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A nurse is providing family education for a client who
wishes to conceive...the nurse should identify that
ovulation is expected to occur on which of the following
calendar dates?
D-the 19th.
The nurse should teach the client that ovulation is
expected to occur 13-15 days after day one of her
menses.
,A nurse in an acute care mental health facility is
planning care for a client who has bipolar disorder and
who is experiencing acute mania. What action should
the nurse take?
Provide the client with finger foods to eat.
A nurse is caring for an infant who has Tetralogy of
Fallot. The nurse notes that the infant exhibits a sudden
onset of cyanosis and is hyperpneic. What action should
the nurse take?
Place the infant in a knee-chest position.
This maximizes the oxygenation status of the infant
during hypercyanotic episodes
A nurse is providing discharge teaching to a client
following gastric bypass surgery for management of
obesity. What is a client statement that indicates
understanding of the teaching?
"I will remain in a reclining position for 30 minutes after I
eat"
Following gastric bypass surgery, clients are at risk for
dumping syndrome. Remaining in a reclining position
,slows gastric emptying and minimizes the risk of
dumping syndrome.
A nurse is teaching a client who has genital herpes
simplex virus. What statement should the nurse include
in the teaching about this STI?
"You should cleanse the lesions with a saline solution
twice each day."
This helps to prevent secondary bacterial infections.
A nurse is caring for a client who has a terminal illness
and is approaching death. Which of the following
actions should the nurse take?
Apply a thin coating of lip balm to the client's lips.
A client who is dying can experience dehydration.
Applying lip balm to the client's lips promotes comfort.
A nurse in an emergency department is assessing a
client who was in a motor-vehicle crash. The client has a
BAC of 0.18% and states, "I would never drink and
drive." This is demonstrating use of which defense
mechanism?
, Denial
Client refuses to acknowledge the reality of a situation.
A nurse is caring for a newly-admitted client who is at
37 weeks of gestation and is experiencing moderate
placental abruption. What should the nurse do?
Insert a large-bore IV catheter.
A 16-18 gauge IV catheter is to be inserted into the
client's brachial artery because fluid volume and blood
replacement might be necessary to correct defects in
coagulation.
A nurse is planning care for a client who has a benign
chondroma of the tibia. Which of the following
interventions should the nurse plan to include?
Palpate for changes in the muscle of the affected
extremity.
The nurse should palpate to monitor for changes such as
muscle spasm, atrophy, or swelling. These manifestations
indicate enlargement of the tumor.