Complete the following sentence by using the list of options. - CORRECT ANSWER -The
nurse understAnds thAt the pAtient hAs likely developed Lithium toxicity And will
need to be monitored for seizure Activity
A nurses prepAring to initiAte intrAvenous fluids viA infusion pump to our client. Which of
the following Actions should the nurse tAke?
ObtAin A surge protector thAt cAn AccommodAte the pump And severAl other
AppliAnces
verify thAt the extension cord for the pump is ungrounded
report the pump hAs A frAyed cord And proceed with the infusion
check the expirAtion dAte on sAfety inspection sticker of the pump - CORRECT ANSWER -
check the expirAtion dAte on sAfety inspection sticker of the pump
A nurse is cAring for A client who hAs An implAnted venous Access port. Which of the
following should the nurse use to Access the port?
A non coring needle
An Angio cAtheter
A butterfly needle
A 25 gAuge needle - CORRECT ANSWER -A non coring needle
A nurse is conducting An initiAl Assessment of A client And notices A discrepAncy between
the client's current IV infusion And the informAtion received during the shift report. Which
of the following Actions should the nurse tAke?
,A. ContAct the chArge nurse to see if the prescription wAs chAnged
b. complete An incident report And plAce it in the client's medicAl record
c. submit A written wArning for the nurse involved in the incident
d. compAre the current infusion with the prescription And the client's medicAtion -
CORRECT ANSWER -compAre the current infusion with the prescription And the client's
medicAtion
cAse study - CORRECT ANSWER -cAse study
cAse study, client diAgnosed with schixophreniA - CORRECT ANSWER -indicAted :
- Ask the client About the content of their hAllucinAtions
- instruct the client on expected hygiene prActices
- Access the client for suicidAl ideAtion
contrAindicAted :
- Allow the client to wAtch tv At A high volume
- plAce the client in A room neAr the Activity room
A nurse is cAring for A client who is neAr the end of life And is on A complete bed rest. The
client stAtes thAt he needs to hAve A bowel movement. The nurse offers A bed pAn. The
client stAtes "I ve AlwAys used the bAthroom". Which of the following responses should the
nurse mAke?
A. Tell me whAt concerns you hAve About using A bedpAn
b. mAke sure to use A neArby furniture to support yourself when wAlking to the bAthroom
c. I will hAve the physicAl therApist AmbulAte you to the bAthroom
d. you hAve to use the bedpAn for your own sAfety - CORRECT ANSWER -Tell me whAt
concerns you hAve About using A bedpAn
,A nurse is cAring for A client who is in lAbor. Select the five Actions the nurse should tAke.
A. IncreAse the flow rAte of the mAintenAnce IV fluid
b. hAve the chArge nurse notify the provider
c. plAce the client in A trendelenburg position
d. exert upwArd pressure on the presenting pArt
e. Attempt to push the umbilicAl cord bAck into the cervix
f. Administer oxygen At 10L/min viA non rebreAther fAce mAsk - CORRECT ANSWER -
IncreAse the flow rAte of the mAintenAnce IV fluid
HAve the chArge nurse notify the provider
PlAce the client in A trendelenburg position
Exert upwArd pressure on the presenting pArt
Administer oxygen At 10L/min viA non rebreAther fAce mAsk
A nurse is providing An in service About client evAcuAtion during A fire. Which of the
following client should the nurse instruct the stAff to evAcuAte first?
A. A client who is AmbulAtory And receiving oxygen
b. A client who hAs A frActure in is imbAlAnce suspension trAction
c. A client who is bedridden And weArs A heAring Aid
d.A client who uses A wheelchAir And is confused - CORRECT ANSWER -A client who is
AmbulAtory And receiving oxygen
CAse Study
, client is 4 dAys postpArtum following A cesAreAn birth Assessment findings - CORRECT
ANSWER -MAstitus :
- pAinful tender breAst
- temperAture
- chills
Endometritus :
- foul smelling lochiA
- temperAture
- chills
A nurse is Assessing A client who hAs A possible right pneumothorAx. Which of the following
findings should the nurse expect the?
A. Reduced right sided breAth sounds
b. intercostAl retrActions
c. High pitched stridor
d. pArAdoxicAl chest movement - CORRECT ANSWER -Reduced right sided breAth sounds
Which of the following interventions should the nurse include in the plAn of cAre? Select All
thAt Apply
A. increAse oxygen flow rAte to 4L/min
b. Assess the clients breAth sounds
c. perform chest percussions And vibrAtion
d. Restrict the clients fluid intAke
e. instruct the client to perform diAphrAgmAtic breAthing
f. plAce the client in A supine position - CORRECT ANSWER -increAse oxygen flow rAte to
4L/min