A nurse in an emergency department is caring for a client. The nurse should first _______, followed
by_________ - ANS -Review the medications that may be causing the client's confusion.
-Using alternative methods to keep the client safe.
A nurse is preparing to obtain a client's vital signs. Which of the following actions should the nurse take
when washing their hands? - ANS Turn off the faucet with a clean paper towel after drying hands.
A nurse is collecting data from a client who has an NG tube set to low intermittent suction. Which of the
following finding indicates hypomagnesemia? - ANS Positive Chvostek's sign
A nurse is preparing to document information about a client's lower legs, which are swollen with 6 mm
edema. Which of the following information should the nurse document? - ANS 3+ pitting edema
A nurse is caring for a group of clients in a long-term care facility. Which of the following actions should
the nurse take to prevent health care-associated infections for these clients? (Select all that apply.) -
ANS -Wash hands after removing gloves
-Use antimicrobial hand gel after refilling a client's water pitcher
-Clean the stethoscope with an antimicrobial wipe after obtaining vital signs
A nurse is checking a client for a pulse deficit after detecting an irregular heart rate. Which of the
following actions should the nurse take? - ANS Count the client's radial and apical pulse simultaneously
with another nurse.
A nurse is contributing to the plan of care for a client who practices Islam. Which of the following
questions should the nurse ask the client to clarify the client's religious preferences? - ANS Do you
consume pork products?
, A nurse is reviewing the medical record of a female client who has heart failure. The nurse should
identify which of the following laboratory results as an indication that the client has fluid volume
excess? - ANS BUN 8 mg/dL (10 to 20 mg/mL)
A nurse is caring for a client who has chronic pain. The nurse recommends that the client concentrate on
a memory of a pleasurable experience. Which of the following complementary therapies is the nurse
suggesting? - ANS Guided imagery
A nurse is collecting data from a client who is 2 days postoperative following a colostomy placement.
Which of the following findings should the nurse report to the provider? - ANS A purple-colored stoma
A nurse is contributing to the plan of care for a client who has a new prescription for a wrist restraint.
Which of the following actions should the nurse include in the plan of care? - ANS Pad bony
prominences on the wrist.
A nurse is preparing to administer a medication to a preschooler and must convert the child's weight
from pounds to kilograms. The child weights 30 lbs. How many kilos does the child weigh? - ANS 13.6
(divide 30/2.2)
A nurse is contributing to the plan of care for a client who is dying. Which of the following interventions
should the nurse recommend to include the client's family in the plan of care? (Select all that apply.) -
ANS -Keep the family updated about the client's status
-Encourage the family to comb the client's hair.
-Tell the client's family what to expect as the client's death nears.
A nurse is caring for client who has prescription for a potassium supplement. The client tells the nurse
that the pill is too large to swallow and refuses to take it. The nurse offers to break the pill into two
smaller pieces. The nurse is demonstrating which of the following ethical principles? - ANS Beneficence