,◉ A nurse is caring for a client who has a temperature of 39.7° C
(103.5° F) and has a prescription for a hypothermia blanket. The
nurse should monitor the client for which of the following adverse
effects of the hypothermia blanket. Answer: Shivering
◉ A nurse is reinforcing teaching about exercise with a client who
has type 1 diabetes mellitus. Which of the following statements by
the client indicates an understanding of the teaching. Answer: "I will
not exercise if my urine is positive for ketones."
◉ A nurse notes a small section of bowel protruding from the
abdominal incision of a client who is postoperative. After calling for
assistance, which of the following actions should the nurse take
first?. Answer: Cover the client's wound with a moist, sterile
dressing.
◉ A nurse is collecting data from a client who has alcohol use
disorder and is experiencing metabolic acidosis. Which of the
following manifestations should the nurse expect?. Answer:
Hyperventilation
◉ A nurse is reinforcing discharge teaching with a client following a
cataract extraction. Which of the following should the nurse include
in the teaching?. Answer: Avoid bending at the waist
◉ A nurse is caring for a client who has heart failure and has been
taking digoxin 0.25 mg daily. The client refuses breakfast and
,reports nausea. Which of the following actions should the nurse take
first?. Answer: Check the client's vital signs.
◉ A nurse is caring for a client who is 3 days postoperative following
a cholecystectomy. The nurse suspects the client's wound is infected
because the drainage from the dressing is yellow and thick. Which of
the following findings should the nurse report as the type of
drainage found?. Answer: Purulent
◉ A nurse is reinforcing discharge teaching to a client following
arthroscopic surgery. To prevent postoperative complications which
of the following actions should be reinforced during the teaching?.
Answer: Administer an opioid analgesic to the client 30 min prior to
initiating CPM exercises.
◉ A nurse is collecting data from a client who has emphysema.
Which of the following findings should the nurse expect? (Select all
that apply.). Answer: 1) Dyspnea 2) Barrel chest 3) Clubbing of the
fingers 4) Shallow respirations
◉ A nurse is caring for a client who sustained a basal skull fracture.
When performing morning hygiene care, the nurse notices a thin
stream of clear drainage coming from out of the client's right nostril.
Which of the following actions should the nurse take first?. Answer:
Test the drainage for glucose.
◉ A nurse is caring for a client who has a spinal cord injury at T-4.
The nurse should recognize that the client is at risk for autonomic
, dysreflexia. Which of the following interventions should the nurse
take to prevent autonomic dysreflexia?. Answer: Prevent bladder
distention.
◉ A nurse is caring for a client who is being evaluated for
endometrial cancer. Which of the following findings should the
nurse expect the client to report?. Answer: Abnormal vaginal
bleeding
◉ A nurse is caring for a client following an open reduction and
internal fixation of a fractured femur. Which of the following findings
is the nurse's priority?. Answer: Altered level of consciousness
◉ A nurse is assisting in the care of a client who is 2 hours
postoperative following a wedge resection of the left lung and has a
chest tube to suction. Which of the following is the priority finding
the nurse should report to the provider?. Answer: Abdomen is
distended
◉ A nurse is reinforcing discharge teaching with a client about how
to care for a newly created ileal conduit. Which of the following
instructions should the nurse include in the teaching?. Answer:
Change the ostomy pouch daily
◉ A nurse is assisting in the plan of care for a client who had a
removal of the pituitary gland. Which of the following actions should
the nurse include in the plan?. Answer: Change the nasal drip pad as
needed.
(103.5° F) and has a prescription for a hypothermia blanket. The
nurse should monitor the client for which of the following adverse
effects of the hypothermia blanket. Answer: Shivering
◉ A nurse is reinforcing teaching about exercise with a client who
has type 1 diabetes mellitus. Which of the following statements by
the client indicates an understanding of the teaching. Answer: "I will
not exercise if my urine is positive for ketones."
◉ A nurse notes a small section of bowel protruding from the
abdominal incision of a client who is postoperative. After calling for
assistance, which of the following actions should the nurse take
first?. Answer: Cover the client's wound with a moist, sterile
dressing.
◉ A nurse is collecting data from a client who has alcohol use
disorder and is experiencing metabolic acidosis. Which of the
following manifestations should the nurse expect?. Answer:
Hyperventilation
◉ A nurse is reinforcing discharge teaching with a client following a
cataract extraction. Which of the following should the nurse include
in the teaching?. Answer: Avoid bending at the waist
◉ A nurse is caring for a client who has heart failure and has been
taking digoxin 0.25 mg daily. The client refuses breakfast and
,reports nausea. Which of the following actions should the nurse take
first?. Answer: Check the client's vital signs.
◉ A nurse is caring for a client who is 3 days postoperative following
a cholecystectomy. The nurse suspects the client's wound is infected
because the drainage from the dressing is yellow and thick. Which of
the following findings should the nurse report as the type of
drainage found?. Answer: Purulent
◉ A nurse is reinforcing discharge teaching to a client following
arthroscopic surgery. To prevent postoperative complications which
of the following actions should be reinforced during the teaching?.
Answer: Administer an opioid analgesic to the client 30 min prior to
initiating CPM exercises.
◉ A nurse is collecting data from a client who has emphysema.
Which of the following findings should the nurse expect? (Select all
that apply.). Answer: 1) Dyspnea 2) Barrel chest 3) Clubbing of the
fingers 4) Shallow respirations
◉ A nurse is caring for a client who sustained a basal skull fracture.
When performing morning hygiene care, the nurse notices a thin
stream of clear drainage coming from out of the client's right nostril.
Which of the following actions should the nurse take first?. Answer:
Test the drainage for glucose.
◉ A nurse is caring for a client who has a spinal cord injury at T-4.
The nurse should recognize that the client is at risk for autonomic
, dysreflexia. Which of the following interventions should the nurse
take to prevent autonomic dysreflexia?. Answer: Prevent bladder
distention.
◉ A nurse is caring for a client who is being evaluated for
endometrial cancer. Which of the following findings should the
nurse expect the client to report?. Answer: Abnormal vaginal
bleeding
◉ A nurse is caring for a client following an open reduction and
internal fixation of a fractured femur. Which of the following findings
is the nurse's priority?. Answer: Altered level of consciousness
◉ A nurse is assisting in the care of a client who is 2 hours
postoperative following a wedge resection of the left lung and has a
chest tube to suction. Which of the following is the priority finding
the nurse should report to the provider?. Answer: Abdomen is
distended
◉ A nurse is reinforcing discharge teaching with a client about how
to care for a newly created ileal conduit. Which of the following
instructions should the nurse include in the teaching?. Answer:
Change the ostomy pouch daily
◉ A nurse is assisting in the plan of care for a client who had a
removal of the pituitary gland. Which of the following actions should
the nurse include in the plan?. Answer: Change the nasal drip pad as
needed.
