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A nurse is assessing a client who has myasthenia gravis. Which of the following client statements should indicate to the nurse that the client needs a referral for occupational therapy?
"I have a hard time with brushing my hair."
A nurse is instructing a client who has a new diagnosis of type 1 diabetes mellitus about the sick- day rules. Which of the following statements by the client indicates an understanding of the teaching?
"I will check my urine for ketones if my blood glucose is greater than 240 mg/dL."
A nurse is assessing an older adult client at a health fair. Which of the following statements by the client is the nurse's priority?
"In the last day, I have had a severe headache and pain around my right eye".
A nurse is caring for a client following a below the knee amputation. The client states, "my life is over". Which of the following responses should the nurse take?
"Would you like to meet with another client who is an amputee?"
A nurse is providing discharge teaching to a client who will be self- administering insulin at home. Which of the following information should the nurse include regarding needle disposal?
"You can discard needles in an empty bleach bottle with a lid."
A nurse is providing instructions to a client who has primary syphilis. Which of the following instructions should the nurse include in the discharge plan?
"You will need three follow-up blood tests within a 24-month period."
A nurse is planning care for a client who is 8 hr. postoperative following a coronary artery bypass grafting. which of the following assessments should the nurse plan to perform first?
Auscultate breath sounds
A nurse is caring for a client following a bronchoscopy. Which of the following action should the nurse take first?
Check the client's gag reflex
A nurse is preparing to administer 1 unit of packed RBCs to an adult client. Which of the following actions should the nurse plan to take?
Complete the transfusion within 2hr
A nurse is teaching a client about using a metered-dose rescue inhaler. which of the following statements should the nurse include in the teaching?
Exhale fully before bringing the inhaler to your lips
A nurse is caring for a client who has hypotension, cool and clammy skin, tachycardia, and tachypnea. In which of the following positions should the nurse place the client?
Feet elevated
A nurse is caring for a client admitted with a skull fracture. which of the following assessment findings should be greatest concern to the nurse?
Glasgow coma scale score changes from 14 to 9
A nurse is caring for a client who is 2 days postoperative following a below the knee amputation and asks about the purpose of maintaining an elastic bandage around the residual limb of the extremity. Which of the following is an appropriate response by the nurse.
Have the client lie prone several times a day
A nurse is admitting a client to a medical unit following placement of a permanent pacemaker. Which of the following requires further assessment by the nurse?
Hiccups
A nurse is caring for a client who is postoperative following a partial thyroidectomy. Which of the following findings is the priority for the nurse to report to the provider?
High-pitched sound on inspiration
A nurse is teaching a client. about the use of the incentive spirometer. which of the following instructions should the nurse include in the teaching?
Hold breaths about 3 to 5 seconds before exhaling
A nurse is assessing a client who has new diagnosis of diabetes mellitus type 1 DM1. Which of the following findings indicate that the client is experiencing hypoglycemia?
Increased perspiration
A nurse is teaching a client who has Grave's disease about recognizing the manifestations of thyroid storm. Which of the following findings should the nurse include in the teaching?
Increased temperature
A nurse is caring for a client who has duodenal ulcer. which of the following actions should the nurse take? (click on the Exhibit button for additional information.)
Infuse packed RBCs
A nurse is preparing to administer daily medications to a client who is undergoing a procedure at 1000 that requires IV contrast dye. which of the following routine medications to give at 0800 should the nurse withhold?
Metformin
A nurse is caring for a client who sustained a spinal cord injury in a driving accident. which of the following actions should the nurse take?
Monitor urine output hourly.
A nurse is caring for a client who is postoperative following a complete thyroidectomy, which of the following findings is the priority for the nurse to report to the provider?
Muscle twitching
A nurse is preparing to administer furosemide to a client who has acute heart failure. Which of the following laboratory results should the nurse identify as a contraindication for receiving the medication?
Potassium 3.2 mEq/L
A nurse is caring for an adolescent client who has an acute kidney injury. Which of the following laboratory findings should the nurse anticipate?
