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1. A nurse is caring for a client who is receiving dialysis treatment.
For each potential nursing intervention, click to specify if the intervention is
indicated or not indicated.: Perform a 12-lead ECG is not indicated. The client is
not reporting chest pain; therefore, a 12-lead ECG is not indicated at this time.
Place the client in Trendelenburg position is indicated. The client should be placed
in the Trendelenburg position to increase blood flow to the heart, improving cardiac
output and organ perfusion.
Administer a 0.9% sodium chloride 200 mL IV bolus is indicated. The nurse should
administer 200 mL of 0.9% sodium chloride IV bolus to increase fluid volume and
the client's blood pressure.
Apply oxygen at 2 L/min via nasal cannula is indicated. The nurse should administer
oxygen at 2 L/min via nasal cannula to increase the amount of oxygen carried in the
blood.
Notify the provider immediately is indicated. The nurse should notify the provider
immediately as part of the nurse's role to provide an update on the client's condition.
Obtain the client's blood glucose level is not indicated. There is no indication that the
client is experiencing hypoglycemia; therefore, obtaining a blood glucose level is not
indicated.
2. A nurse is caring for a client who is postoperative following abdominal
surgery.
A nurse is caring for a client who is postoperative. Which of the following
actions should the nurse take?: Apply oxygen via a face mask is incorrect. It is
not necessary to place a face mask on the client because their SaO2 is within the
expected reference range of 95% to 100%.
Instruct the client to splint the abdomen with a pillow for coughing is correct. It
is important for the client to turn, cough, and deep breathe to reduce the risk for
respiratory complications. The nurse should instruct the client to splint the incision
while performing these actions to reduce the risk of complications to the surgical
incision.
Plan to ambulate the client as soon as possible is correct. The nurse should plan to
ambulate the client as soon as possible to promote ventilation and decrease the risk
of thrombosis.
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Report urinary output to the provider is correct. The client should produce at least 30
mL of urine per hour. Therefore, the nurse should report this finding to the provider.
Ask the client to rate their pain on a 0 to 10 pain scale is correct. The nurse
should have the client rate their pain prior to and following the administration of pain
medication to evaluate its effectiveness.
3. A nurse is caring for a client who is receiving total parenteral nutrition (TPN).
A new bag is not available when the current infusion is nearly completed.
which actions should the nurse take?
Keep the line open with 0.9% sodium chloride until the new bag arrives.
Administer dextrose 10% in water until the new bag arrives.
Flush the line and cap the port until the new bag arrives.
Decrease the infusion rate until the new bag arrives.: Administer dextrose 10%
in water until the new bag arrives
4. A nurse is caring for a client who had a nephrostomy tube inserted 12 hr.
ago. Which of the following findings should the nurse report to the provider?
The client's urinary output has increased.
The client reports back pain.
The client's urine color is red tinged.
The client's tube requires irrigation.: The client reports back pain
The nurse should notify the provider if the client reports back pain, which can indicate
that the nephrostomy tube is dislodged or clogged.
5. A nurse is caring for a client who is having a seizure. Which of the following
interventions is the nurse's priority?: Turn the client to the side.
6. A nurse in a provider's office is assessing a client who has hypertension and
takes propranolol. Which of the following findings should indicate to the nurse
that the client is experiencing an adverse reaction to this medication?: Report
of a night cough.
(the nurse should recognize that this is an early indication of heart failure and report
this adverse reaction to the provider)
7. A nurse is planning to irrigate and dress a clean, granulating wound for a
client who has a pressure injury. Which of the following actions should the
nurse take?: Use a 30-mL syringe.
(Nurse should use a 30-60 mL syringe with an 18 or 19-gauge catheter to deliver
the ideal pressure of 8 pounds per square inch (psi) when irrigating a wound.)
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8. A nurse is assessing a client who has Graves' disease. Which of the follow-
ing images should indicate to the nurse that the client has exophthalmos?: -
Last picture or the picture with wide-opened, bulging eyes.
9. A nurse is caring for a client who has DKA. Which of the following findings
should indicate to the nurse that the client's condition is improving?: glucose
272 mg/dL
10. A nurse is caring for a client who has hypothyroidism. Which of the follow-
ing manifestations should the nurse expect?: Constipation
(due to client's decrease in metabolism, resulting in slow motility of the gastrointesti-
nal tract.)
11. A nurse is preparing to administer a blood transfusion to a client who has
anemia. Which of the following actions should the nurse take first?: Check for
the type and number of units of blood to administer.
12. A nurse is caring for a client who has a leg cast and is returning to
demonstrate the proper use of crutches while climbing stairs. Place boxes in
order.: 1. Places body weight on the crutches.
2. Advances the unaffected leg onto the stair.
3. Shift their weight from the crutches to the unaffected leg.
4. Brings the crutches and the affected leg up the stair
13. A nurse is teaching a group of newly licensed nurses about pain manage-
ment for older adult clients. Which of the following instructions should the
nurse include?: Ibuprofen can cause gastrointestinal bleeding in older adult clients.
14. A nurse is teaching a client who has a family history of colorectal cancer.
To help mitigate this risk, which of the following dietary alterations should the
nurse recommend?: Add cabbage to the diet
15. A nurse in an emergency department is caring for a client who has
full-thickness burns over 20% of their total body surface area. After ensuring
patent airway and giving oxygen, which should the nurse administer first?: IV
fluids
16. A nurse is caring for a client who has terminal cancer. The client tells
the nurse, "I wish I could stop these treatments. I am ready to die." Which
statement should the nurse make?: "Discontinuing with the treatments is your
choice if it is your wish to do so."
17. A nurse is providing teaching to a client who has cancer and a new pre-
scription for an opioid analgesic for pain management. Which of the following
information should the nurse include in the teaching?: "You should void every
4 hours to decrease the risk of urinary retention."