The nurse is caring for a client with severe iron deficiency anemia. Which interventions
should the nurse include in the client's plan of care? (Select all that apply.)
Give this one a try later!
Instruct assistive personnel to allow the client to rest during care activities.
Monitor the client for palpitations and orthostatic hypotension.
Review the client's medical record for NSAID use.
Encourage the client to eat more green leafy vegetables and beans.
Monitor the client's stool for color, consistency and frequency.
The nurse has administered haloperidol 5 mg orally (PO) as needed (PRN) to a client
with a diagnosis of schizophrenia. Which of the following behaviors justify use of this
chemical restraint?
Give this one a try later!
, The client is verbalizing a plan to harm another client.
The client is expressing paranoid delusions.
The client is experiencing command hallucinations.
The nurse is providing care for a client who was recently diagnosed with end-stage
heart failure. The client does not have advance directives in place. Which of the
following statements by the nurse would be appropriate? (Select all that apply.)
Give this one a try later!
"Have you thought about what you want done as your disease progresses?"
"What does your family know about your condition and prognosis?"
"Have you discussed your wishes regarding resuscitation with your health
care provider?"
The nurse is assisting in the admission of a 73-year-old client who has a fractured right
hip. Which interventions should the nurse include in the client's plan of care? (Select
all that apply.)
Ask about the client's pain level with every set of vital signs.
Perform daily circulation, motion and sensation checks on the client's right leg.
Palpate the client's bilateral pedal pulses every four hours.
Place the client on continuous pulse oximetry.
Reposition the client every hour to prevent skin breakdown.
Give this one a try later!
The client with a hip fracture is at risk for impaired perfusion to the affected
extremity. Monitoring bilateral pedal pulses allows the nurse to compare
the pulse strength in the injured site with that in the non-injured site. A
decrease in the injured leg could signal a decrease in circulation that would
require immediate intervention. A fat embolism is also a risk with a hip
fracture and continuous pulse oximetry would allow the nurse to identify
hypoxia quickly which could be associated with a fat embolism. Clients with
a hip fracture usually experience great pain and assessing pain with each
, set of vital signs is key to effective pain management. Circulation, motion
and sensation checks should be completed at least every four hours, not
daily.
A nurse is taking a health history from parents of a child admitted with possible Reye's
syndrome. Which recent illness should the nurse recognize as being associated with
an increased the risk for the development of Reye's syndrome?
1. Varicella
2. Meningitis
3. Hepatitis
4. Rubeola
Give this one a try later!
1. Varicella -
The nurse is reviewing the medical record of a client with diabetes who was admitted
for a surgical site infection. Which findings should the nurse report to the health care
provider? (Select all that apply.)
Give this one a try later!
In reviewing the lab values, the nurse should notify the HCP of the positive
glucose in urine (normally, glucose is not seen in urine), A1C of 8% (desired
range for a client with diabetes is 7% or less), and the serum glucose level
of 220 mg/dL, which is higher than the normal range of 70 to 110 mg/dL.
These abnormal lab results indicate that the client's diabetes is not
managed well and most likely contributed to the client developing an
infection.
, The office nurse is discussing how to prevent an acute gouty attack with a client who
has gout. Which actions should the nurse recommend to the client? (Select all that
apply.)
Limit their intake of shellfish and red meats.
Take the prescribed prednisone regularly.
Limit their consumption of alcohol.
Implement stress reduction techniques.
Give this one a try later!
limit shellfish/meat intake
limit consumption of alcohol
stress reduction techniques
The client has an order for intermittent gastrostomy tube (G-tube) feedings. What is
the priority action by the nurse to accurately assess correct placement of the G-tube?
1Listen for active bowel sounds in all four quadrants
2Measure the pH of stomach content aspirate
3Auscultate the abdomen while instilling 10 mL of air into the G-tube
4Measure the length of tubing from the insertion site each shift
Give this one a try later!
1Listen for active bowel sounds in all four quadrants
2Measure the pH of stomach content aspirate -
3Auscultate the abdomen while instilling 10 mL of air int1Listen for active
bowel sounds in all four quadrants
2Measure the pH of stomach content aspirate -
3Auscultate the abdomen while instilling 10 mL of air into the G-tube
4Measure the length of tubing from the insertion site each shifto the G-
tube
4Measure the length of tubing from the insertion site each shift
should the nurse include in the client's plan of care? (Select all that apply.)
