And Answers
IV catheter insertion - ANSWER Preparing a child, inform about discomfort, avoid mummy
restraint
Arteriovenous fistula - ANSWER Report absence of bruit, presence of thrill
Implantable cardioverter defibrillator - ANSWER Understanding includes wearing loose
clothing around ICD
Feelings of ambivalence in pregnancy - ANSWER Nurse should encourage client to describe
feelings
Bowel-training program - ANSWER Include administering rectal suppository in care plan
Pain management in active labor - ANSWER Action includes placing client in a warm shower
Triage after a disaster - ANSWER Assign highest priority to below-the-knee amputation
Belt restraints protocol - ANSWER Guideline includes documenting client's condition every 15
min
Nursing leadership - ANSWER Effective leader acts as an advocate for the nursing unit
Diabetes mellitus plan of care - ANSWER Hba1c 10% indicates a need to revise the plan of
care
Notifiable infectious disease - ANSWER Chlamydia is a nationally notifiable infectious disease
Group facilitation techniques - ANSWER Include using modeling to help clients improve
interpersonal skills
, Orthodox Judaism practices - ANSWER Include providing unleavened bread during Passover
Pulmonary embolism treatment effectiveness - ANSWER Less anxiety reported by the client
indicates effectiveness
Diazepam overdose - ANSWER Administer flumazenil to the client
Cocaine use - ANSWER Expect elevated temperature in a client who used cocaine
Newborn blood glucose level - ANSWER Expect jitteriness with a blood glucose level of 30
mg/dl
Health care proxy - ANSWER Proxy should make health care decisions regardless of client's
ability
PACU nausea management - ANSWER First action should be turning the client on their side
Depression crisis management - ANSWER First action should be confirming the client's
perception of the event
Bipolar disorder acute mania - ANSWER Document the client's condition every 15 minutes
when using restraints
LPN delegation in medical-surgical unit - ANSWER Delegate a postoperative client with NG
tube set to continuous suction
Paraplegic client care plan - ANSWER Include shifting weight every 15 min while sitting in the
care plan
Pudendal block - ANSWER Pain-management option for a client dilated to 10 cm and pushing