Funds

A nurse is collecting data from a client. Which of the following statements by the nurse reflects the communication technique of clarifying?

"It sounds like your pain is intermittent"

The nurse enters A clients room and find smoke coming from under the bed. What sequence of actions should the nurse take In this situation?

1. Movie client out of the room 2. Pool to get fire alarm 3. Shut all surrounding windows and doors 4. Attempt to put out the smoke with a fire extinguisher

After collecting data from a client, the nurse documents 1+ pedal edema bilaterally. This indicates the nurse observed an indentation of which of the following depths after applying pressure?

2 mm

In nurses can portray out this post operative tonsillectomy.Which of the following actions should the nurse take?

Administer analgesics to the child on a routine throughout the day and night

A nurses admitting a client who has measles. Which of the following types of transmission precautions should the nurse initiate?

Airborne

Eggers is getting for a client who has methicillin-resistant Staphylococcus (MRSA). Which of the following precautions should the nurse implement?

Apply a gown when in the clients room

A nurse is reinforcing teaching with the client about lifestyle changes to manage a chronic illness. Which of the following strategy should the nurse use first to helpThe client make a commitment to these lifestyle changes

Assist the client to identify ways that these changes will result in positive personal outcomes.

Nurse is caring for a client was admitted to a long-term care facility for rehabilitation after a total hip arthroplasty. Which of the following time should the nurse begin assisting with discharge planning.

At the time of admission

A nurse is taking a clients vital signs. Which of the following findings is outside of the expected reference range?

BP 144/90 mmhg

Nurses collecting baseline data of a client peripheral Vascular system. Which of the following location should the nurse palpate the posterior tibial pulse?

Below the medial malleolus

Energy skiing for a client who was transferred to the surgical unit by structure from the PACU. Which of the following actions should the nurse perform first after the transfer?

Check the patient's vital signs

A nurse document clubbing of the fingernails for a client who has emphysema.The nurse should identify which of the following is the underlying case of this funding?

Chronic hypoxemia

A nurse is assisting with the admission interview for a client. Which of the following items of data should the nurse collector and introduction phase of the interview?

Clients comfort and ability to participate in the interview

A nurse is assisting with teaching Licensed nurse about pain management and clients age 65 and older. Which of the following pieces of information should the nurse include?

Clients who are age 65 and older are reluctant to report pain

Nurses contributing to the plan of care for client who has had a stroke and is scheduled to receive feedings via gastrostomy tube. Which of the following actions should the nurse recommend prior to initiating each feeding?

Elevate the head of the bed

Anders is preparing to administer liquid medication for my bottle to a client. Which of the following actions should the nurse take?

Hold a medication bottle with the label against the palm of the hand when pouring

A nurses caring for client was a terminal illness. The family wants to care for the client at home. Which of the following statements indicates that the nurse understands family centered care?

Let's set up a meeting time with the doctor to discuss your options for home-care.

During the insertion of a urinary catheter for client, the tip of the catheter brushes against the nurses arm. Which of the following actions should the nurse take?

Obtain a new catheter and reattempt insertion

A nurses osculating the heart sounds of the client list developed chest pain that worsens with inspiration. The nurse hears a High pitched scratching sound with the diaphragm of the stethoscopePlaced at the third intercostal space of the left sternal border. Which of the following part sounds should the nurse documents?

Pericardial friction rub

A nurse is collecting data about a client's periphery all pulses. Which of the foreign description should the nurse used to document the findings?

Periphery all pulses bilaterally symmetric, equal and strong in all four extremities

Nurse is changing the dressings for a client who is three days postoperative following a cholecystectomy. The nurseObservesYellow, six drainage on the dressing. The nurse to document this finding as which of the following types of drainage?

Purulent exudate

A nurse is planning to administer pain medication to a client who has had post operative pain following abdominal surgery. Which of the following actions should the nurse take first?

Use the pain scale to determine the clients level of pain

Anderson performing a straight urinary catheterization for a female who has urinary retention. Which of the following actions indicates the nurse is maintaining sterile technique?

Wiping the labia minora in an anteroposterior direction

A nurse is collecting data about clients respiratory system.Which of the following breath sounds should the nurse expect to hear over the periphery of the major lung fields?

vesicular

A nurse is assisting with discharge teaching for a client Who has type II diabetes mellitus. The client expresses concerns about cooking an appropriate diet for her diabetes due to her cultural beliefs and preferences. Which of the following responses should the nurse provide?

"The dietitian will help you choose foods that meet both your cultural and health acquirements"

A nurse is collecting data regarding a clients nutritional status during a community health screening. The nurse determines the client is consuming 500 cal per dayMore than his energy level requires.When will the client have gained 4.5kg or 10 pounds

10 weeks

A nurse finds a client sitting on the floor by the toilet in the bathroom adjacent to theRoom.He stated he's fun after slipping on the tile floor, but is having difficulty getting up.Which of the following action should the nurse take first?

Collect data from the client about any health alterations before, during, or after the fall

The nurse is assisting with the admission of a client who undergo a craniotomy. During the procedure phase of the nursing process, which of the following areas should the nurse contribute?

Establish client outcomes

A nurse is discussing fire safety with newly hired nurses. Which of the following actions is the priority for workers in the healthcare setting?

Evacuate clients from the unit

A nurses praying to measure client what pressure with a sphygmomanometer in her and the stethoscope. Which of the following actions should the nurse take?

Have a client place both feet flat on the floor

A nurse in an urgent care center is caring for a 15-year-old client whose symptoms suggest a sexually transmitted infection. The clients parent is unavailable, but the clients grandmother accompanied the client to the clinic. Which of the following actions should the nurse take?

Have the adolescent sign the consent form

A nurse is reinforcing teaching with a middle adult client about disease prevention and health maintenance. Which of the following diagnostic tests should the nurse recommended as part of the routine health screening for women ages 50-64 years old of age

I examine nation every two years

A nurse is reviewing the use of side rails with an administrative personnel.Which of the following statements by the AP indicates that further instruction is required?

I should not have all four side rails up in less there's a prescription order for restraints

A nurse on a medical surgical floor is caring for a client who develops deep, rapid respirations. Arterial blood gas analysis includes the following values: pH 7.25, PaCo2 40, AND hC03- 18. Which of the following acid-base imbalances should the nurse identify and report to the provider?

Metabolic acidosis

Innerst monitoring a clients laboratory results. Which of the following results should the nurse report to the provider?

Potassium 3.0 mEq/L

A nurse is collecting data from a client and admission. The client reports a latex allergy. Which of the following precautions should the nurse takes when caring for this client?

Wrap IV tubing with tape

The nurses preparing to administer a policy to a client for an NG tube and observes that the unit Mark on the tube has since moved since the last feeding. Which of the following action should the nurse plan to take?

Requests an x-ray of the clients abdomen

A nurse is reviewing a clients laboratory report. The clients ABG Levels are pH 7.5, PaCO2 32 mmhg, snd HC03-24 mEq/L. The nurse should determine that the client has which of the following acid-base imbalances?

Respiratory alkalosis

Nurse at A screening clinic is collecting data for a client who reports a history of heart murmur related to aortic valve stenosis. Which of the following anatomical areas should the nurse Placed the stethoscope to auscultate the aortic valve?

Second intercostal space to the right of the sternum

A nurse is reinforcing teaching with a client about a surgical procedure that she will undergo later in the day. The client states that no one has spoken to her about the procedure before. Which of the following actions should the nurse take?

Stop reinforcing the teaching and check with the surgeon about the informed consent