comprehensive review

The nurse is caring for a client with Clostridium difficile infection. Prior to entering the room, which step would the nurse take? Put on a gown. Apply a face mask. Put on goggles. Apply foot protection.

Put on a gown.

A client has been admitted for a scheduled bunionectomy. The client has presented the nurse with a detailed interdisciplinary care plan based on internet research that the client has conducted. What is the nurse's best initial response to this client? Affirm the client's efforts to engage in their healthcare. Educate the client about the fact that the care team normally creates the care plan. Assess the client for potential nonadherence to prescribed treatments. Compare and contrast the client's care plan with standard preoperative care.

Affirm the client's efforts to engage in their healthcare.

A nurse is conducting a cancer risk screening program. Which client is at greatest risk for skin cancer? 45-year-old health care worker 15-year-old high school student 30-year-old butcher 60-year-old mountain biker

60-year-old mountain biker

The nurse is caring for a young child on the oncology unit who has developed thrombocytopenia after cancer treatment. What is the priority action for the nurse to implement when caring for this client? Assess for signs of infection. Ensure a safe environment. Plan for extra nap times. Encourage high-protein foods.

Ensure a safe environment.

A nurse in the pediatric intensive care unit is caring for the only survivor of a house fire that killed seven people. Reporters from local newspapers and television stations are at the hospital, trying to obtain information about the child's condition. How should the nurse best handle this situation? The nurse may not disclose information regarding the child's condition. The nurse may disclose the child's condition, but not the child's name. The nurse may make a statement about how sad she feels for the child's family and friends. The nurse should contact a lawyer because of the legal issues involved in caring for the child.

The nurse may not disclose information regarding the child's condition.

Before performing an otoscopic examination on a child, where should the nurse palpate for tenderness? tragus, mastoid process, and helix helix, umbo, and tragus tragus, cochlea, and lobule mastoid process, incus, and malleus

ragus, mastoid process, and helix

Which health-promoting activity should the nurse teach the client who recently underwent a laryngectomy? Cleanse the mouth three times a day. Avoid taking tub baths. Develop an aggressive program of exercise to increase airway functioning. Dehumidify the air for comfort.

Cleanse the mouth three times a day.

Thirty people are injured in a train derailment. Which client should be transported to the hospital first? a 20-year-old who is unresponsive and has a high injury to his spinal cord an 80-year-old who has a compound fracture of the arm a 10-year-old with a laceration on his leg a 25-year-old with a sucking chest wound

a 25-year-old with a sucking chest wound

The nurse is caring for a child with a life-threatening illness. The parents of the child want to introduce acupuncture and herbal medicines into the treatment regime. What is the most effective way for the nurse to react to this request? Have the family discuss the options with the physician. Suggest that the family speak with others who have used those options. Discourage the family from interfering with the prescribed treatments. Help the family perform an internet search to learn more about the options.

Have the family discuss the options with the physician.

A child with a body surface area (BSA) of 0.82 m2 has been prescribed actinomycin 2.5 mg/m2intravenously. What is the correct amount to be given? Record your answer using two decimal places.

2.05

The nurse is providing care for a client with a tracheotomy whose pulse oximeter has recently alarmed, showing the oxygen saturation to be 77%. The nurse has repositioned the client and applied supplemental oxygen, interventions that have raised the oxygen levels to 80% and somewhat decreased work of breathing. The client is not in immediate distress, and level of consciousness remains high. The nurse should page which practitioner? respiratory therapist physical therapist physician occupational therapist

respiratory therapist

The nurse is completing discharge teaching with a client who had a long hospital stay. The client gives the nurse a handmade sweater for the personal nursing care. What is the best response by the nurse? Select all that apply. "I cannot take this gift while I am at work." "Maybe I can meet you for coffee next week." "My hospital has a policy that does not allow a nurse to accept gifts." "Thank you for recognizing my work, I will enjoy wearing this sweater." "I appreciate the gift but it not appropriate for me to take a personal gift."

