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A nurse on a med surge unit has recieved change of shift report and will
care for 4 clients. Which of the following clients needs will the nurse
assign to an AP?
A. Feeding a client who was admitted 24 hours ago with aspiration
pneumonia
B. Reinforcing teaching with a client who is learning to walk with a quad
cane
C. Reapplying a condom catheter for a client who has urinary
incontinence
D. Applying a sterile dressing to a pressure ulcer
C. Reapplying a condom catheter for a client who has urinary
incontinence
,A nonstress test is scheduled for a client at 34-weeks gestation who
developed hypertension, periorbital edema, and proteinuria. Which of the
following nursing actions should be included in the care plan in order to
BEST prepare the client for the diagnostic test?
1. Start an intravenous line for an oxytocin infusion.
2. Obtain a signed consent prior to the procedure.
3. Instruct client to push a button when she feels fetal movement.
4. Attach a spiral electrode to the fetal head.
3. Instruct client to push a button when she feels fetal movement.
Which of the following nursing interventions is MOST important for a
45-year-old woman with rheumatoid arthritis?
1. Provide support to flexed joints with pillows and pads.
2. Position her on her abdomen several times a day.
3. Massage the inflamed joints with creams and oils.
4. Assist her with heat application and ROM exercises.
4. Assist her with heat application and ROM exercises.
The nurse is caring for a young adult admitted to the hospital with a
severe head injury. The nurse should position the patient
1. with his neck in a midline position and the head of the bed elevated 30°.
2. side-lying with his head extended and the bed flat.
3. in high Fowler's position with his head maintained in a neutral position.
4. in semi-Fowler's position with his head turned to the side.
1. with his neck in a midline position and the head of the bed elevated 30°.
,The nurse is teaching a 40-year-old man diagnosed with a lower motor
neuron disorder to perform intermittent self-catheterization at home. The
nurse should instruct the client to
1. use a new sterile catheter each time he performs a catheterization.
2. perform the Valsalva maneuver(holding breath and bearing down)
before doing the catheterization.
3. perform the catheterization procedure every 8 hours.
4. limit his fluid intake to reduce the number of times a catheterization is
needed.
2. perform the Valsalva maneuver(holding breath and bearing down)
before doing the catheterization.
A client is being discharged with sublingual nitroglycerin (Nitrostat).
The client should be cautioned by the nurse to
1. take the medication five minutes after the pain has started.
2. stop taking the medication if a stinging sensation is absent.
3. take the medication on an empty stomach.
4. avoid abrupt changes in posture.
4. avoid abrupt changes in posture.
, A nurse manager of a med surge unit is assigning care responsibilities
for the oncoming shift. A client is waiting transfer back to the unit from
the PACU following thoracic surgery. To which staff member should
the nurse assign the client?
A. Charge nurse
B. RN
C. LVN
D. AP
B. RN
A nurse is caring for a client who decides not to have surgery despite
significant blockages in his coronary arteries. The nurse understands that
this clients choice is an example of what principles?
A. Fidelity
B. Autonomy
C. Justice
D. Nonmalificience
A. Fidelity