Mix

a client who is 24 hour post operative abdominal surgery refuses to ambulate. Which of the following actions should the nurse take first?

Ask the client to rate his pain level management of pain is a priority for encouraging post op activity

A nurse is assessing a preschooler who has cystic fibrosis and has been receiving oxygen therapy for the past 36 hours. which of the following findings should the nurse identify is an indication that the client has developed oxygen toxicity

Bradypnea - due to depression of the respiratiory drive in a client who has chronic hypoxia ( cystic fibrosis )

a nurse is assessing a client who has been taking lithium carbonate for the past month for bipolar disorder. Which of the following assessment findings should the nurse identify as the priority?

Confusion -indicates advance toxicity, coarse hand tremors confusion ecg changes and sedation

A nurse is teaching a client who is postoperative following a total knee arthroplasty and is to receive enoxaparin. The nurse should explain that the purpose of this medication is to prevent which of the following complication.

Deep Vein Thrombosis to prevent deep vien thrombosis duh.

a rn is planning care for a group of clients and is working with a licensed practical nurse LPN and an assistive personnel which of the following task should the RN delegate to the LPN?

Insertion of a nasogastric tube prep of bed/collection stool= ap

a nurse is developing a care plan for a client who is immobile which of the following interventions should the nurse include?

Maintain correct body alignment with the use of trochanter rolls -to prevent external rotation and abduction of the hips which will maintain correct body alignment

a nurse is caring for a client who is sat risk for developing diabetes insipidus the nurse should plan to monitor the client for which of the following?

Polyuria increased output often greater amounts than 4l a day

A nurse gets a call from a person who identifies herself as the clients mother. The caller ask for information about the client but is unable to provide a security password. which of the following actions should the nurse take?

Tell the caller that she cannot give out client information

a nurse is assessing a client who has schizophrenia and is taking chlorpromazine which of the following findings is the priority for the nurse to report to the provider?

Temperature 39.4 C 103 -

A nurse on a peds unit is planning a educational session for staff nurses to teach them about working with parents who children are candidates for organ donation which of the following information should the nurse plan to include?

The family may have the child in an open casket if they wish because organ donation does not disfigure the child's body.

A nurse is caring for a client who is 12 hr post operative is receiving PCA for pain control and requires a blood pressure check in 10 min which of the following staff members should the nurse assign to collect this information

an assistive personnel who is assisting a client to return to bed.

A nurse is planning d/c teaching for a client who has colorectal cancer and is post op following a new colostomy. The client expresses concerns about discharge and states, I have no health insurance and cannot pay for the ostomy supplies. which of the following actions should the nurse plan to take?

arrange for a referral to social services initiate a consult with an enterostomal therapist provide client with info about the american cancer society give client in about local support groups

a nurse is caring for a client who had a recent stroke. Prior to transferring the client to the bedside commode, which of the following actions should the nurse take first?

assess the client for functional limitations

a nurse is providing teaching to a client who has hep a which of the following instructions should the nurse include?

bleach everything

A nurse is caring for a newborn whose parent asks why her baby is receiving K the nurse should explain to the parents that the newborn should receive vitamin k to prevent which of the following

bleeding at birth because the have low levels of k

true labor sign

cervix transitions to anterior position

a nurse is aseessing a client who has schizophrenia nurse should identify the following alteration in speech as which of the following

clang association chooses words based off their sounds

a nurse is caring for a group of clients which of the following clients should the nurse identify is in need of an interdisciplinary care conference?

client with type 1 diabetes and has repeated hospitalizations

a nurs is preparing to administer 2 units of fresh frozen plasma to an older adult client which of the following actions should the nurse plan to take?

enter the plasma product number into the medical record

A nurse is caring for an older adult client who has generalized anxiety disorder and is to begin taking alprazolam. which of the following actions should the nurse take?

fall risk

Acute phase of kawasaki disease s/s

fever unresponsive to antipyretics/tachy/ subacute is pain in the joints/peeling soles and palms

a client is receiving lorazepam iv for panic attacks and develops a respiratory rate of 6/min and blood pressure of 90/44 mmHg which of the following medications should the nurse anticipate administering?

flumazenil - reverses effects of lorazepam and support client respirations with bag valve

a nurse is in an outpatient mental health clinic is working with a client who has ptsd and ask the nurse to recommend a nonpharmological theraoy to provide relief of manifestations which of the therapies should the nurse teach the client to use to help alleviate his distress

guided imagery

A nurse is assessing an adolescent who has sickle cell anemia. The nurse should identify which of the following findings as an indication of vasoocclusive crisis

hematuria resulting from ischemia of the kidneys

a nurse us providing discharge instructions to a client who has a new prescription for warfarin which of the following statesments should nurse identify as indication that the client understands the teaching

i should report a change in my color of stools

a nurse is providing discharge instructions to a client who has a new prescription for amitriptyline to treat depression. The nurse should identify which of the following clients statements indicates an understanding of the teaching

i should watch for common reactions like dry like dry mouth and aconstipation gum

A nurse is caring for a toddler who has infectious gastroenteritis. Which of the following actions should the nurse take?

initiate oral rehydration for the toddler due to diarrhea

a nurse is preparing to administer 15 units of regular insulin and 20 units of NPH insulin which of the following actions should the nurse plan to take?

inject 20 units of air into the NPH insulin vial -

a nurse is caring for a client who has bipolar disorder. The nurse observes that the client is becoming increasingly restless and is pacing the unit, speaking rapidly frequently using profanities and sexual references which of the following actions should the nurse take first?

move client to a quiet place away from others -risk for others

a nurse is caring for a client who is to start taking captopril for a new diagnosis of hypertension. Which of the following task should the nurse delegate to an assisstive personnel?

obtain blood pressure before and after medication administration

a nurse is preparing to admin 2 units of packed rbc to a client who has anemia. which of the following actions should the nurse take prior to initiating the blood transfusion?

obtain venous access using 20 gauge needle or larger

2nd stage pressure ulcer will look like

partial thickness skin loss, blister formation visible subq is ulcer 3

mom wants to stop breastfeeding wants to bottlefeed baby what to do to help prevent discomfort of engorgment

place icepacks to reduce swelling

nurse is caring for a client who had a stroke 6 hours ago. Which of the following interventions should the nurse implememnt to lower the risk of the increased intracranial pressure ICP

place the client in a quiet environment -minimize risk

A nurse is caring for a toddler who is postoperative following a tonsillectomy. Which of the following actions should the nurse take?

position the client so the head is lower than the chest. - place in lateral or prone with head lower than chest to avoid aspiration of saliva or blood from surgical site

A nurse is teaching a female client who has disorder about methadone. which of the following information should the nurse include the teaching

sedation is a common adverse effect of this medication - adverse effects

a nurse acute mental health facility is planning care for an adolescent who has anorexia nervosa which of the following interventions should the nurse include in the clients plan of care?

supervise the client during and after eating possible purging or hiding food

a community health nurse is reviewing the medical records of four clients the nurse should report which of the following clients to the CDC an adolescent client who has foodborne botulism

they can develop dysphagia, dropping eyelids and vision changes in 12 to 36 hours neuro symptoms flaccid prarlysis and cranial nerve impairment

a nurse is assessing a client who has skeletal traction for femur fracture which of the following findings should the nurse identify as the priority?

upper chest petechiae greatest risk to fat embolism syndrome life threatening of fractures