"My hospital has a policy that does not allow a nurse to accept gifts." "I appreciate the gift but it not appropriate for me to take a personal gift."

The mother of a neonate expresses concern about how to continue breastfeeding when she returns to work in 6 weeks. How should the nurse respond? "It's a challenge now, but you'll be an expert at breastfeeding by then!" "If things get difficult, don't feel guilty if you need to supplement with formula." "Speak to your employer to see if they'll allow you time to express milk while you're at work." "You can develop and practice a plan now for expressing milk and feeding so you're ready."

"You can develop and practice a plan now for expressing milk and feeding so you're ready."

A client is transferred to the intensive care unit after evacuation of a subdural hematoma. Which nursing intervention reduces the client's risk of increased intracranial pressure (ICP)? encouraging oral fluid intake suctioning the client once each shift elevating the head of the bed 90 degrees administering a stool softener as ordered

administering a stool softener as ordered

The health care provider (HCP) prescribes a serum lithium level tomorrow for a client with bipolar disorder, manic phase, who has been receiving lithium 300 mg PO three times daily for the past 5 days. At what time should the nurse plan to have the blood specimen obtained? before bedtime after lunch before breakfast during the afternoon

before breakfast

A nurse should expect to administer which medication to a client with gout? aspirin furosemide colchicine calcium gluconate

colchicine

Which night clothes would the nurse recommend for an infant with atopic dermatitis? a diaper and short-sleeved shirt one-piece cotton pajamas with long sleeves two-piece flannel pajamas with short sleeves a woolen sleeper with feet and mittens

one-piece cotton pajamas with long sleeves

A client is scheduled for a renal arteriogram. No allergies are recorded in the client's medical record, and the client is unable to provide allergy information. During the arteriogram, the nurse should be alert for which assessment finding that may indicate an allergic reaction to the dye used? psoriasis hypoventilation pruritus nausea

pruritus

A nurse is assigned to care for a postoperative client with diabetes mellitus. During the assessment interview, the client reports that he's impotent and says he's concerned about the effect on his marriage. In planning this client's care, the most appropriate intervention would be to encourage the client to ask questions about personal sexuality. provide time for privacy. provide support for the spouse or significant other. suggest referral to a sex counselor or other appropriate professional.

suggest referral to a sex counselor or other appropriate professional.

A nurse inadvertently gives a client a double dose of an ordered medication. After discovering the error, whom should the nurse notify first? the client the prescriber the pharmacist the risk manager

the prescriber

A client diagnosed with an empyema is scheduled for a thoracentesis. The nurse should prepare the client for this procedure with which action? Position the client sitting upright on the edge of the bed and leaning forward. Start a peripheral I.V. line and administer the necessary sedative drugs. Prepare to transport the client to the catheterization laboratory. Remove the water pitcher and remind the client not to eat or drink anything for 6 hours.

Position the client sitting upright on the edge of the bed and leaning forward.

While assessing a multigravid client at 10 weeks' gestation, the nurse notes a purplish color to the vagina and cervix. The nurse documents this as what finding? Goodell's sign Chadwick's sign Hegar's sign melasma

Chadwick's sign

A client in home hospice care verbalizes to the caregiver a desire to meet with the client's minister. The caregiver does not want the minister to visit or to interact with the minister because of different values and beliefs and asks the home health nurse how to handle this situation. To prevent further disagreement between the client and caregiver, what is the best recommendation for the nurse to implement? Explain to the caregiver how to be assertive without being insensitive to the client's wishes. Arrange for an alternative caregiver to be available for the client when the minister visits. Discuss other options for spiritual counseling that may be appropriate to the client and caregiver. Resolve with the client and caregiver the concerns related to the minister making a home visit.

Arrange for an alternative caregiver to be available for the client when the minister visits.

