in the pain assessment? (Select all that apply.) |
Pain history including location, intensity and quality of pain Pain pattern including precipitating and alleviating factors |
A client who sustained a large open wound as a result of an accident is receiving daily sterile dressing changes. To maintain sterility when changing the dressing, the nurse should: |
Remove the sterile drape from its package by lifting it by the corners. |
The nurse assesses a client's pulse and documents the strength of the pulse as 3+. The nurse understands that this indicates the pulse is: |
full |
A nurse manager is evaluating the performance of the LPN/LVN who is supervising Unlicensed Assistive Personnel (UAP). What action indicates to the nurse manager that the LPN/LVN needs further instruction? |
Asks the UAP to assess the client's response to a respiratory treatment |
A nurse is reviewing a client's plan of care. What is the determining factor in the revision of the plan? |
Effectiveness of the interventions |
A nurse has provided discharge instructions to a client who received a prescription for a walker to use for assistance with ambulation. The nurse determines that the teaching has been effective when the client: |
Moves the walker no more than 12 inches in front of the client during use |
A client with a terminal illness reaches the stage of acceptance. How can the nurse best help the client during this stage? |
Stay nearby without initiating conversation |
A nurse is obtaining a health history from the newly admitted client who has chronic pain in the knee. What should the nurse include in the pain assessment? (Select all that apply.) |
Pain history including location, intensity and quality of pain Pain pattern including precipitating and alleviating factors |
The nurse should monitor for which involuntary physiological response in a client who is experiencing pain? |
Perspiring |
What are the best ways for a nurse to be protected legally? (Select all that apply.) |
Provide care within the parameters of the state's nurse practice act. Document consistently and objectively. Clearly document a client's non-adherence to the medical regimen |
Which drug requires the nurse to monitor the client for signs of hyperkalemia? |
Spironolactone |
An 85-year-old client is alert and able to participate in care. The nurse understands that, according to Erikson, a person's adjustment to the period of senescence will depend largely on adjustment to which developmental stage? |
Generativity versus role stagnation |
A client is admitted to the hospital for an elective surgical procedure. The client tells a nurse about the emotional stress of recently disclosing being a homosexual to family and friends. What is the nurse's first consideration when planning care? |
Identifying personal feelings toward this client |
A dying client is coping with feelings regarding impending death. The nurse bases care on the theory of death and dying by Kübler-Ross. During which stage of grieving should the nurse primarily use nonverbal interventions? |
Acceptance |
A nurse applies an ice pack to a client's leg for 20 minutes. The cold application will cause what physiological effect? |
Local Anasthesia |
While caring for a client with a Hemovac portable wound drainage system, the nurse observes that the collection container is half full. The nurse empties the container. What is the next nursing intervention? |
Compress the container before closing the port |
When suctioning a client with a tracheostomy, an important safety measure for the nurse is to: |
Apply suction only as the catheter is being withdrawn. |
What effect of povidone-iodine (Betadine) does a nurse consider when using it on the client's skin before obtaining a specimen for a blood culture? |
Eliminates surface bacteria that may contaminate the culture |
A nurse is caring for a client who has a Hemovac portable wound suction device after abdominal surgery. What is the reason why the nurse empties the device when it is half full? |
Negative pressure in the unit lessens as fluid accumulates, interfering with further drainage. |
The nurse instructs a client that, in addition to building bones and teeth, calcium is also important for: |
Blood clotting |
When meeting the unique preoperative teaching needs of an older adult, the nurse plans a teaching program based on the principle that learning: |
Requires continued reinforcement |
A nurse is helping a client who observes the traditional Jewish dietary laws to prepare a dietary menu. What considerations should the nurse make? |
Meat and milk at the same meal are forbidden |
A client being treated for Influenza A (H1N1) is scheduled for a computed tomography (CT) scan. To ensure client and visitor safety during transport, the nurse should take which precaution? |
Place a surgical mask on the client |
