PN Comprehensive Online Practice 2020 A

PN Comprehensive Online Practice 2020 A A nurse is assisting with the care of a client who has a terminal illness. The client practices Orthodox Judaism. Which of the following actions should the nurse take? ANS: Assure the client that a family member will stay with the body after death RAT: The nurse should assure the client that a family member will remain with the body until burial A nurse is reviewing a client's medication record and notices that a double dose of oral digoxin was administered 1 hour ago. Which of the following actions should the nurse take first? ANS: Obtain a set of the client's vital signs RAT: The first action the nurse should take when using the nursing process is to collect data from the client. Digoxin can cause bradycardia. By obtaining the client's vital signs, the nurse can identify the need for intervention A nurse is instructing an assistive personnel (AP) about caring for a client who has hepatitis A and is incontinent of stool. Which of the following infection control precautions should the nurse instruct the AP to use? ANS: Contact RAT: Hepatitis A is spread by the fecal-oral route. Standard precautions are usually sufficient to prevent the spread of infection. However, if the client who has hepatitis A is also incontinent of stool, then contact precautions are indicated A nurse is assisting with the transfer of a client to a long-term care facility. The nurse should review which of the following sections of the electronic health record to locate information about the client's personal health insurance? ANS: Admission sheet RAT: The nurse will find client data, such as date of birth, occupation, and the client's source of health insurance, on the client's admission sheet A nurse is inspecting the skin of a newborn. Which of the following findings should the nurse report to the provider? ANS: Generalized petechiae RAT: Petechiae are an expected finding over the presenting part of the newborn, such as on the forehead in a brow presentation, and also anywhere on the head of the newborns who has a nuchal cord, which is an umbilical cord around the neck. However, petechiae all over the newborn's body can indicate infection or a decreased platelet count and should be reported to the provider