The nurse is monitoring a client who appears to be hallucinating. The client displays paranoid speech content, seems agitated, and gestures at a figure on the television. Which nursing interventions are appropriate? Select all that apply. In a firm voice, instruct the client to stop the behavior. Reinforce that the client is not in any danger. Acknowledge the presence of the hallucinations. Instruct other team members to ignore the client's behavior. Delegate client assessment to a licensed practical/vocational nurse Use a calm voice and simple commands.

Acknowledge the presence of the hallucinations. Use a calm voice and simple commands. Reinforce that the client is not in any danger.

A client had surgery 6 hours ago. The client has a prescription for a narcotic for pain every 3 to 4 hours. The last dose was administered at 1500. When the nurse enters the room at 1800, the client is restless and grimacing. What action should the nurse take first? Ask the unlicensed assistive personnel (UAP) to help reposition the client. Administer the narcotic to relieve the pain. Assess the client to determine the cause of the grimacing. Turn the lights down to minimize the client's restlessness.

Assess the client to determine the cause of the grimacing.

A client is about to have a tympanoplasty and asks the nurse what the surgical procedure involves. What should the nurse do first when answering the question? Assess the client's understanding of what the healthcare provider has explained. Describe the surgical procedure. Tell the client that the procedure will close the perforation and prevent recurrent infection. Explain that the procedure will improve hearing.

Assess the client's understanding of what the healthcare provider has explained.

The nursing student is having difficulty obtaining a mobile computer for the purpose of administering medications using the electronic medical record. The student has been reprimanded for delivering medications late in the past and wants to ensure timely administration. What action should the student take? Print a copy of the medication record at the nurse's station to use at the bedside in order to administer the medications on time. Use the medication dispensing terminal to prepare the medications, and print a dispensing receipt to use for patient identification at the beside. Speak to the instructor about the unavailability of mobile computers for medication administration, and request assistance in obtaining one. Wait for a mobile computer to become available, and explain to the instructor that the reason for late administration was related to adhering to safety policy.

Speak to the instructor about the unavailability of mobile computers for medication administration, and request assistance in obtaining one.

A nurse is caring for a 5-year-old child who's in the terminal stages of cancer. Which statements are true? Select all that apply. The parents may be at different stages in dealing with the child's death. The child is thinking about the future and knows he may not be able to participate. The dying child may become clingy and act like a toddler. Whispering in the child's room will help the child to cope. The death of a child may have long-term disruptive effects on the family. The child does not fully understand the concept of death.

The parents may be at different stages in dealing with the child's death. The dying child may become clingy and act like a toddler. The death of a child may have long-term disruptive effects on the family. The child does not fully understand the concept of death.

A client with bladder cancer had the bladder removed and an ileal conduit created for urine diversion. While changing this client's pouch, the nurse observes that the area around the stoma is red, weeping, and painful. What should the nurse conclude? The skin wasn't lubricated before the pouch was applied. The pouch faceplate doesn't fit the stoma. A skin barrier was applied properly. Stoma dilation wasn't performed.

The pouch faceplate doesn't fit the stoma.

A nurse is teaching child care classes for adolescent parents. To enhance the adolescents' understanding of infant safety, the nurse would suggest that the parent: discuss infant safety with the pediatrician. review a video about pregnancy prevention. crawl around on the floor looking for potential hazards from the viewpoint of an infant. attend a lecture about poison control.

crawl around on the floor looking for potential hazards from the viewpoint of an infant.

A client with deep vein thrombosis suddenly develops dyspnea, tachypnea, and chest discomfort. What should the nurse do first? Elevate the head of the bed 30 to 45 degrees. Encourage the client to cough and deep breathe. Auscultate the lungs to detect abnormal breath sounds. Contact the health care provider (HCP).

Elevate the head of the bed 30 to 45 degrees.

