What action should a nurse take when inserting an IV catheter for a 7-
year-old child? - correct answer✔ ✔ Tell the child they will feel
discomfort during the catheter insertion.
What finding should a nurse report for a client with an arteriovenous
fistula? - correct answer✔ ✔ Absence of a bruit.
What statement indicates understanding of discharge teaching for a
client with an implantable cardioverter defibrillator? - correct answer✔
✔ I will wear loose clothing around my ICD.
What is an appropriate response for a nurse to make to a client at 14
weeks gestation who feels ambivalent about being pregnant? - correct
answer✔ ✔ Describe your feelings to me about being pregnant.
What should a nurse include in the care plan for a client on a bowel-
training program after a spinal cord injury? - correct answer✔ ✔
Administer a rectal suppository 30 minutes prior to scheduled
defecation times.
,What action should a nurse take for a client in active labor requesting
pain management? - correct answer✔ ✔ Place the client in a warm
shower.
In triage after a disaster, which type of injury should a nurse assign the
highest priority? - correct answer✔ ✔ 95% full-thickness body burn.
What guideline should a nurse include when updating protocols for the
use of belt restraints? - correct answer✔ ✔ Document the client's
condition every 15 minutes.
What characteristic should be included about effective nursing
leadership? - correct answer✔ ✔ Acts as an advocate for the nursing
unit.
What laboratory finding indicates a need to revise the care plan for a
client with diabetes mellitus? - correct answer✔ ✔ An HbA1c of
10%.
Which sexually transmitted infection is a nationally notifiable disease
that must be reported to the state health department? - correct answer✔
✔ Chlamydia.
,What group facilitation technique should a nurse teach a newly licensed
nurse for a mental health unit? - correct answer✔ ✔ Use modeling to
help clients improve their interpersonal skills.
What dietary action should a nurse include in the care plan for a client
practicing Orthodox Judaism during Passover? - correct answer✔ ✔
Provide unleavened bread.
What finding indicates the effectiveness of treatment for a client with a
pulmonary embolism? - correct answer✔ ✔ The client reports
feeling less anxious.
What is the next action a nurse should take after securing the airway of a
client who ingested thirty diazepam tablets? - correct answer✔ ✔
Administer flumazenil to the client.
What finding should a nurse expect in a client who used cocaine one
hour ago? - correct answer✔ ✔ Elevated temperature.
What manifestation should a nurse expect in a newborn with a blood
glucose level of 30 mg/dl? - correct answer✔ ✔ Jitteriness.
Which laboratory finding in a school-age child should a nurse report to
the provider? - correct answer✔ ✔ WBC count of 14,000/mm3.
, What should a charge nurse include about designating a health care
proxy? - correct answer✔ ✔ The proxy should make health care
decisions for the client regardless of the client's ability to do so.
What can a proxy do if the client is under anesthesia? - correct answer✔
✔ Make treatment decisions for the client.
What is the first action a nurse should take for a client in the PACU who
reports nausea? - correct answer✔ ✔ Turn the client on their side.
In a situational crisis, what should a nurse do first for a client with a
history of depression? - correct answer✔ ✔ Confirm the client's
perception of the event.
What should a nurse do after obtaining a verbal prescription for
restraints for a client in acute mania? - correct answer✔ ✔ Obtain a
prescription for restraint within 4 hours.
Which client should a charge nurse delegate to an LPN? - correct answer
✔ ✔ A client who is postoperative following a bowel resection with
an NG tube set to continuous suction.