The nurse is caring for a client with cellulitis of the leg. At 11:00 AM, the client reported
itching and received a PRN dose of diphenhydramine. At 9:00 PM, the client reports
trouble sleeping and requests another dose of diphenhydramine to help with sleep.
Which action is most appropriate?
Request a prescription for a sleep aid from the health care provider
The home health nurse visits a client with inflammatory bowel disease who recently
underwent a total colectomy with ileostomy creation. Which statement by the client
indicates that the client understands ileostomy care?
, I cut the appliance opening slightly larger than my stoma.
The nurse checks a client's blood pressure using an automatic, noninvasive machine. The
nurse notes that the machine inflates for an unusually long amount of time, and the client
reports intense pain in the arm with the cuff. The device suddenly stops inflation and
displays an error message. Which action by the nurse is appropriate?
Send the machine for maintenance and repeat the measurement manually
The nurse is caring for a 5 clients and is assisted by experienced UAP . Which tasks can
the nurse safely delegate to the UAP?
- Emptying a urinary drainage bag and recording output
- Providing perineal care for a client with a urinary catheter
- Reapplying sequential compression devices
The student nurse assists in caring for a client who is scheduled for electroconvulsive
therapy for the treatment of depression. Which statement by the student indicates a need
for further teaching?
, Because this client has a mental illness, the agent with medical power of
attorney should sign the informed consent document.
A nurse is caring for a client 1 day postoperative craniotomy. Which nursing actions are
appropriate to prevent increased intracranial pressure?
- Administer stool softener
- Dim lights when not providing care
- Maintain body in midline position
The nurse is walking through a mall parking lot and witnesses the collapse of a child. The
child is not breathing and has a pulse of 50/min. After the nurse calls emergency services
and delivers rescue breaths for 2 minutes, the child is still not breathing and is now pale
with a pulse of 49/min. What is the nurse's next action
Give this one a try later!
Begin chest compression
The nurse understands that which factor increases a client's risk of experiencing atypical
symptoms of myocardial infarction?
Give this one a try later!
, Female gender
The nurse reinforces teaching to a 15 year primigravid client at 16 weeks gestation during
an initial prenatal visit. Which information would be a priority for the nurse to include?
Give this one a try later!
Stress the importance of consistent prenatal care.
The nurse is reviewing home instructions with the client who just underwent cataracts
surgery with intraocular lens implantation. Which of the ff clients statements indicate
appropriate understanding of the teaching?
Give this one a try later!
- I need to wear an eye patch at night
- I should avoid sexual intercourse until I'm healed
- I will increase my fluid intake and take docusate daily
A 4-year old is diagnosed with Duchenne muscular dystrophy. Which nursing teaching is
most appropriate to reinforce for this child's parents?
Give this one a try later!
itching and received a PRN dose of diphenhydramine. At 9:00 PM, the client reports
trouble sleeping and requests another dose of diphenhydramine to help with sleep.
Which action is most appropriate?
Request a prescription for a sleep aid from the health care provider
The home health nurse visits a client with inflammatory bowel disease who recently
underwent a total colectomy with ileostomy creation. Which statement by the client
indicates that the client understands ileostomy care?
, I cut the appliance opening slightly larger than my stoma.
The nurse checks a client's blood pressure using an automatic, noninvasive machine. The
nurse notes that the machine inflates for an unusually long amount of time, and the client
reports intense pain in the arm with the cuff. The device suddenly stops inflation and
displays an error message. Which action by the nurse is appropriate?
Send the machine for maintenance and repeat the measurement manually
The nurse is caring for a 5 clients and is assisted by experienced UAP . Which tasks can
the nurse safely delegate to the UAP?
- Emptying a urinary drainage bag and recording output
- Providing perineal care for a client with a urinary catheter
- Reapplying sequential compression devices
The student nurse assists in caring for a client who is scheduled for electroconvulsive
therapy for the treatment of depression. Which statement by the student indicates a need
for further teaching?
, Because this client has a mental illness, the agent with medical power of
attorney should sign the informed consent document.
A nurse is caring for a client 1 day postoperative craniotomy. Which nursing actions are
appropriate to prevent increased intracranial pressure?
- Administer stool softener
- Dim lights when not providing care
- Maintain body in midline position
The nurse is walking through a mall parking lot and witnesses the collapse of a child. The
child is not breathing and has a pulse of 50/min. After the nurse calls emergency services
and delivers rescue breaths for 2 minutes, the child is still not breathing and is now pale
with a pulse of 49/min. What is the nurse's next action
Give this one a try later!
Begin chest compression
The nurse understands that which factor increases a client's risk of experiencing atypical
symptoms of myocardial infarction?
Give this one a try later!
, Female gender
The nurse reinforces teaching to a 15 year primigravid client at 16 weeks gestation during
an initial prenatal visit. Which information would be a priority for the nurse to include?
Give this one a try later!
Stress the importance of consistent prenatal care.
The nurse is reviewing home instructions with the client who just underwent cataracts
surgery with intraocular lens implantation. Which of the ff clients statements indicate
appropriate understanding of the teaching?
Give this one a try later!
- I need to wear an eye patch at night
- I should avoid sexual intercourse until I'm healed
- I will increase my fluid intake and take docusate daily
A 4-year old is diagnosed with Duchenne muscular dystrophy. Which nursing teaching is
most appropriate to reinforce for this child's parents?
Give this one a try later!
