GRADED
AXnurse,XanXemergencyXdepartmentXcompleteXanXassessmentXonXanXadolescentXclientXthatXhasXco
nductXdisorder.XTheXclientXthreatenXsuicideXtoXaXteacherXatXschoolXwhichXofXtheXfollowingXstatem
entsXshouldXtheXnurseXincludeXinXtheXassessment.X-XTellXmeXhowXoftenXdoXyouXdrinkXalcohol?
AXnurseXisXobservingXbondingXtoXtheXclient,XherXnewborn,XwhichXofXtheXfollowingXactionsXbyXtheX
clientXrequiresXtheXnurseXtoXinterveneX-XViewingXtheXnewborn'sXactionsXtoXbeXuncooperative
AXnurseXisXcaringXforXaXclientXwhoXisXtakingXlevothyroxine,XwhichXofXtheXfollowingXfindingXshoul
dXindicateXthatXtheXmedicationXwasXeffectiveX-XWeightXloss
AXnurseXisXplanning,XdischargeXteachingXforXcordXcareXforXaXparentXofXaXnewbornXwhichXinstruct
ionsXwouldXyouXincludeXinXtheXteachingX-
XKeepXtheXcordXdryXuntilXitXfallsXoffX(cordXshouldXbeXkeptXcleanXandXdryXtoXpreventXinfection)
AXnurseXisXassessingXaXclientXinXPACU,XwhichXofXtheXfollowingXfindingsXindicatesXdecreasedXcard
iacXoutputX-Xoliguria
AXnurseXisXassistingXwithXmass,XcasualtyXtriageXexplosionXatXaXlocalXfactoryXwhichXofXtheXfollowi
ngXclient.XShouldXtheXnurseXidentifyXasXaXpriority.X-
XAXclientXwithXindicationsXofXhypovolemicXshock
AXnurseXisXreceivingXreportXonXforXclientsXwhichXofXtheXfollowingXclientXshouldXtheXnurseXassessXf
irstX-XAXclientXwhoXisXchronicXkidneyXdiseaseXwithXcloudy,XdiasylateXoutflow
AXnurseXisXcaringXforXaXclientXjustXreceivedXtheXfirstXdoseXofXlisinopril.XTheXfollowingXisXappropria
teXnursingXintervention.X-XProvideXstandbyXassistXwithXtheXclientXfromXbed
AXnurseXisXcaringXforXaXclientXwhoXisXinXlabor,XandXisXreceivingXelectronicsXfetalXmonitoring.XTheX
nurseXisXreviewingXtheXmonitorXtracingXinXnotesXearlyXdecelerations,XwhichXofXtheXfollowingXshoul
dXtheXnurseXexpectX-XHeadXcompression
AXnurseXisXcaringXforXaXclientXwhoXhasXchronicXkidneyXdisease.XTheXnurseXshouldXidentifyXwhichX
ofXtheXfollowingXlaboratoryXvaluesXasXanXindicationXofXhemodialysis.X-
XGlomerularXfiltrationXrateXofX14XML/minute
AXnurseXisXcaringXforXanXinfantXwhoXhasXprescriptionXforXcontinuousXpulseXoximetry.XTheXfollo
wingXisXanXappropriateXactionXforXtheXnurseXtoXtake.X-
XHeatXtheXskinXoneXminuteXpriorXtoXplacingXtheXprogram
AXnurseXinXaXmentalXhealthXfacilityXreceivesXaXchangeXofXshiftXreportXonXfourXclientsXwhichXofXthe
XfollowingXclient.XShould XtheXnurseXplanXtoXassessXfirst.X-
XClientXplacedXinXrestraintsXtoXtheXaggressiveXbehavior
AXnurseXworkingXatXtheXclinicXisXteachingXaXgroupXofXclientsXwhoXareXpregnantXonXtheXuseXofXnon
,pharmacologicalXpainXmanagement,XwhichXofXtheXfollowingXstatementXbyXtheXnurseXisXan
, appropriateXdescriptionXofXtheXuseXofXhypnosisXduringXlaborX-
XHypnosisXpromotesXincreaseXcontrolXofXherXpainXperceptionXduringXcontractions
AXnurseXinXaXCountyXJailXhealthXclinicXisXleadingXgroupXtherapyXsession.XAXclientXwhoXwasXincar
ceratedXforXtheftXisXaddressingXtheXgroup.XWhichXofXtheXfollowingXisXanXexampleXofXreactionXform
ation?X-XIXthinkXthatXpeopleXjustXyou'reXjustXlazyXandXshouldXearnXmoneyXhonestly
AXnurseXisXobtainingXaXmedicalXhistoryXofXaXclientXwhoXhasXaXnewXprescriptionXforXIsosorbideXmo
notitrateXwhichXofXtheXfollowingXshouldXtheXnurseXidentifyXasXaXcontraindicationXtoXmedicationX-
Xglaucoma
16X-XNoXquestions
TheXnurseXisXcaringXforXaXclientXrecoveringXfromXanXacuteXmyocardialXinfraction,XwhichXofXtheXfo
llowingXinterventionXshouldXtheXnurseXincludeXinXtheXpointXofXcareX-
XObtainXaXcardiacXrehabilitationXconsult
AXnurseXisXcaringXforXaXclientXwhoXhasXbreastXcancerXandXhasXbeenXcoveringXreceivingXchemoth
erapy,XwhichXofXtheXfollowingXlaboratoryXvalueXshouldXnurseXreportXtoXtheXproviderX-
XWBCX3,000/mm3
HomeXhealthXnurseXisXcarefullyXplannedXforXAlzheimer'sXdiseaseXtoXtheXfollowingXaction.XShouldX
theXnurseXincludeXinXtheXplanXofXcareX-XPlaceXaXdailyXcalendarXinXtheXkitchen
AXnurseXisXperformingXchangeXofXshiftXassessmentsXonXfourXclientsXwhichXofXtheXfollowingXfindi
ngs.XShouldXtheXnurseXreportXtoXtheXproviderXfirst.X-
XClientXwhoXhasXgastroenteritisXandXhisXlethargicXandXconfused
AXnurseXisXcaringXforXaXclientXwhoXisXinXtheXsecondXtrimesterXofXpregnancyXandXaskXhowXtoXtreatX
constipationXwhichXofXtheXfollowingXstatementsXbyXtheXnurseXisXappropriateX-
XDrinkXhotXwaterXwithXlemonXjuiceXeachXmorningXwhenX youXwakeXup
22X-XNoXquestion
AXnurseXisXcaringXforXaXclientXwhoXisXpreparingXhisXadvanceXdirectives,XwhichXofXtheXfollowingXs
tatementsXbyXtheXclientXindicatesXanXunderstandingXofXadvanceXdirectivesXSATAX-
XIXhaveXtheXrightXtoXrefuseXtreatment
MyXhealthXcareXproxyXcanXmakeXmedicalXdecisionsXforXme
AXnurseXisXcaringXforXaXclientXwhoXisX32XweeksXgestationXandXhasXaXhistoryXofXcardiacXdiseaseXw
hichXofXtheXfollowingXpositionsXtoXtheXnurseXplaceXtheXclientXtoXbestXpromoteXoptimal,XcardiacXout
putX-XLeftXlateral
AXnurseXisXcaringXforXaXgroupXofXclientsXwhichXofXtheXfollowingXclient.XShouldXtheXnurseXassigne
dXtoXanXAP.X-
XClientXwhoXhadXaXcerebralXvascularXaccidentXtwoXdaysXago,XandXneedsXhelpXtoileting