A nurse is assisting with the plan of care for a client following a
transurethral resection of the prostate. Which of the following interventions should the nurse
include in the plan of care?
The nurse should irrigate the bladder using strict sterile technique and maintain closed catheter
drainage system to minimize the risk of infection.
A nurse is reviewing a client's electronic medical record and finds that an assistive per sonnel
recorder the client's temperature as 35.3 degrees Celsius (95.5 degrees F) 2 hrs earlier. Which of
the following actions should the nurse take first?
check the clients temp
A nurse is receiving change-of-
shift report for four clients. Which of the following clients should the nurse see first?
A client whose urinary output was 100mL for the past 12 hrs
A nurse in reinforcing teaching about weight loss with a female older adult client who is
overweight. Which of the following statements should the nurse include in teaching?
keep fat intake to no more that 30% of daily caloric intake.
, A nurse is collecting data from a client who has iron deficiency anemia. Which of the following
findings should the nurse expect?
difficulty concentrating
A Nurse is collecting data from an older adult client who is 48 hr postoperative following
abdominal surgery. The provider writes a prescription to advance the client to a re gular Diet.
For which of the following findings should the nurse notify the provider?
The client has absent bowel sounds
A parent brings her adolescent son to an urgent care center and states. "He is high on
something and needs help" The client is
exhibiting agitation and paranoia and reports visual hallucinations. The nurse should suspect
intoxication with which of the following substances?
Methamphetamines
A nurse notices an assistive personnel taking a nap in the break room during he meal t ime. The
AP appears drowsy while performing routine tasks. Which of the following a ctions should the
nurse take?
Report the observations about the ap to the unit's nurse manager.
A nurse is reinforcing teaching with a client who has a fluid volume deficit about selec ting foods
that have a high water content. The nurse should include that which of the following raw foods
contains the highest amount of water per 1 cup serving?
cherry tomatoes
The nurse is position a client who is scheduled for a lumbar puncture. The nurse should assist
the client into which of the following positions?
lateral recumbent
A nurse is talking with a client whose son died in a motor- vehicle crash 2 weeks ago. The client
states "I really thought I'd be back to my usual routines by now, but I can't think of anythingelse
except my son is gone" Which of the following responses should the nurse make?
Grieving for your son is hard work. It will take as much time as you need to come to terms with
your loss.
A nurse is assisting with monitoring a client who is at 40 weeks of gestation and is in active
labor. The nurse recognizes late deceleration on the fetal monitor tracing. Whichof the following
actions should the nurse take?