Informed Consent for ECT ✔️A client has the right to withdraw consent for the treatment at any time.
Fraying on Electrical Cord ✔️The nurse should first remove the device from the room.
Hydromorphone Prescription ✔️The nurse should count the current number of unit doses available in the medication dispensing system.
Priority Finding Post Cast Placement ✔️A client 2 hours post cast placement with 2+ pitting edema and pallor has the priority finding.
Disulfiram Alcohol Use ✔️A client should limit alcohol use to one drink daily while taking disulfiram.
Fluoxetine and Tyramine ✔️A client should avoid foods containing tyramine while taking fluoxetine.
Sustained-Release Methylphenidate ✔️A client should take the sustained-release methylphenidate every morning.
Major Depressive Disorder Precautions ✔️The nurse should implement seizure precautions for the client.
Narcissistic Personality Disorder Expectation ✔️The nurse should expect the client to be preoccupied with aging.
Time Management in Nursing ✔️The nurse should first determine goals of the day.
Change-of-Shift Assessment Priority ✔️The priority finding is a client with pneumonia, productive cough, and fever of 38.8° C (101.8° F).
Medication Administration Documentation ✔️The nurse should document administration of the medication upon removal from the medication
dispensing system.
Withholding Medication ✔️The nurse should withhold hydromorphone if the client does not appear to be in pain.
Client Teaching in Mental Health ✔️Understanding is indicated when a client states they will take their lithium on an empty stomach.
Seizure Precautions ✔️Implementing seizure precautions is a priority action for a client with major depressive disorder.
Client Assessment in Mental Health ✔️Encouraging the client to verbalize feelings is an important action but not the first priority.
Electrical Device Safety ✔️Reporting the defect to the equipment maintenance staff is necessary but should follow immediate removal of the
device.
Medication Dispensing System ✔️The nurse should ensure the device inspection sticker is current as part of routine safety checks.
Postoperative Care ✔️Monitoring for pain is crucial after administering hydromorphone.
Effective Client Teaching ✔️Clients should be able to articulate the importance of medication adherence.
Managing Nursing Tasks ✔️Developing an hourly time frame for tasks can help manage time effectively.
Client Assessment Findings ✔️Identifying priority findings is essential during shift changes.
Understanding Medication Effects ✔️Clients must understand the effects and side effects of their medications.
Determine goals of the day ✔️Establish specific objectives for daily activities.
Magnesium sulfate via continuous IV infusion ✔️A treatment for preeclampsia requiring careful monitoring.
Restrict the client's total fluid intake to 250 mL/hr ✔️A guideline for fluid management in certain medical conditions.
Measure the client's urine output every hour ✔️A critical action to monitor kidney function and fluid balance.
Give the client protamine if signs of magnesium sulfate toxicity occur ✔️An emergency intervention for reversing magnesium toxicity.
Monitor the FHR via Doppler every 30 min ✔️A procedure to assess fetal heart rate during labor.
Wounds healing by primary intention ✔️Wounds that heal with minimal scarring, typically surgical incisions.
Approximated surgical incision ✔️A type of wound expected to heal by primary intention.
, Client taking clozapine to treat schizophrenia and reports sore throat ✔️A priority client due to potential agranulocytosis risk.
Client has OCD and is upset about a change in daily routine ✔️A client with stable condition, less urgent than others.
Client has narcissistic personality disorder and is mocking others during group therapy ✔️A client displaying disruptive behavior, but not
immediately life-threatening.
Client who has depressive disorder and requires assistance with ADLs ✔️A client needing support but not in immediate danger.
Implanted venous access port ✔️A device for long-term venous access in patients.
A non-coring needle ✔️A specialized needle used to access implanted ports.
Client who has pneumonia and feels chest pain ✔️A patient requiring urgent assessment for potential cardiac issues.
12 lead ECG ✔️A priority diagnostic test for evaluating cardiac function.
Assessing growth and development of a 3 y/o child ✔️Evaluating developmental milestones in early childhood.
Can your child ride a tricycle? ✔️A question to assess gross motor skills in a 3-year-old.
Fetal heart tones assessment at 12 weeks of gestation ✔️A procedure to monitor fetal health early in pregnancy.
Position the ultrasound stethoscope above the symphysis pubis to assess the FHR ✔️A technique for detecting fetal heart tones during early
pregnancy.
Chest tube with a water seal drainage system ✔️A system used to manage pleural effusions or pneumothorax.
Tidaling in the water seal ✔️Indicates that the chest tube system is functioning correctly.
The system is working properly ✔️An indication that the drainage system is effectively managing fluid.
Heparin for DVT ✔️A client who is receiving heparin for DVT should be recommended for early discharge.
HTN as contraindication ✔️Hypertension (HTN) in the child's medical history is a contraindication for becoming a living kidney donor.
Lochia serosa ✔️Lochia serosa is an expected assessment finding for a client who is 4 days postpartum.
Fundus 4 cm below umbilicus ✔️A fundus 4 cm (1.6 in) below the umbilicus is an expected assessment finding for a client who is 4 days
postpartum.
Postural drainage for cystic fibrosis ✔️The nurse should perform postural drainage twice a day for a child with cystic fibrosis.
Oxygen tank safety ✔️The oxygen tank should be placed away from curtains or drapes in a home care setting.
Seizure precautions for meningitis ✔️Implementing seizure precautions is an action the nurse should take for a client with bacterial meningitis.
K 3.3 mEq/L ✔️A potassium level of 3.3 mEq/L should be reported to the provider prior to hip arthroplasty.
Resetting suction drain ✔️The nurse should reset the vacuum by compressing the container for a closed suction drain after a modified radical
mastectomy.
Leukemia and platelet level ✔️A client with leukemia and a platelet level of 95,000/mm3 should be assessed first.
Neonatal abstinence syndrome ✔️A newborn experiencing neonatal abstinence syndrome is a concern for a mother who tested positive for
heroin during pregnancy.
COPD and oxygen system ✔️A home care nurse should ensure that the client checks the gauge of the compressed oxygen system weekly.
Postpartum assessment findings ✔️The nurse should expect a foul perineal odor and a fundus displaced to the right as potential assessment
findings.
Bronchodilator administration ✔️A bronchodilator should be administered after the postural drainage procedure.
Fundus position postpartum ✔️The fundus should be assessed for its position relative to the umbilicus in postpartum clients.