A nurse is caring for an adult client who has attempted suicide. The client tells the
nurse he is calling his family to come pick him up. Which of the following actions by
the nurse is appropriate when the client insists on leaving the facility against medical
advice? ✔✔discuss risks associated with leaving
A nurse is caring for a client who is receiving parenteral nutrition through a
nontunneled central venous catheter and reports hearing a gurgling sound on the
side of the catheter. The nurse suspects the catheter has migrated to the jugular vein.
Which of the following actions should the nurse take first? ✔✔stop the infusion
A nurse is reinforcing teaching with the caregiver of a client who has aphasia. The
nurse should include which of the following communication strategies in the
teaching? ✔✔cue client by providing cards that portray common needs
A nurse is caring for a child who is 24 hr postoperative following a supratentorial
craniotomy. The nurse should maintain the child in which of the following positions?
✔✔supine with head of the bed (HOB) elevated to 30 degrees
A nurse working in a hospice facility is talking to a client's son who is distressed
because his mother cries frequently and says she wants to die. Which of the
following responses by the nurse is appropriate? ✔✔"Let's discuss some strategies
you can use when this happens again."
A nurse working in a provider's office is reinforcing teaching with a client who is 14
weeks of gestation. The nurse should instruct the client to immediately notify the
provider if she experiences which of the following? ✔✔Facial edema
A nurse is caring for a child who has leukemia and is prescribed a transfusion of
platelets. Which of the following should the client experience as a result of the
transfusion? ✔✔Reduced bleeding time
A nurse is reinforcing teaching with a client who is prescribed buspirone (BuSpar).
Which of the following statements by the client indicates an understanding of the
teaching? ✔✔"I can have 1-2 alcoholic beverages a week."
A nurse is caring for a school-age child who is newly diagnosed with type 1 diabetes
mellitus. Which of the following actions by the nurse is appropriate to prepare the
child for administration of insulin? ✔✔Allow the child to manipulate the medical
equipment
A nurse is caring for a client who has a urinary tract infection and is prescribed
ciprofloxacin (Cipro). The client exhibits urticaria and angioedema following
administration of the medication. Which of the following is the first action the nurse
should take? ✔✔Determine respiratory status