Fundamentals 1
A nurse is caring for a child who is postoperative following a tonsillectomy. Which of the following actions should the nurse take?
Administer analgesics to the child on a routine schedule throughout the day and night.
A nurse is assessing the heart sounds of a client who has developed chest pain that becomes worse with inspiration. The nurse auscultates a high-pitched scratching sound during both systole and diastole with the diaphragm of the stethoscope positioned at the left sternal border. Which of the following heart sounds should the nurse document?
Pericardial friction rub
A nurse is providing teaching to a client who has heart failure about how to reduce his daily intake of sodium. Which of the following factors is the most important in determining the client's ability to learn new dietary habits.
The involvement of the client in planning the change
a nurse is teaching an assistive personnel about proper hand hygiene. Which of the following statements by the AP indicates an understanding of the teaching?
There are times I should use soap and water rather than an alcohol-based hand rub to clean my hands.
A nurse is caring for a client who is unstable and has vital signs measured every 15 minutes by an electronic blood pressure machine. The nurse notices the machine begins to measure the blood pressure at varied intervals and the readings are inconsistent. Which of the following actions should the nurse take?
disconnect the machine, manually every 15 minutes
A nurse is teaching a group of older adults about expected changes of aging. Which of the following statements by a group member indicates that the teaching has been effective?
I should expect my heart rate to take longer to return to normal after exercise as I get older.
A nurse is caring for a client who is postoperative and has paralytic ileus. Which of the following abdominal assessments should the nurse ex
Absent bowel sounds with distention
A nurse is caring for a client who reports abdominal pain. An assessment by the nurse reveals the client has a temperature of 39.2 heart rate of 105/min, a soft contender abdomen, and menses overdue by 2 days. Which of the following findings should be the nurse's priority?
temperature
A nurse is planning to obtain vitals signs of a 2 year old child who is experiencing diarrhea and who might have a right ear infection. Which of the following routes should the nurse use to obtain the temperature
temporal
A nurse is witnessing a client sign an informed consent form for surgery. which of the following describes what the nurse is affirming by this action
the signature on the preoperative consent form is the clients