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It expresses your wishes regarding health care when you can
no longer communicate." - ANSWER-A nurse is caring for a
client in a provider's office. The client asks about the purpose
of a living will. Which of the following is the appropriate
response by the nurse?
Wait 5 min after instillation before instilling the drops in the
other eye. -
ANSWER-A nurse is planning to administer an ophthalmic
medication to a client. Which of the following actions will
minimize systemic absorption of the medication?
Don a gown and gloves when providing perineal care. -
ANSWER-A nurse is
caring for a client who has a methicillin-resistant
Staphylococcus aureus
(MRSA) infection. Which of the following actions should the
nurse plan to take?
History of renal calculi - ANSWER-A nurse is reviewing the
medical record of a client who is requesting an oral
,contraceptive. Which of the following findings should the nurse
identify as a contraindication to the use of oral contraceptives?
"I will notify my provider if I develop a tremor." - ANSWER-A
nurse is reinforcing teaching with a client who has a new
prescription for lithium carbonate. Which of the following client
statements indicates an understanding of the teaching?
Cough with hemoptysis - ANSWER-A nurse is caring for
a client who is
undergoing evaluation for a thoracic aortic aneurysm. Which
of the following
findings should make the nurse suspect an impending rupture
of the aneurysm?
The client was not harmed as a result of the incident. -
ANSWER-A nurse collecting data from a client who is receiving
a continuous IV infusion of 0.9% sodium chloride. The nurse
discovers the IV infusion pump was set incorrectly and the
client received 200 mL more than prescribed. Data collection
reveals that the client is stable. The nurse recognizes that this
incident is not considered malpractice for which of the
following reasons?
Prevent the client from leaving the facility. - ANSWER-A nurse
is escorting a client to his car following discharge from an
acute mental health facility. The client states intentions to harm
a friend when he leaves the facility. Which of the following
actions should the nurse take?
,Place the client in a side-lying position. - ANSWER-A nurse is
caring for a client who is 5 days postoperative following
abdominal surgery. The client tells the nurse that he was
coughing and "felt a pop" at the incision site. The nurse
examines the incision and finds wound dehiscence and
evisceration. Which of the following actions should the nurse
take?
Take the child on a tour of the surgery and recovery areas. -
ANSWER-A nurse
is planning to reinforce teaching with a preschooler who is
about to undergo an
incision and drainage for cellulitis on the left arm. Which
of the following
techniques should the
nurse use?
Check the client's vital signs. - ANSWER-A nurse receives a
verbal order for a client to receive a stat dose of meperidine 100
mg PO. She administers the medication, charts the
administration, and then realizes she has administered
phenytoin 100 mg PO. Which of the following actions should
the nurse take first?
Repeat the test on another finger. - ANSWER-A nurse is caring
for a postoperative client and obtains a pulse oximeter reading
of 89%. Which of the following interventions should the nurse
take first?
, withdraw 5 units of regular insulin from the vial. - ANSWER-A
nurse is preparing to administer 5 units of regular insulin and
20 units of NPH insulin to a client who has type 1 diabetes
mellitus. Which of the following actions should the nurse take
first?
Strain the client's urine. - ANSWER-A nurse is caring for a
client who has
urolithiasis. Which of the following actions should
the nurse take?
The mother places the newborn in prone position. - ANSWER-A
nurse is observing the mother of a 12-hr-old newborn. Which of
the following actions by the mother requires intervention by the
nurse?
Sodium level of 130 mEg/L for a client who has bipolar disorder
and takes lithium - ANSWER-A nurse in a mental health facility
is reviewing the laboratory reports for four clients. Which of the
following results should the nurse report to the provider
immediately?
A client who has heart failure and reports severe dyspnea -
ANSWER-After receiving change-of-shift report, which of the
following clients should the nurse collect data from first?
Community-acquired pneumonia - ANSWER-A nurse is
assisting with the admission of a client who has Hodgkin's