1. A male client admitted the morning of his scheduled surgery tells the PN that
he drankwater last night. What intervention will the PN implement first?
Determine the amount of water and exact time it was taken
2. A client receives ondansetron prior to chemotherapy treatment. How
should the PNevaluate this medication?
Monitor the client for nausea or vomiting following the treatment
3. The PN is caring for an older adult client who is confused and spends...factor
contributesto an increased risk for impaired skin integrity for this client?
Has increasing episodes of urinary incontinence
4. The pn determines that a client with cirrhosis is experiencing peripheral take?
Protect the client’s feet from injury
5. A client is admitted to the postoperative surgical unit after a left lobectomy
with two chest tubes observes the water-sealed chambers, set and
prescribed suction of 20cm water. what action should the PN implement?
Maintain system integrity and to promote lung re-expansion
6. Photo of chest and locating apical HR
Just below the left nipple
7. At the end of a 12-hour shift the PN observes the urine in a client’s drainage.
What actionshould the PN take next?
Note the most recent white blood count
8. Thirty minutes after receiving IV morphine, a postoperative male client
continue to ratehis pain...what action should the PN implement first?
, Implement complementary pain relief methods
9. A male client has been diagnosed with schizophrenia is withdrawn,
isolates himself in....with one or two word responses. The morning the PN
observes that he...Which intervention is most important for the PN to
implement?
Measure appropriate vital signs
10. The PN is assisting a female client to obtain a voided specimen for
uri...meatus. Whichintervention is performed next?
Initiate the urine stream?
11. An 8-year old is placed in 90-90 traction for a fractured femur that resulted
from...furtheraction by the PN?
Weights are touching the foot of the bed
12. The PN is reviewing diet instructions with a female client who has
hyper...she hasincreased her intakes of protein and calories. What action
should the PN take?
Encourage the client to continue the dietary changes she has made
13. A mother brings her 5-year old child to the clinic for school physical examinations.
Which assessment... PN that intergenerational violence may be occurring in the
home?-
The 6-year old son hits his younger sister during the interview
-the 10-year old daughter has circular burns on her trunk and legs
-the 3-year old has multiple bruises on the chest and both legs
14. A client has a prescription to discontinue intravenous therapy when the liter
that is infusing at 150 mL per hour is...1200 the PN notes that there are 750 ml of
solution remaining. At what time should the nurse expect to discontinue the
, intravenous therapy?
1700
15. The PN is caring for a client who had a total laryngectomy, left radical neck
dissection...client is receiving nasogastric tube feedings via an internal pump.
today the rate of the feeding was increased...ml/hr. What parameter should the
PN use to evaluate the clients tolerate to the rate of the feeding?
Gastric residual volumes
16. A new mother is breastfeeding her newborn for the first time after delivery and
complainsof nipple pain...Based on the client complaint, what action should the
PN take?
Ensure that all the areolar tissue of the nipple is in the infants’ mouth.
17. Which site should the PN use when administering an injection of Rho (D)
Immunenegative postpartum client?
Deltoid
18. Before inserting medication into a client’s vagina, what instructions should the
pn...
urinate until bladder is empty
19. An 18-year old female client with pelvic inflammatory disease (PID0 asks the
pn..Whichinformation is best for the PN to provide?
A history of untreated gonorrhea can lead to PID
20. A new mother is bottle feeding instead of breastfeeding her newborn, The
PN...mosteffectively deal with breast engorgement and discomfort?
Wear a supportive bra at all times
21. A young adult male tells the PN he has declared to change his hours at work
so that hecan...his community. Which stage of Maslow's development is this
young adult attempting to achieve?