A nurse is admitting a client who has an abdominal wound with a large amount of purple tissue drainage. Which of the following types of transmission precautions should the nurse initiate?
Protective environment
Airborne precautions
Droplet precautions
Contact precautions Correct Answer - Contact precautions
A nurse is caring for a client who is expressing anger about his diagnosis of colorectal cancer. Which of the following actions should the nurse take?
-Discuss the risk factors for colon cancer.
-Focus teaching on what the client will need to do in the future to manage his illness.
-Provide the client with written information about the phases of loss & grief.
-Reassure the client that this is an expected response to grief. Correct Answer - -
Reassure the client that this is an expected response to grief.
A nurse is caring for a client who is postoperative following a knee arthroplasty & requires the use of thigh-length sequential compression sleeves. Which of the following actions should the nurse take?
-Assist the client into a prone position
-Place a sleeve over the top of each leg with the opening at the knee
-Make sure two finger can fit under the sleeves
-Set ankle pressure at 65 mmHg Correct Answer - -Make sure two finger can fit under the sleeves A nurse is preparing to apply a dressing for a client who has a stage 2 pressure injury. Which of the following types of dressings should the nurse use?
Alienate
Gauze
Transparent
Hydrocolloid Correct Answer - Hydrocolloid
A nurse is preparing an education program for the staff about advocacy. Which of the following information should the nurse include?
-Advocacy ensures clients' safety, health, & rights.
-Advocacy series that nurses are able to explain their own actions.
-Advocacy ensures that nurses follow through on their promises to clients.
-Advocacy ensures fairness in client care delivery and use of resources. Correct Answer - Advocacy ensures clients' safety, health, & rights.
A nurse is admitting a new client. Which of the following actions should the nurse take while performing medication reconciliation?
-Verify the client's name on their identification bracelet with the medication administration record
-Call the pharmacy to determine whether the client's medications are available
-Compare the clients home medications with the provider's prescriptions
-Place the client's home medication bottles in a secure location Correct Answer - Compare the clients home medications with the provider's prescriptions
A nurse is assessing an older adult client's risk for falls. Which of the following assessments should the nurse use to identify the client's safety need? (Select all that
apply)
-Lacrimal apparatus -Pupil clarity
-Appearance of bulbar conjunctivae
-Visual fields
-Visual acuity Correct Answer - Pupil clarity
Visual fields
Visual acuity
A nurse is providing discharge instructions to a client who will be using a walker. Which of the following client statements indicates an understanding of the teaching?
-"I can place an extension cord across my living room to plug in my television."
-"I will hire someone to trim the tree that hangs low over the stairs of my front porch."
-"I will place my alarm clock on my bedroom dresser across the room."
-"I will replace the old throw rug in my kitchen with a new one." Correct Answer - -"I will hire someone to trim the tree that hangs low over the stairs of my front porch."
A nurse is reviewing a client's fluid & electrolyte status. Which of the following findings should the nurse report to the provider?
BUN 15 mg/dL
Creatinine 0.8 mg/dL
Sodium 143 mEq/L
Potassium 5.4 mEq/L Correct Answer - Potassium 5.4 mEq/L
nurse is caring for a client who is postoperative and is exhibiting signs of hemorrhagic shock. the nurse notifies the surgeon, who tells the nurse to continue