The home care nurse is conducting a follow-up visit to a client who was recently discharged to home with intermittent total parental nutrition (TPN) therapy. What statement by the client leads the nurse to determine that additional teaching is needed? "I will change the I.V. administration tubing every week." "If the catheter dressing becomes loose, I will change the dressing." "I will wash my hands prior to initiating my nightly TPN." "I will avoid catheter contact with lint-producing materials."

"I will change the I.V. administration tubing every week."

A client who is recovering from a subtotal gastrectomy experiences dumping syndrome and is to eat six small meals a day. The client asks the nurse, "When will I be able to eat three meals a day again like I used to?" Which response by the nurse is most appropriate? "Eating six meals a day is time-consuming, isn't it?" "You will have to eat six small meals a day for the rest of your life." "You will be able to tolerate three meals a day before you are discharged." "Most clients can resume their normal meal patterns in about 6 to 12 months."

"Most clients can resume their normal meal patterns in about 6 to 12 months."

The nurse is to administer 1,200 mg of an antibiotic. The drug is prepared with 6 g of the drug in 2 mL of solution. The nurse should administer how many milliliters of the drug? Record your answer using one decimal place.

0.4

The nurse receives a prescription for amoxicillin 80 mg/kg/day to be administered in two divided does to an infant who weighs 19 lb 8 oz (9 kg). The medication is supplied as 250 mg/ml. How many milliliters should the nurse administer for one dose? Record your answer using one decimal place.

1.4

The health care provider (HCP) prescribes an intravenous infusion of 5% dextrose in 0.45 normal saline to be infused at 2 mL/kg per hour in an infant who weighs 9 lb (4.1 kg). How many milliliters per hour of the solution should the nurse infuse? Round to one decimal place.

8.2

The nurse is assessing a client who has been experiencing black stools for the past month. The client suddenly reports chest and stomach pain. What is the most important action by the nurse? Administer oxygen via nasal cannula Assess the client's vital signs Initiate cardiac monitoring Draw blood for laboratory analysis

Assess the client's vital signs

Glulisine insulin is prescribed to be administered to a client before each meal. To assist the day-shift nurse who is receiving the report, the night-shift nurse gives the morning dose of glulisine. When the day-shift nurse goes to the room of the client who requires glulisine, the nurse finds that the client is not in the room. The client's roommate tells the nurse that the client "went for a test." What should the nurse do next? Bring a small glass of juice, and locate the client. Call the client's health care provider (HCP). Check the computerized care plan to determine what test was scheduled. Send the nurse's assistant to the X-ray department to bring the client back to his room.

Check the computerized care plan to determine what test was scheduled.

A nurse is preparing for the discharge of a neonate born 7 weeks premature. The neonate has had several apneic episodes and will need a home apnea monitor but will require no other specialized care. Which nursing diagnosis is most appropriate for the neonate's parents? Risk for aspiration related to nil orally status. Deficient knowledge related to ventilatory support. Deficient knowledge related to lack of exposure to apnea monitor. Deficient knowledge related to inability to cope.

Deficient knowledge related to lack of exposure to apnea monitor.

A client is in the withdrawn phase of catatonia due to schizophrenia. This is the client's first admission to an early psychosis program at an urban hospital. At present, the client is completely stuporous. What is the priority while giving care to the client during this phase of symptoms? Explain all physical care activities in simple, explicit terms as though expecting a response. Maintain a quiet atmosphere, speaking as little as possible to the client. Provide as much sensory stimulation as possible using conversation, radio, and television. Ask the client to do exactly the opposite of what is desired.

Explain all physical care activities in simple, explicit terms as though expecting a response.

The nurse is assigned the care of a client with acute renal failure and hypernatremia. Which actions can be delegated to the unlicensed assistive personnel (UAP)? Select all that apply. Monitor for dehydration. Obtain and monitor vital signs. Administer IV fluid. Oral care every 4 hours. Urinary catheter insertion.

Oral care every 4 hours. Obtain and monitor vital signs.

