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,A nurse is assessing a client who received 2 units of packed RBCs 48 hrs ago. Which of the following
findings should indicate to the nurse that the therapy has been effective? - correct ans:hemoglobin 14.9
g/dL
a nurse working in an emergency department is triaging four clients. which of the following clients
should the nurse recommend for treatment first? - correct ans:a middle adult client who has unstable
vital signs
a nurse is caring for a client who has fluid volume overload. which of the following tasks should the
nurse delegate to an assistive personnel? - correct ans:measure the client's daily weight
a nurse is preparing to administer mannitol 0.2 g/kg IV bolus over 5 min as a test dose to a client who
has severe oliguria. The client weighs 198 lb. what is the amount in grams the nurse should administer? -
correct ans:18 g
a nurse is conducting a physical examination for an adolescent and is assessing the rang of motion of the
legs, which of the following images indicates the adolescent is abducting the hip joint? - correct
ans:Moving the leg away from the midline of the body (off to the side, not to the front)
a nurse is caring for a client who has hyperthyroidism. which of the following findings should the nurse
expect? - correct ans:tremors
tachycardia, diaphoresis, weight loss, insomnia, exopthalmia
hypothyroidism has dry corase hair, bradycardia, and periorbital edema
a nurse is assessing a school age child who has bacterial meningitis. which of the following findings
should the nurse expect? - correct ans:nuchal rigidity
also weight loss
a nurse is assessing a newborn's heart rate. which of the following actions should the nurse take? -
correct ans:auscultate the apical pulse at least 1 min
,a nurse is preparing to assist with a thoracentesis for a client who has pleurisy. the nurse should plan to
perform which of the following actions? - correct ans:instruct the client to avoid coughing during the
procedure
a nurse is the emergency department is assessing a preschooler who has a facial laceration. the nurse
should identify which of the following findings as a potential indication of child sexual abuse? - correct
ans:the child exhibits discomfort while walking
a nurse is preparing to teach about dietary management to a client who has crohn's disease and an
enteroenteric fistula. which of the following nutrients should the nurse instruct the client to decrease in
their diet? - correct ans:fiber - reduce diarrhea and inflammation
a nurse is caring for a client who has a prescription for a continuous passive motion CPM machine
following a total knee arthroplasty. which of the following actions should the nurse take? - correct
ans:Turn off the CPM machine during mealtime
promote client comfort and dietary intake
a nurse is preparing to initiate IV access for an older adult client. Which of the following sites should the
nurse select when initiating the IV for this client? - correct ans:radial vein of the inner arm
a nurse is developing a client education program about osteoporosis for older adult clients. the nurse
should include which of the following variables as a risk factor for osteoporosis? - correct ans:sedentary
lifestyle
also, small framed body with a thin build, estrogen deficiency
a nurse in an emergency department is caring for a child who has a fever and fluid filled vesicles on the
trunk and extremities. which of the following interventions should the nurse identify as the priority? -
correct ans:initiate transmission based precautions
a nurse is caring for a client who has a clogged percutaneous gastrostomy feeding tube. which of the
following actions should the nurse take first? - correct ans:change the position of the client
, a home health care nurse is developing a teaching plan for a client who has a new ileostomy. which of
the following instructions should the nurse include? - correct ans:empty the appliance when it is one
third to one half full
a nurse is reviewing the laboratory report of a client who has end stage kidney disease and received
hemodialysis 24 hr ago. Which of the following laboratory values should the nurse report to the
provider? - correct ans:sodium 148 mEq/L
a nurse is caring for four clients. which of the following tasks should the nurse delegate to an assistive
personnel? - correct ans:Arrange the lunch tray for a client who has a hip fracture
a nurse is preparing a client for a paracentesis. which of the following actions should the nurse take? -
correct ans:instruct the client to void
a nurse has received change of shift report on four assigned clients. for which of the following clients
should the nurse intervene to prevent a potential food and medication interaction? - correct ans:a client
who is receiving an MAOI and is requesting a cheeseburger for dinner
a nurse is planning care for a client who has rheumatoid arthritis and has moderate to severe pain in
multiple joints. which of the following actions should the nurse plan to take? - correct ans:allow for
frequent rest periods throughout the day
a nurse is caring for a client who is receiving continuous bladder irrigation following a transurethral
resection of the prostate. the client reports bladder spasms, and the nurse observes a decreased urinary
output. which of the following actions should the nurse take? - correct ans:irrigate the catheter with
0.9% sodium chloride irrigation
a nurse is assessing a client who has COPD. which of the following findings should the nurse expect? -
correct ans:pH 7.31
a nurse in a community center is providing an educational session to a group of client about ovarian
cancer. which of the following manifestations of ovarian cancer should the nurse include in the
teaching? - correct ans:abdominal bloating