Terms (131)
Hide definitions
The nurse is called to the waiting room of a pediatric clinic. The frantic mother states, "I think
my 4-month-old baby is choking!" What steps will the nurse take? (Select all that apply.)
Note any obstruction or absence of breathing.
Deliver five backslaps between the shoulder blades.
Place the infant over the nurse's arm.
Which fluid will the nurse select to administer with the prescribed blood transfusion?
Normal saline
,When assisting a client from the bed to a chair, which procedure is best for the nurse to
follow?
With the nurse's feet spread apart and knees aligned with the client's knees, stand and pivot
the client into the chair.
How many mL will the nurse document on the client's intake and output record from the
items listed? _____ mL
1200 mL water
4 ounce container of gelatin
8 ounces of orange juice
355 mL can of soda1 cup of soup
Answer: 2155
Rationale: 1200 + 240 (8 oz) + 240 (1 cup) + 120 (4 oz) + 355 = 2155
,The nurse observes a UAP taking a client's blood pressure in the lower extremity. Which
observation of this procedure requires the nurse to intervene with the UAP's approach?
The UAP auscultates the popliteal pulse with the cuff on the lower leg.
During a clinic visit, the mother of a 7-year-old reports to the nurse that her child is often
awake until midnight playing and is then very difficult to awaken in the morning for school.
Which assessment data should the nurse obtain in response to the mother's concern?
Description of the family's home environment
The nurse identifies a potential for infection in a client with partial-thickness (second-
degree) and full-thickness (third-degree) burns. What action has the highest priority in
decreasing the client's risk of infection?
Use of careful handwashing technique
, The nurse assesses a 2-year-old who is admitted for dehydration and finds that the
peripheral IV rate by gravity has slowed, even though the venous access site is healthy. What
should the nurse do next?
Check for kinks in the tubing and raise the IV pole.
The nurse manager of a skilled nursing (chronic care) unit is instructing UAPs on ways to
prevent complications of immobility. Which action should be included in this instruction?
Perform range-of-motion exercises to prevent contractures.
Hide definitions
The nurse is called to the waiting room of a pediatric clinic. The frantic mother states, "I think
my 4-month-old baby is choking!" What steps will the nurse take? (Select all that apply.)
Note any obstruction or absence of breathing.
Deliver five backslaps between the shoulder blades.
Place the infant over the nurse's arm.
Which fluid will the nurse select to administer with the prescribed blood transfusion?
Normal saline
,When assisting a client from the bed to a chair, which procedure is best for the nurse to
follow?
With the nurse's feet spread apart and knees aligned with the client's knees, stand and pivot
the client into the chair.
How many mL will the nurse document on the client's intake and output record from the
items listed? _____ mL
1200 mL water
4 ounce container of gelatin
8 ounces of orange juice
355 mL can of soda1 cup of soup
Answer: 2155
Rationale: 1200 + 240 (8 oz) + 240 (1 cup) + 120 (4 oz) + 355 = 2155
,The nurse observes a UAP taking a client's blood pressure in the lower extremity. Which
observation of this procedure requires the nurse to intervene with the UAP's approach?
The UAP auscultates the popliteal pulse with the cuff on the lower leg.
During a clinic visit, the mother of a 7-year-old reports to the nurse that her child is often
awake until midnight playing and is then very difficult to awaken in the morning for school.
Which assessment data should the nurse obtain in response to the mother's concern?
Description of the family's home environment
The nurse identifies a potential for infection in a client with partial-thickness (second-
degree) and full-thickness (third-degree) burns. What action has the highest priority in
decreasing the client's risk of infection?
Use of careful handwashing technique
, The nurse assesses a 2-year-old who is admitted for dehydration and finds that the
peripheral IV rate by gravity has slowed, even though the venous access site is healthy. What
should the nurse do next?
Check for kinks in the tubing and raise the IV pole.
The nurse manager of a skilled nursing (chronic care) unit is instructing UAPs on ways to
prevent complications of immobility. Which action should be included in this instruction?
Perform range-of-motion exercises to prevent contractures.
