UPDATED SOLUTION 2026
A nurse is caring for a preschooler on the pediatric
unit experiencing anaphlayctic shock. Which four
actions should the nurse take.
Monitor vital signs frequently
D/C supplemental O2
Administer NS IV
D/C IV medication
Administer epi IM
Monitor output Q2hrs - (correct answer --->)D/C
IV medication
Administer epi IM
Monitor vital signs frequently
Administer NS IV
A nurse is caring for a client who is 24hrs post-op
following a C/S.
Box 1: Seizures; hyperglycemia; hypoxemia;
infection; PP hemorrhage
Box 2: BP; O2; WBC; BG; Platelet count - (correct
answer --->)Box 1: seizures
Box 2: BP
,A nurse is caring for a client who has schizophrenia
in an inpatient facility. Highlight important findings.
Hyperactive bowel sounds noted x 4.
and last doctor's appointment was 6 months ago.
Client alert and oriented to person and place
Agitated
Speech disorganized.
Client has involuntary tongue movement and foot
tremor
Client reports an increase in urination and had one
episode of incontinence
Family noticed increased agitation and delusions -
(correct answer --->)When analyzing cues, the
nurse should identify that the client is taking a
second-generation antipsychotic medication, which
can lead to manifestations of tardive dyskinesia,
including involuntary tongue movement and foot
tremors. Frequent urination and incontinence are
side effects of aripiprazole and should be reported to
the provider. An increase in agitation is a safety risk
for the client, staff, and others on the unit and
requires immediate de-escalation.
A nurse is preparing to teach about dietary
management to a client who has Crohn's disease
and an enteroenteric fistula. Which of the following
,nutrients should the nurse instruct the client to
decrease in their diet?
a. Calories
b. Protein
c. Potassium
d. Fiber - (correct answer --->)d. Fiber
Manifestations of ADHD and ID - (correct
answer --->)ADHD: losing neccesaryu things;
interrupting others, intellectual impairment,
hypersensitivity to sensory input
ID: ??
A nurse is caring for a 68-year-old client who is 2
days postoperative following surgical repair of a left
hip fracture.
Complete the bowtie. - (correct answer ---
>)Condition: intestinal obstruction
Actions to take: Assist to semi-fowlers and
administer iv fluids
Peramiters to monitor: Bowl sounds and urine output
A nurse is teaching a client who has a new
prescripion for digoxin about manifestations of
, toxicity. which of the follwoing should the nurse
include.
a. Constipation
b. Nausea
c. Wheezing
d. Muscle rigidity - (correct answer --->)Nausea
The nurse should instruct the client to monitor for
and report manifestations of digoxin toxicity, such as
nausea, anorexia, abdominal pain, bradycardia, and
visual changes.
A client who has high blood pressure is having
difficulty following their treatment plan. Which of the
following factors should the nurse recognize as
being the greatest barrier to the client's ability to be
compliant?
Absence of symptoms - (correct answer --->)
A nurse working on an inpatient mental health unit is
caring for a client who is experiencing active suicidal
ideations. Which of the following interventions
should the nurse recommend including in the plan of
care to ensure a safe client care environment? -