A 2-day postoperative patient is receiving 2520
1000 mL normal saline over 10 hours. The
patient has an intake of 4 ounces of
orange juice, one 8-ounce cup of coffee,
3 cups of water, and 1 cup of tea. This
patient has a total intake of _________ mL
over the 12-hour period.
A 63-year-old Arab American male states Assess for pain
his left leg is "hot." What is the nurse's best
first response?
The adult daughter of a skilled facility An infection
resident is concerned because the
patient is becoming increasingly irritable
and nasty to the daughter and care
providers. What should the nurse suspect
is occuring with the patient?
The client diagnosed with lung cancer Discuss implementing an advance directive
has been told the cancer has
metastasized to the brain. Which
intervention should the practical nurse
expect to implement?
,The client diagnosed with lung cancer is "It doesn't matter if I smoke now. I already have cancer."
being discharged. Which statement made
by the client indicates a reiteration of
information is required?
The client experienced a fall. Nursing Administer oxygen.
assessment reveals that the client is
experiencing tachycardia, hypotension,
confusion, tachypnea, and flat jugular
veins. What should be the nurse's first
response?
A client experiencing shock has had a Notify the physician.
urinary output of 250 mL in the last 10
hours. What is the nurse's most
appropriate response?
The client has an eviscerated abdominal Apply sterile normal saline dressing
wound. Which intervention should the
practical nurse implement?
,A client has had abdominal surgery and Mediate 1 hour prior to ambulating the client.
has orders to be ambulated three times a
day. Oral pain medication has been
ordered for the client. What should the
nurse do to facilitate ambulation?
The client is complaining of excruciating "He is experiencing phantom limb pain."
pain in a foot that has been amputated.
The family tells the nurse that the client is
just addicted to pain medications. What is
the nurse's best response?
The client is diagnosed with peritonitis. The client has a decrease in temperature and a soft abdomen
Which information indicates to the
practical nurse the client's condition is
improving?
The client is one (1) day postoperative Fluid and electrolyte imbalance
major abdominal surgery. Which client
problem is a priority?
The client reports frequent use of "Do you drink alcohol?"
acetaminophen. How should the nurse
best respond?
, The client who had abdominal surgery Inspect the abdominal wound incision
tells the practical nurse, "I felt something
give way in my stomach." Which
intervention should the practical nurse
implement first?
A client with chronic pain has been What medications the client has taken
admitted with a fever. The nursing
assessment reveals that the client has a
decreased level of consciousness. What
should the nurse ask the family about?
A college student is brought into the Handle the feet gently.
emergency department with possible
frostbite of both feet after losing Elevate the feet to heart level.
consciousness in a snow drift while
walking home from a party. What actions Cover the feet with dry sterile gauze.
should the nurse take at this time?
Select all that apply.
1000 mL normal saline over 10 hours. The
patient has an intake of 4 ounces of
orange juice, one 8-ounce cup of coffee,
3 cups of water, and 1 cup of tea. This
patient has a total intake of _________ mL
over the 12-hour period.
A 63-year-old Arab American male states Assess for pain
his left leg is "hot." What is the nurse's best
first response?
The adult daughter of a skilled facility An infection
resident is concerned because the
patient is becoming increasingly irritable
and nasty to the daughter and care
providers. What should the nurse suspect
is occuring with the patient?
The client diagnosed with lung cancer Discuss implementing an advance directive
has been told the cancer has
metastasized to the brain. Which
intervention should the practical nurse
expect to implement?
,The client diagnosed with lung cancer is "It doesn't matter if I smoke now. I already have cancer."
being discharged. Which statement made
by the client indicates a reiteration of
information is required?
The client experienced a fall. Nursing Administer oxygen.
assessment reveals that the client is
experiencing tachycardia, hypotension,
confusion, tachypnea, and flat jugular
veins. What should be the nurse's first
response?
A client experiencing shock has had a Notify the physician.
urinary output of 250 mL in the last 10
hours. What is the nurse's most
appropriate response?
The client has an eviscerated abdominal Apply sterile normal saline dressing
wound. Which intervention should the
practical nurse implement?
,A client has had abdominal surgery and Mediate 1 hour prior to ambulating the client.
has orders to be ambulated three times a
day. Oral pain medication has been
ordered for the client. What should the
nurse do to facilitate ambulation?
The client is complaining of excruciating "He is experiencing phantom limb pain."
pain in a foot that has been amputated.
The family tells the nurse that the client is
just addicted to pain medications. What is
the nurse's best response?
The client is diagnosed with peritonitis. The client has a decrease in temperature and a soft abdomen
Which information indicates to the
practical nurse the client's condition is
improving?
The client is one (1) day postoperative Fluid and electrolyte imbalance
major abdominal surgery. Which client
problem is a priority?
The client reports frequent use of "Do you drink alcohol?"
acetaminophen. How should the nurse
best respond?
, The client who had abdominal surgery Inspect the abdominal wound incision
tells the practical nurse, "I felt something
give way in my stomach." Which
intervention should the practical nurse
implement first?
A client with chronic pain has been What medications the client has taken
admitted with a fever. The nursing
assessment reveals that the client has a
decreased level of consciousness. What
should the nurse ask the family about?
A college student is brought into the Handle the feet gently.
emergency department with possible
frostbite of both feet after losing Elevate the feet to heart level.
consciousness in a snow drift while
walking home from a party. What actions Cover the feet with dry sterile gauze.
should the nurse take at this time?
Select all that apply.
