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A nurse on a pediatric unit is Obtain the child's dietary history
caring for a toddler who has
poor dietary intake.
Which of the following actions
should the nurse take first?
A nurse is reinforcing teaching Avoid pregnancy for at least 28 days after receiving the vaccine.
with a client who is postpartum
about the measles, mumps,
and rubella (MMR) vaccine.
Which of the following
instructions should the nurse
include in the teaching?
A nurse is preparing to perform Clean the wound from center to outer edges
a wet-to-dry dressing change
for a client who has an infected
abdominal wound.
Which of the following
techniques should the nurse use
when performing this dressing
change?
A nurse is reinforcing teaching My partner will use condoms with spermicides
with a female client about
contraception.
Which of the following
statements by the client
indicates an understanding of
the teaching?
,A nurse is caring for a client who displacement
has bipolar disorder. The client
yells at the nurse whenever
medication changes
are prescribed by the client's
provider.
The nurse should identify that
the client is using which of the
following defense mechanisms?
A nurse is providing care to a Soiled linens are placed on the floor
client who is
Immune-compromised.
Which of the following should
the nurse identify as a possible
source of infection?
A nurse is caring for a client who ensure that the client gave informed consent
has peptic ulcer disease and is
scheduled to undergo an
esophagogastroduodenoscopy.
Which of the following actions
should the nurse take prior to
the procedure?
A nurse is assisting in the care of -Request a consult for case management
a client. Nurses' Notes 2000: -Maintain a safe and private environment for the client
-Administer sexually transmitted infection prophylaxis
Client presents to emergency -Provide resources for local support services
department and states, "I have
been assaulted." Client was
immediately placed in a
treatment room.
(Select all that apply)
A nurse is contributing to the Increase protein in the diet.
plan of care for a client who has
leukemia and is experiencing
chronic fatigue.
Which of the following
interventions should the nurse
plan to include?
A nurse is collecting data from a Bright red vaginal bleeding
client who has placenta previa.
Which of the following findings
should the nurse expect?
, -Provide the client with written information about advance
A nurse is assisting with the care directives
of a client. Laboratory Results -Instruct the client that an advance directive is a legal document
and must be honored by care providers
1100: -Initiate a power of attorney for health care document
(Select 4) -Communicate advance directives status via the medical record
and shift report
A nurse is reviewing client Giving change-of-shift report to a nurse outside the client's room
confidentiality with other staff
members.
The nurse should identify that
which of the following actions is
an example of protecting client
confidentiality?
A nurse is assisting with Position the client's head toward Mecca
postmortem care for a client
who was a devout follower of
Islam. Which of the following
actions should the nurse take?
A nurse is reinforcing teaching I should have my baby latch on to my nipple and areola during
about breastfeeding with the feeding."
mother of a full-term
newborn who is 5 days old.
Which of the following
statements by the mother
indicates an understanding of the
teaching?
A nurse is assisting with the -Assign the client to a negative pressure airflow room
admission of a client who has -Initiate contact precautions for the client
varicella zoster.
Which of the following
interventions should the nurse
plan to implement?
(Select all that apply)
A nurse is preparing to test a -" Lie down and I will stroke the bottom of your foot."
client's plantar Babinski reflex.
Which of the following
instructions should the nurse
give to prepare the client for this
test?
A nurse is assisting with the Adult day care facility
discharge of an older adult
client who has early onset
dementia and lives with their
adult child who works full time
Which of the following
resources should the nurse
recommend to the family to
assist with the client's care?