Potassium 6.8mEq/L
A nurse is preparing a client for a lumbar puncture which of the following images indicates the position the nurse should assist the client into for this procedure? This question has a diagram
Side lying
A nurse is planning care for a client who has status epilepticus. Which of the following interventions is the nurse's priority to include?
Turn the client to the lateral position during seizure activity
A nurse in the PACU is assessing a client who is post-operative following general anesthesia. Which of the following findings is the priority to address?
Vomiting upon arousal
A nurse is caring for a client who has hypervolemia. Which of the following is an expected assessment finding?
Weight gain
A nurse is caring for an older adult client who has dementia. Which of the following questions should the nurse ask to assess the client's abstract thinking?
What is meant by the saying "Don't beat around the bush?"
A nurse in a clinic is providing preventive teaching to an older adult client during a well visit. The nurse should instruct the client that which of the following immunizations are recommended for healthy adult after age 60? select all that apply:
a. Herpes Zoster b. Influenza e. Pneumococcal Polysaccharide
A nurse is teaching about measure to prevent recuring urinary tract infections with a female client. Which of the following information should the nurse include in the teaching?
b. drink 3 L of fluids daily c. drink low-fructose cranberry juice f. Wipe the perineal area from front to back after urinating
A nurse is planning care for a client who has a central venous access device for intermittent infusions. Which of the following actions should the nurse include in the plan of care?
flush the catheter using a 10 ml syringe
A nurse is preparing to receive a client from surgery following a transverse colon resection with colostomy placement. The nurse should expect to assess the stoma at which of the following locations? Upper left abdomen (This one is a diagram choose the point on the top left of the abdomen)
on top
A nurse is assessing a client who has an arteriovenous (AV) gas in the left forearm. Which of the following should indicate to the nurse a complication of vascular access?
Absence of a bruit
A nurse is admitting a client to the emergency department after a gunshot wound to the abdomen. Which of the following actions should the nurse take to help prevent the onset of acute kidney failure?
Administer IV fluids to the client
A nurse is planning care for a client who is 1 day postoperative following an open cholecystectomy. Which of the following interventions should the nurse include in the plan of care?
Apply compression stocking to the extremities
A nurse is planning care for a client who has developed nephrotic syndrome. Which of the following dietary recommendations should the nurse include?
Decrease protein intake
A nurse is assessing a client who has a pressure ulcer. Which of the following findings should the nurse expect as an indication the wound is healing?
Dark red granulation tissue
A nurse is caring for a client following a cardiac-catherization who has hives and urticaria following administration of IV contrast dye. Which of the following Medication should the nurse plan to administer?
Diphenhydramine
A home care nurse is to use non-pharmacological pain relief measures for an adult client who has severe chronic back pain. which of the following guideline should the nurse use?
Distraction changes the client's perception of pain but does not affect the cause
A nurse is planning care for an older adult client who has Meniere's disease. Which of the following interventions should the nurse include in the plan?
Encourage the client to change positions slowly.
A nurse is caring for a client who is receiving epidural analgesia. Which of the following assessment finding is the nurse's priority?
Hypotension
A nurse is providing discharge teaching for a client who has a new tracheostomy. Which of the following statements by the client indicates an understanding of the teaching?
I'll insert the obturator after cleaning my stoma
A nurse is planning care for a client who has dementia. Which of the following interventions should the nurse plan to include?
Place the client's bed at the lowest height.
A nurse is caring for a client who has cervical cancer and is receiving brachytherapy. Which of the following actions should the nurse take?
Keep soiled bed linens in the client's room.
A nurse is reviewing ABG results for a client who has COPD. Which of the following should the nurse expect?
PaCO2 48 mm Hg
A nurse is caring for a client who has cervical cancer and a sealed radiation implant. Which of the following actions should the nurse take?
Place long handled forceps at the client's bedside
A nurse in the emergency department is caring for a client who has a gunshot wound to the abdomen. Which of the following action should the nurse take first?
Remove all the client's clothing
A client who is ideal and communicates using sign language is being admitted by a nurse who does not know sign language. Which of the following actions should the nurse take?
Request an interpreter during the initial assessment