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D) restlessness
A nurse checks a client who is on a volume-cycled ventilator. Which finding indicates
that the client may need suctioning?
A) drowsiness
B) complaint of nausea
C) pulse rate of 92
D) restlessness
c. Advice the client to maintain bedrest so that safety can be ensured.
, An unlicensed assistive personnel (UAP) is assigned to provide personal care for a
client whose
prescribed activity is bedrest with bedside commode use. The UAP reports to the
nurse that the
client is so obese that the UAP feels unable to safely assist the client in transferring
from the bed
to the bedside commode. How should the nurse respond?
a. Determine the client's level of mobility and need for assistance.
b. Instruct the UAP that all clients deserve equal care.
c. Advice the client to maintain bedrest so that safety can be ensured.
d. Assign another UAP to care for the client
c. Distribute a shopping list of suggested healthy snack items.
A nurse determines that more than 25% of the students at a middle school are
overweight. The
nurse presents the information at the parent-teacher meeting. What action is most
important
for the nurse to include in the meeting?
a. Provide information on ways to increase activity for the family.
b. Have several teachers talk about health risks associated with obesity.
c. Distribute a shopping list of suggested healthy snack items.
d. Determine the parents' degree of concern about their children's weight.
D) Serum potassium 6 mEq/L
, The nurse is reviewing laboratory results on a client with acute renal failure. Which
one of the following should be reported immediately?
A) Blood urea nitrogen 50 mg/dl
B) Hemoglobin of 10.3 mg/dl
C) Venous blood pH 7.30
D) Serum potassium 6 mEq/L
a. Add sterile water to the suction control chamber.
an adult male who fell 20 feet from the roof of this home has multiple injuries,
including a right
pneumothorax. Chest tubes were inserted in the emergency department prior to his
transfer to
the intensive care unit (ICU). the nurse notes that the suction control chamber is
bubbling at the
- 10 cm H2O mark, with fluctuation in the water seal, and over the past hour 75 ml of
bright red
blood is measured in the collection chamber. Which intervention should the nurse
implement?
a. Add sterile water to the suction control chamber.
b. Give blood from the collection chamber as autotransfusion
c. Manipulate blood in tubing to drain into chamber.
d. Increase wall suction to eliminate fluctuation in water seal
A) Hold the tube feeding and notify the provider
Give this one a go later!
The health care provider order reads "aspirate nasogastric feeding (NG) tuber every
4
hours and check pH of aspirate." The pH of the aspirate is 10. Which action should
the
nurse take?
, A) Hold the tube feeding and notify the provider
B) Administer the tube feeding as scheduled
C) Irrigate the tube with diet cola soda
D) Apply intermittent suction to the feeding tube
A) S3 ventricular gallop
Give this one a go later!
The nurse is performing an assessment on a client in congestive heart failure.
Auscultation of the heart is most likely to reveal
A) S3 ventricular gallop
B) Apical click
C) Systolic murmur
D) Split S2
a. Ensure adequate IV and oral fluid intake.
Give this one a go later!
The nurse is caring for a client who is having a sickle cell crisis. What intervention
should the
nurse include in this client's plan of care?
a. Ensure adequate IV and oral fluid intake.
b. Provide ice packs to major joint areas.
c. Space analgesics to prevent addiction to narcotics.
d. Re-enforce the importance of nutritional balance
B) "The tube will remove excess air from your chest."
Give this one a go later!
D) restlessness
A nurse checks a client who is on a volume-cycled ventilator. Which finding indicates
that the client may need suctioning?
A) drowsiness
B) complaint of nausea
C) pulse rate of 92
D) restlessness
c. Advice the client to maintain bedrest so that safety can be ensured.
, An unlicensed assistive personnel (UAP) is assigned to provide personal care for a
client whose
prescribed activity is bedrest with bedside commode use. The UAP reports to the
nurse that the
client is so obese that the UAP feels unable to safely assist the client in transferring
from the bed
to the bedside commode. How should the nurse respond?
a. Determine the client's level of mobility and need for assistance.
b. Instruct the UAP that all clients deserve equal care.
c. Advice the client to maintain bedrest so that safety can be ensured.
d. Assign another UAP to care for the client
c. Distribute a shopping list of suggested healthy snack items.
A nurse determines that more than 25% of the students at a middle school are
overweight. The
nurse presents the information at the parent-teacher meeting. What action is most
important
for the nurse to include in the meeting?
a. Provide information on ways to increase activity for the family.
b. Have several teachers talk about health risks associated with obesity.
c. Distribute a shopping list of suggested healthy snack items.
d. Determine the parents' degree of concern about their children's weight.
D) Serum potassium 6 mEq/L
, The nurse is reviewing laboratory results on a client with acute renal failure. Which
one of the following should be reported immediately?
A) Blood urea nitrogen 50 mg/dl
B) Hemoglobin of 10.3 mg/dl
C) Venous blood pH 7.30
D) Serum potassium 6 mEq/L
a. Add sterile water to the suction control chamber.
an adult male who fell 20 feet from the roof of this home has multiple injuries,
including a right
pneumothorax. Chest tubes were inserted in the emergency department prior to his
transfer to
the intensive care unit (ICU). the nurse notes that the suction control chamber is
bubbling at the
- 10 cm H2O mark, with fluctuation in the water seal, and over the past hour 75 ml of
bright red
blood is measured in the collection chamber. Which intervention should the nurse
implement?
a. Add sterile water to the suction control chamber.
b. Give blood from the collection chamber as autotransfusion
c. Manipulate blood in tubing to drain into chamber.
d. Increase wall suction to eliminate fluctuation in water seal
A) Hold the tube feeding and notify the provider
Give this one a go later!
The health care provider order reads "aspirate nasogastric feeding (NG) tuber every
4
hours and check pH of aspirate." The pH of the aspirate is 10. Which action should
the
nurse take?
, A) Hold the tube feeding and notify the provider
B) Administer the tube feeding as scheduled
C) Irrigate the tube with diet cola soda
D) Apply intermittent suction to the feeding tube
A) S3 ventricular gallop
Give this one a go later!
The nurse is performing an assessment on a client in congestive heart failure.
Auscultation of the heart is most likely to reveal
A) S3 ventricular gallop
B) Apical click
C) Systolic murmur
D) Split S2
a. Ensure adequate IV and oral fluid intake.
Give this one a go later!
The nurse is caring for a client who is having a sickle cell crisis. What intervention
should the
nurse include in this client's plan of care?
a. Ensure adequate IV and oral fluid intake.
b. Provide ice packs to major joint areas.
c. Space analgesics to prevent addiction to narcotics.
d. Re-enforce the importance of nutritional balance
B) "The tube will remove excess air from your chest."
Give this one a go later!