A nurse is reviewing a client's plan of care. What is the determining factor in the revision of the plan? |
Effectiveness of the interventions |
A nurse is evaluating the effectiveness of treatment for a client with excessive fluid volume. What clinical finding indicates that treatment has been successful? |
Clear breath sounds |
When providing care for a client with a nasogastric (NG) tube, the nurse should take measures to prevent what serious complication? |
Aspiration pneumonia |
A client who experienced extensive burns is receiving IV fluids to replace fluid loss. The nurse should monitor for which initial sign of fluid overload? |
Crackles in the lungs |
A client with a history of ulcerative colitis is admitted to the hospital because of severe rectal bleeding. The client engages in angry outbursts and places excessive demands on the staff. One day an unlicensed assistive personnel (UAP) tells the nurse, "I've had it. I am not putting up with that behavior. I'm not going in there again." What is the best response by the nurse? |
"The client's frightened and taking it out on the staff. Let's think of approaches we can take." |
When nurses are conducting health assessment interviews with older clients, they should: |
Spend time in several short sessions to elicit more complete information from the clients |
A nursing supervisor sends unlicensed assistive personnel (UAP) to help relieve the burden of care on a short-staffed medical-surgical unit. Which tasks can be delegated to UAP? (Select all that apply.) |
Taking routine vital signs. Answering clients' call lights. Changing linens on an occupied bed. |
The nurse is interviewing a client admitted for uncontrolled diabetes after binging on alcohol for the past two weeks. The client states "I am worried about how I am going to pay my bills for my family while I am hospitalized." Which statement by the nurse would best elicit information from the client? |
"You are worried about paying your bills?" |
A nurse is caring for a newly admitted client in a long-term care facility. The nurse notes that the client has a decreased attention span and cannot concentrate. The nurse suspects which effects of sensory deprivation? |
Cognitive response |
A nurse receives a shift report on four adult clients that are between the ages of 25-55. Which client should the nurse assess first? |
Female client on warfarin (Coumadin) with an International Normalized Ratio (INR) of 7.5 |
A nurse is discussing weight loss with an obese individual with Ménière's disease. Which suggestion by the nurse is most important? |
Keep a diary of all foods eaten each day |
A client reports nausea, vomiting, and seeing a yellow light around objects. A diagnosis of hypokalemia is made. Upon a review of the client's prescribed medication list, the nurse determines that what is the likely cause of the clinical findings? |
Digoxin |
The nurse is caring for a client that underwent a rhinoplasty surgical procedure 5 hours ago. After administering pain medication, the nurse notes the client is swallowing frequently. The nurse understands that the cause of frequent swallowing is most likely caused from: |
Bleeding posterior to the nasal packing |
A client has seeds containing radium implanted in the pharyngeal area. What should the nurse include in the client's plan of care? |
Maintain the client in an isolation room |
A health care provider has prescribed isoniazid (Laniazid) for a client. Which instruction should the nurse give the client about this medication? |
Drinking alcohol daily can cause drug-induced hepatitis |
Which nursing interventions require a nurse to wear gloves? (Select all that apply.) |
Cleaning a newborn immediately after delivery Emptying a portable wound drainage |
An older client who is receiving chemotherapy for cancer has severe nausea and vomiting and becomes dehydrated. The client is admitted to the hospital for rehydration therapy. Which interventions have specific gerontologic implications the nurse must consider? (Select all that apply.) |
Assessment of skin turgor Administration of antiemetic drugs Replacement of fluid and electrolytes |
Health promotion efforts within the health care system should include efforts related to secondary prevention. Which activities reflect secondary prevention interventions in relation to health promotion? (Select all that apply.) |
Encouraging regular dental checkups Teaching the procedure for breast self-examination |
To decrease abdominal distention following a client's surgery, what actions should the nurse take? (Select all that apply.) |
Encourage ambulation Auscultate bowel sounds |
A client becomes anxious after being scheduled for a colostomy. What is the most effective way for the nurse to help the client? |
Encourage the client to express feelings. |