ANSWERS WITH SOLUTIONS 2024
An adult woman who has a history of inferior myocardial infection, esophageal reflex, and type 1
diabetes mellitus (OM) is admitted to the telemetr unit for sudden onset of dizzines with palpitations
and a burning sensation in her chest. Which intervention should the nurse implement first? - ANSWER
Evaluate telemetry cardiac rhythm
When conducting diet teaching for a client who was diagnosed with a myocardial Infarction, which snack
foods should the nurse encourage the to eat? ( Select all that apply .) - ANSWER Fresh turkey slices and
berries. Raw unsalted almonds and apples.
A male client who is experiencing musculoskeletal pain is discharged with instructions to take Ibuprofena
nonsteroidal antidrug mouth BID. After receiving discharge teaching, the client states he plans to take
the medication twice daily with breakfast and dinner How respond ? - ANSWER Confirm that the client
has an effective plan for when to take the medication
A client at 28- weeks gestation is admitted to the obstetrical unit following her involvement in a motor
vehicle collision. After stabilizing the nurse a fetal monitor reading What action should the nurse take if
fetal tachycardia is assessed on the monitor? - ANSWER Contact the healthcare provider after initiating
oxygen per face mask.
Four hours after the administers Interferon subcutaneously to a client, the client develops a headache,
muscle aches and a fever of 101.8° F (38.8°C). What action should the nurse implement? - ANSWER
Administer a prescribed PRN dose of acetaminophen for these side effects.
The nurse is caring for a client with a suspected diagnosis of osteomyelitis . Which diagnostic test should
the nurse prepare the client to expect the healthcare provider to prescribe? - ANSWER Radionuclide
bone scan.
When the nurse attempts to teach self- administration of insulin injections to a client who is newly
diagnosed with type 1 diabetes mellitus the client tells the nurse in a loud voice to leave the room.
Which action should the nurse take? - ANSWER Leave the client's room and return later in the day.
What is the primary goal when planning nursing care for a client with degenerative joint disease (DJD)? -
ANSWER Achieve satisfactory pain control.
, The nurse observes an unlicensed assistive personnel (UAP ) who is preparing to provide personal care
for a client who requires contact precautions The UAP has applied a gown and gloves and secured the
tops of the gloves over the gown sleeves . What action should the nurse take ? - ANSWER Assist the UAP
with application of a face mask or face shield.
While the nurse is conducting an admission assessment of a female client with bipolar disorder , the
client suddenly begins to take off her clothes and throw them about the room . Which action should the
nurse take first ? - ANSWER State it is unacceptable to undress during the interview.
An older adult male reporting abdominal pain is admitted to the hospital from a long -term care facility .
It has been 7 days since his last bowel movement , his abdomen is distended , and he just vomited 150 of
dark brown emesis . In what order should the nurse implement these interventions ? ( Arrange with the
highest priority intervention on top , and lowest priority intervention on bottom ) - ANSWER 1. Elevate
the head of the bed.
2. Offer PRN pain medication.
3. Complete focused assessment.
4. Send emesis sample to the lab.
What is the primary purpose for initiating nursing interventions that promote good nutrition, rest and
exercise, and stress reduction for clients diagnosed with an HIV infection ? - ANSWER Improve function
of the immune system.
A nurse who works in the nursery is attending the vaginal delivery of a term infant What action should
the nurse complete leaving the deliver room? - ANSWER Place the ID bands on the infant and mother.
The nurse is preparing a client with an acoustic neuroma for a magnetic resonance image (MRI ) Which
client complaint is -threatening and should be reported to the healthcare provider immediately ? -
ANSWER Intensifying headache
A client with chronic kidney disease (CKD ) is discharged with a prescription for epoetin alfa
subcutaneously In teaching the client about the medication , the nurse should emphasize the benefit of
Increasing which food product in the diet ? - ANSWER Iron-rich foods.