ANSWERS
The nurse is monitoring the client. Select five findings that indicate that the client is
experiencing an adverse reaction to the nursing interventions, and the plan of care should be
updated.
-blood pressure
-Heart rate
-Respiratory rate
-Temperature
-Pain level
Complete the following sentence by using the list of options. Following the interaction with the
client the nurse should _____ followed by_____.
-notify the nurse manager of the problem
-Complete of facility incident report
A nurses reinforcing discharge teaching with a client who is two days postpartum. The patient
expresses concern about a lack of family support and limited financial resources. Which of the
following responses should the nurse make?
How do you feel about discussing your concerns with a social worker?
, A nurse is assisting with the discharge planning for a client. Which of the following actions
should the nurse plan to take?
Include community resource phone numbers with the clients discharge instructions
A nurse observes an assistive personnel (AP) taking a picture of a client who has not given
consent. The nurse should identify that the AP has committed which of the following torts?
Invasion of privacy
A nurse is assisting with the discharge of a client who was in a motor vehicle crash 24 hours ago.
The client tells the nurse, "My vision, seems blurry, and I am having difficulty speaking clearly."
which of the following action should the nurse take first?
Check the client for indications of increased intercranial pressure
A nurse in a skilled nursing facility is caring for a group of clients. Which of the following actions
demonstrates the nurses role as client advocate?
The nurse assists a client in communication end of life decisions to the provider
A nurse is contributing to the plan of care for a client who states they are devout Hindu. To
adhere to the clients, religious dietary practices, which of the following food options should the
nurse offer to the client?
yogurt