A nurse is teaching a client who has a new prescription for estradiol. For which of
the following adverse effects of this medication should the nurse instruct the
client to monitor and report to the provider?
Hypotension
Headaches
Bruising
Oliguria - correct answers-Headaches
The nurse should instruct the client to monitor for and report headaches.
Headaches can be an indication of a thromboembolic stroke because estradiol
increases the risk for adverse cardiovascular events
A nurse is preparing to administer diazepam 0.3 mg/kg IV bolus to a toddler who
weighs 22 lb and is experiencing a grand mal seizure. Available is diazepam
solution for injection 5 mg/mL. How many mL should the nurse administer? -
correct answers-0.6 mL
A nurse is caring for a client who is 12 hr postoperative, is receiving PCA for pain
control, and requires a blood pressure check in 10 min. Which of the following
staff members should the nurse assign to collect this information?
,An RN who is monitoring a client who started receiving a blood transfusion 5 min
ago
An assistive personnel (AP) who just began performing a bed bath
A licensed practical nurse (LPN) who is reinforcing discharge instructions with a
client
An assistive personnel (AP) who is assisting a client to return to bed - correct
answers-An assistive personnel (AP) who is assisting a client to return to bed
Performing a blood pressure check is within the range of function of an AP, and
the AP should be available to obtain a blood pressure within the specified time
A nurse is creating a plan of care for a child who has acute lymphoid leukemia and
an absolute neutrophil count of 400/mm^3. Which of the following interventions
should the nurse include in the plan?
Encourage friends and family to visit the child
Withhold administering the varicella vaccine to the child
Collect a daily urine specimen from the child to check for proteinuria
Provide a low-protein diet for the child - correct answers-Withhold administering
the varicella vaccine to the child
,A child who has severe immunodeficiency should not receive a lie vaccine due to
the risk of developing the disease. Inactivated vaccines can be administered to
children who are immunosuppressed.
A nurse is providing teaching about improving nutrition for a client who has
multiple sclerosis. Which of the following instructions should the nurse include?
(SATA)
A speech pathologist will be performing a swallowing study for you
You should rest before eating a meal
You should restrict foods that are high in vitamin D
Reduce your intake of dietary fiber
Thicken your beverages before drinking - correct answers-A speech pathologist
will be performing a swallowing study for you
You should rest before eating a meal
Thicken your beverages before drinking
A nurse is providing dietary teaching to the parents of a 6-month old infant. Which
of the following instructions should the nurse include?
Provide the infant with 1 cup of cereal
Give the infant 240 mL (8 oz) of juice per day
, Introduce new foods one at a time over 5 to 7 days
Give whole milk first, then small amounts of solid food - correct answers-
Introduce new foods one at a time over 5 to 7 days
The parents should introduce new foods one at a time over 5 to 7 days to identify
potential food allergies
A charge nurse is planning care for a client who has mechanical restraints in
place. Which of the following interventions should the nurse include in the plan?
Remove the client's restraints while sleeping
Document the client's status every 60 min
Check for a new prescription every 6 hours
Provide a staff member to stay with the client continuously - correct answers-
Provide a staff member to stay with the client continuously
A staff member must remain continuously with a client who is in restraints or
view the client via audiovisual equipment if necessary due to the risk of injury
A community health nurse is assisting with the development of a disaster
management plan. The nurse should include which of the following nursing
responsibilities in the disaster response stage of the plan?