Questions with Detailed Verified Answers
A nurse is assisting with monitoring a client who is in labor and has spontaneous
rupture of membranes following a vaginal examination. The provider reports the
client's cervix is dilated to 1 cm with an unengaged presenting part. Which of the
following actions should the nurse take? Ans: Apply the external fetal heart rate
monitor.
A Nurse is collecting data from a client who has bipolar disorder and is experiencing
acute mania. Which of the following findings is the nurse's priority? Ans: lack of sleep
A nurse is reinforcing teaching with a client who has a type 2 diabetes mellitus and
reports waking during the night with tremors and anxiety. which of the following
information should the nurse provide to help the client manage his symptoms? Ans:
Eat a bedtime snack
a Nurse is reinforcing teaching for a client who has a coronary artery disease and is
taking low-dose aspirin daily. The nurse should include that this medication has which
of the following therapeutic effects for CAD? Ans: Antiplatelet
A nurse is collecting data from a client who has an unprepared femur fracture and
rates his pain as 8 on a scale of 0 to 10. The client is talking and caught with a visitor.
Which of the following of the prescribed medication should the nurse administer?
Ans: Hydromorphone 5 mg orally.
A nurse is reinforcing preoperative teaching with a client scheduled for a bowel
retention with ileostomy. which of the following descriptions should the nurse give of
the expected output from a mature ileostomy? Ans: liquid with little odor
A nurse is caring for a client who is 16 hr postoperative following a total hip
arthroplasty. the client reports numbness, pain, and tingling in the affected leg. Which
of the following actions should the nurse take first? Ans: compare capillary refill in
toes bilateraly
,A nurse is reinforcing teaching with a client who has acute diverticulitis. Which of the
following statements by the client indicates an understanding of the teaching about the
acute phase of diverticulitis? Ans: "I will receive the nutrient I need through my IV
Fluid"
A nurse in reinforcing teaching with a client about cancer prevention. The nurse
should include that frequent consumption of which of the following foods increases the
risk of cancer? Ans: Lamb
A nurse is assisting in teaching a group of staff nurses about hepatitis A. Which of the
following modes should the nurse include as a method of transmitting hepatitis A?
Ans: Consumption of contaminated food.
A nurse is reinforcing teaching with a client who is bottle feeding he full-term newborn
with formula. Which of the following instructions should the nurse include in the
teaching? Ans: Although is is unnecessary to be rigid about feeding times, six to eight
feedings every 24 hrs should support a full-term newborn's nutrition adequately. Fewer
feedings in the initial weeks could delay the estabilment of an adequate weight-gain
pattern.
A nurse is assisting with the plan of care for a client following a transurethral resection
of the prostate. Which of the following interventions should the nurse include in the
plan of care? Ans: The nurse should irrigate the bladder using strict sterile technique
and maintain closed catheter drainage system to minimize the rick of infection.
A nurse is reviewing a client's electronic medical record and finds that an assistive
personnel recorder the client's temperature as 35.3 degrees Celsius (95.5 degrees F) 2
hrs earlier. Which of the following actions should the nurse take firsT? Ans: Check
the client's temperature.
A nurse is receiving change-of-shift report for four clients. Which of the following
clients should the nurse see first? Ans: A client whose urinary output was 100mL for
the past 12 hrs
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, A nurse in reinforcing teaching about weight loss with a female older adult client who
is overweight. Which of the following statements should the nurse include in teaching?
Ans: keep fat intake to no more that 30% of daily caloric intake.
A nurse is collecting data from a client who has iron deficiency anemia. Which of the
following findings should the nurse expect? Ans: Difficulty concentrating.
A Nurse is collecting data from an older adult client who is 48 hr postoperative
following abdominal surgery. The provider writes a prescription to advance the client
to a regular Diet. For which of the following findings should the nurse notify the
provider? Ans: The client has absent bowel sounds.
A nurse is reinforcing discharge teaching with a client who is postoperative following
transurethral resection fo the prostate. Which of the following instructions should the
nurse include in the teaching? Ans: perform Kegel exercises daily.
A nurse is reinforcing teaching about ways to reduce solid fat consumption with a
client who has an elevate cholesterol level. which of the following strategies should the
nurse include in the teaching? Ans: purchase beef that is a loin cut.
A nurse is reinforcing teaching with a client who has a new prescription for prednisone
for the treatment of Addison's disease. which of the following instructions should the
nurse include in the teaching? Ans: You will need to schedule a bone density test.
A nurse is collecting data from a client who has type 2 diabetes mellitus and is
concerned about weight gain during pregnancy. Which of the following responses
should the nurse make? Ans: You weight gain should be the same as for someone
without diabetes.
A nurse is reinforcing teaching with the parent of a preschooler who has lactose
intolerance. Which of the following statements by the parent indicates an
understanding of the teaching? Ans: I should offer my child yogurt that has a probiotic
as a snack.
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