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Ensure the client's weights are hanging freely from the bed.
A nurse is assisting with the care of a client
who has a femur fracture and is in skeletal
traction. Which of the following actions
should the nurse take
Take this medication between meals
A nurse in a provider's office is reinforcing
teaching with a client who has anemia and
has been taking ferrous gluconate for
several weeks. Which of the following
instructions should the nurse include?
Take this medication between meals.
A nurse in a provider's office is reinforcing
teaching with a client who has anemia and
has been taking ferrous gluconate for
several weeks. Which of the following
instructions should the nurse include?
Wash daily with an antibacterial soap.
A nurse is reviewing the plan of care for a
client who has cellulitis of the leg. Which of
the following interventions should the nurse
recommend?
Avoid medications in capsule or enteric form.
A nurse is reinforcing teaching with a client
who is postoperative after having an
ileostomy established. Which of the
following instructions should the nurse
include in the teaching?
"Large incisions will be made in the burned tissue to improve circulation."
A nurse is caring for a client with severe
burns to both lower extremities. The client
is scheduled for an escharotomy and
wants to know what the procedure
involves. Which of the following statements
is appropriate for the nurse to make?
Decreased color perception
A nurse is collecting data from a client who
has a possible cataract. Which of the
following manifestations should the nurse
expect the client to report?
Maintain the client in Fowler's position.
A nurse is contributing to the plan of care
for a client who has an intestinal
obstruction and is receiving continuous
gastrointestinal decompression using a
nasogastric tube. Which of the following
interventions should the nurse include in
the plan of care?
1) Buffalo hump 2) Purple striations 3) Moon face
A nurse is caring for a client who has
Cushing's syndrome. Which of the
following clinical manifestations should the
nurse expect to observe? (Select all that
apply.)
Monitor intake and output hourly
A nurse is caring for a client who is in the
oliguric phase of acute kidney injury. Which
of the following actions should the nurse
take?
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"You will remain NPO for 8 hours before the procedure."
A nurse is reinforcing teaching about an
esophagogastroduodenoscopy with a client
who has upper gastric pain. Which of the
following statements should the nurse
include in the teaching?
Postictal phase
A nurse is caring for a client who is difficult
to arouse and very sleepy for several hours
following a generalized tonic-clonic
seizure. Which of the following descriptions
should the nurse use when documenting
this finding in the medical record?
"The pain will dissipate if you ambulate frequently."
A nurse is reinforcing teaching with a client
who reports right shoulder pain following a
laparoscopic cholecystectomy. Which of
the following statements should the nurse
make?
Verify that the suction regulator is on.
A nurse is checking the suction control
chamber of a client's chest tube and notes
that there is no bubbling in the suction
control chamber. Which of the following
actions should the nurse take?
Encourage fluid intake. 2) Monitor the puncture site for hematoma.
A nurse is assisting with the care of a client
immediately following a lumbar puncture.
Which of the following actions should the
nurse take? (Select all that apply.)
Prevent aspiration.
A nurse is assisting with the care of a client
who is postoperative following surgical
repair of a fractured mandible. The client's
jaw is wired shut to repair and stabilize the
fracture. The nurse should recognize which
of the following is the priority action?
Hardened skin
A nurse is collecting data from a client who
has scleroderma. Which of the following
findings should the nurse expect?
Add thickener to fluids.
A nurse is caring for an older adult client
who has dysphagia and left-sided
weakness following a stroke. Which of the
following actions should the nurse take?
Airway obstruction
A nurse is caring for a client who has
partial-thickness and full-thickness burns of
his head, neck, and chest. The nurse
should recognize which of the following is
the priority risk to the client?
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1) Take the medication 45 minutes before eating.
A nurse is reinforcing teaching with a client
who is newly diagnosed with myasthenia
gravis and is to start taking neostigmine.
Which of the following instructions should
the nurse include in the teaching?
Notify the provider.. Determine the patency of the tubing.
A nurse is caring for a client who is 12
hours postoperative following a
transurethral resection of the prostate
(TURP) and has a 3-way urinary catheter
with continuous irrigation. The nurse notes
there has not been any urinary output in
the last hour. Which of the following actions
should the nurse perform first?
"The biopsy can be uncomfortable, but we will try to keep you as comfortable as
A nurse is caring for a client scheduled for possible."
a bone marrow biopsy. The client
expresses fear about the procedure and
asks the nurse if the biopsy will hurt. Which
of the following responses should the
nurse make?
Re-establish communication.
A nurse is assisting with planning care for a
client who is recovering from a left-
hemispheric stroke. Which of the following
interventions should the nurse include in
the plan?
Hypotension
A nurse is assisting with the care of a client
who has diabetes insipidus. The nurse
should monitor the client for which of the
following manifestations?
Take temperature once a day
A nurse is reinforcing teaching with a client
who has HIV and is being discharged to
home. Which of the following instructions
should the nurse include in the teaching?
Provide humidified oxygen.
A nurse is caring for a client who is
postoperative following a tracheostomy,
and has copious and tenacious secretions.
Which of the following is an acceptable
method for the nurse to use to thin this
client's secretions?
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