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,The nurse assigns an unlicensed assistive personnel A. None.
(UAP) to take the vital signs of a client who is positive for
Human Immunodeficiency Virus (HIV). What protective
apparel should the nurse counsel the UAP to wear when
carrying out this assignment?
A. None.
B. Gown, gloves, mask.
C. Gloves and mask.
D. Gloves only.
A client with Guillain-Barre syndrome requires a D. With the client, develop a system of eye blinks to communicate "yes" or "no."
tracheostomy and mechanical ventilation due to the
progression of the disease. What nursing intervention is
most helpful in aiding this clinet to communicate with the
staff and family?
A. Speak slowly and disntinctly while in direct view of the
client.
B. Teach the client to point to a letter board word chart to
communicate needs.
C. Provide the client with a pencil and tablet of paper.
D. With the client, develop a system of eye blinks to
communicate "yes" or "no."
A client with peptic ulcer disease (PUD) is admitted to the A. Preparing the client for emergency abdominal surgery.
emergency room complaining of sudden severe upper
abdominal pain. Assessment indicates an extremely
tender and rigid abdomen, B/P of 90/60 mmHg, and
pulse of 110 beat/minute. The emergency department
nurse should anticipate implementation of which
intervention?
A. Preparing the client for emergency abdominal surgery.
B. Infusing the proton pump inhibitor Protonix
intravenously.
C. Administering an iced saline lavage.
D. Inserting a nasogastric tube to decompress the bowel.
Which finding should the nurse expect a client to exhibit B. Disruption in sleep patterns.
who is newly diagnosed with fibromyalgia?
A. Recent joint trauma.
B. Disruption in sleep patterns.
C. Unexplained weight gain.
D. Itching and rash.
, A male client with diabetes mellitus reports that he has D. Review the findings of his glycosylated hemoglobin test.
had trouble following his diet, and the result of his fasting
blood glucose test is 90 mg/dl. What action should the
nurse implement first?
A. Obtain a urine specimen from the client to test for
ketonuria.
B. Assure the client that his diabetes control is within
normal limits.
C. Schedule the client to attend classes about diet
management.
D. Review the findings of his glycosylated hemoglobin
test.
A multipara postpartum client complain intense cramping C. Take a prescribed analgesic an hour prior to breastfeeding.
while breastfeeding. What instruction should the nurse
provide to the client?
A. Change the infant's position during the next feeding.
B. Void and completely empty bladder before each
feeding.
C. Take a prescribed analgesic an hour prior to
breastfeeding.
D. Drink two glasses of water 30 minutes prior to
breastfeeding.
A nurse is preparing to teach the parents of a child who D. " The purpose of the dressing is to protect the incision from fecal
had a surgical repair of myelomeningocele how to contamination."
change an occlusive dressing on the child's back. Which
statement by the parents indicates that they understand
this procedure?
A. "We should rapidly remove the tape from the edges of
the dressing when changing it."
B. "The dressing should be wetted periodically to keep
the skin incision moist."
C. "The dressing will help dry the sutures for ease of
removal."
D. " The purpose of the dressing is to protect the incision
from fecal contamination."
While the nurse is preparing to administer a high volume B. Assess the client's ability to independently turn to his left side.
saline enema to a male client, the client appears anxious
and states that he is not able to turn on his right side
without help because of a recent stroke. What action
should the nurse take first?
A. Reassure the client that he can remain in any position
of comfort during the enema.
B. Assess the client's ability to independently turn to his
left side.
C. Instruct the client that the procedure will only last
about ten minutes.
D. Ask a UAP to assist the client to maintain a right lateral
position.