Give this one a try later!
Instruct assistive personnel to allow the client to rest during care activities.
Monitor the client for palpitations and orthostatic hypotension.
Review the client's medical record for NSAID use.
Encourage the client to eat more green leafy vegetables and beans.
Monitor the client's stool for color, consistency and frequency.
The nurse has administered haloperidol 5 mg orally (PO) as needed (PRN) to a client
with a diagnosis of schizophrenia. Which of the following behaviors justify use of this
chemical restraint?
Give this one a try later!
, The client is verbalizing a plan to harm another client.
The client is expressing paranoid delusions.
The client is experiencing command hallucinations.
The nurse is providing care for a client who was recently diagnosed with end-stage
heart failure. The client does not have advance directives in place. Which of the
following statements by the nurse would be appropriate? (Select all that apply.)
Give this one a try later!
"Have you thought about what you want done as your disease progresses?"
"What does your family know about your condition and prognosis?"
"Have you discussed your wishes regarding resuscitation with your health
care provider?"
The nurse is assisting in the admission of a 73-year-old client who has a fractured right
hip. Which interventions should the nurse include in the client's plan of care? (Select
all that apply.)
Ask about the client's pain level with every set of vital signs.
Perform daily circulation, motion and sensation checks on the client's right leg.
Palpate the client's bilateral pedal pulses every four hours.
Place the client on continuous pulse oximetry.
Reposition the client every hour to prevent skin breakdown.
Give this one a try later!
The client with a hip fracture is at risk for impaired perfusion to the affected
extremity. Monitoring bilateral pedal pulses allows the nurse to compare
the pulse strength in the injured site with that in the non-injured site. A
decrease in the injured leg could signal a decrease in circulation that would
require immediate intervention. A fat embolism is also a risk with a hip
fracture and continuous pulse oximetry would allow the nurse to identify
hypoxia quickly which could be associated with a fat embolism. Clients with
a hip fracture usually experience great pain and assessing pain with each
, set of vital signs is key to effective pain management. Circulation, motion
and sensation checks should be completed at least every four hours, not
daily.
A nurse is taking a health history from parents of a child admitted with possible Reye's
syndrome. Which recent illness should the nurse recognize as being associated with
an increased the risk for the development of Reye's syndrome?
1. Varicella
2. Meningitis
3. Hepatitis
4. Rubeola
Give this one a try later!
1. Varicella -
The nurse is reviewing the medical record of a client with diabetes who was admitted
for a surgical site infection. Which findings should the nurse report to the health care
provider? (Select all that apply.)
Give this one a try later!
In reviewing the lab values, the nurse should notify the HCP of the positive
glucose in urine (normally, glucose is not seen in urine), A1C of 8% (desired
range for a client with diabetes is 7% or less), and the serum glucose level
of 220 mg/dL, which is higher than the normal range of 70 to 110 mg/dL.
These abnormal lab results indicate that the client's diabetes is not
managed well and most likely contributed to the client developing an
infection.
, The office nurse is discussing how to prevent an acute gouty attack with a client who
has gout. Which actions should the nurse recommend to the client? (Select all that
apply.)
Limit their intake of shellfish and red meats.
Take the prescribed prednisone regularly.
Limit their consumption of alcohol.
Implement stress reduction techniques.
Give this one a try later!
limit shellfish/meat intake
limit consumption of alcohol
stress reduction techniques
The client has an order for intermittent gastrostomy tube (G-tube) feedings. What is
the priority action by the nurse to accurately assess correct placement of the G-tube?
1Listen for active bowel sounds in all four quadrants
2Measure the pH of stomach content aspirate
3Auscultate the abdomen while instilling 10 mL of air into the G-tube
4Measure the length of tubing from the insertion site each shift
Give this one a try later!
1Listen for active bowel sounds in all four quadrants
2Measure the pH of stomach content aspirate -
3Auscultate the abdomen while instilling 10 mL of air int1Listen for active
bowel sounds in all four quadrants
2Measure the pH of stomach content aspirate -
3Auscultate the abdomen while instilling 10 mL of air into the G-tube
4Measure the length of tubing from the insertion site each shifto the G-
tube
4Measure the length of tubing from the insertion site each shift