When preparing a client for surgery to treat appendicitis, the nurse formulates a nursing diagnosis of Risk for infection related to inflammation, perforation, and surgery. What is the rationale for choosing this nursing diagnosis? Obstruction of the appendix may increase venous drainage and cause the appendix to rupture. Obstruction of the appendix reduces arterial flow, leading to ischemia, inflammation, and rupture of the appendix. The appendix may develop gangrene and rupture, especially in a middle-aged client. Infection of the appendix diminishes necrotic arterial blood flow and increases venous drainage.

Obstruction of the appendix reduces arterial flow, leading to ischemia, inflammation, and rupture of the appendix.

A nurse is caring for a client admitted with pernicious anemia. Which set of findings should the nurse expect when assessing the client? Pallor, bradycardia, and reduced pulse pressure Pallor, tachycardia, and a sore tongue Sore tongue, dyspnea, and weight gain Angina pectoris, double vision, and anorexia

Pallor, tachycardia, and a sore tongue

Which intervention should the nurse anticipate using when caring for a term neonate diagnosed with transient tachypnea at 2 hours after birth? Monitor the neonate's color and cry every 4 hours. Feed the neonate with a bottle every 3 hours. Obtain extracorporeal membrane oxygenation equipment. Provide warm, humidified oxygen in a warm environment.

Provide warm, humidified oxygen in a warm environment.

A preschool-age child presents to the emergency department. His father tearfully reports that his son was on his shoulders in the driveway playing when he began to fall. When the child began to fall, the father grabbed him by the leg, swinging him toward the grass to avoid landing on the pavement. As the father swung his son, the child hit his head on the driveway and twisted his right leg. After a complete examination, it is determined that the child has a skull fracture and a spiral fracture of the femur. Which action should the nurse take? Restrict the father's visitation. Notify the police immediately. Refer the father for parenting classes. Record the father's story in the medical record.

Record the father's story in the medical record.

The nurse is supervising a student nurse who is performing tracheostomy care for a client. Which action performed by the student would require nurse intervention? Change soiled tracheostomy ties and secure tube in place. Suction tracheostomy tube before performing tracheostomy care. Remove inner cannula and clean using universal precautions. Replace inner cannula and clean stoma site.

Remove inner cannula and clean using universal precautions.

Which statement regarding heart sounds is correct? S1 and S2 sound equally loud over the entire cardiac area. S1 is fainter at the apex, and S2 is loudest at the base. S1 is loudest at the base, and S2 is loudest at the apex. S1 is loudest at the apex, and S2 is loudest at the base.

S1 is loudest at the apex, and S2 is loudest at the base.

A client is on a stretcher and needs to be transported to another location. Which action should the nurse take to prevent a personal injury when transporting this client? Stand at the head of the stretcher and push the device. Stand at the foot of the stretcher and pull with the arms. Stand at the side of the stretcher and push with the arms. Stand at the foot of the stretcher and pull the client's feet.

Stand at the head of the stretcher and push the device.

A child, who uses an inhaled bronchodilator only when needed for asthma, has a best peak expiratory flow rate is 270 L/min. The child's current peak flow reading is 180 L/min. How does the nurse interpret this reading? The child's asthma is under good control, so the routine treatment plan should continue. The child needs to use a short-acting inhaled beta2-agonist medication. This is a medical emergency requiring a trip to the emergency department for treatment. The child needs to use inhaled cromolyn sodium.

The child needs to use a short-acting inhaled beta2-agonist medication.

The nurse has given a client a nitroglycerin tablet sublingually for angina. Which vital signs should be assessed following administration of nitroglycerin? pulse rate oxygen saturation respiratory rate blood pressure

blood pressure

While caring for a just born female term neonate, the nurse observes that the neonate's clitoris is enlarged and there is some fusion of the posterior labia majora. The nurse should notify the health care provider because these findings are associated with which problem? renal disorders Potter's syndrome ambiguous genitalia Turner's syndrome

ambiguous genitalia

When the nurse talks with a client with multiple sclerosis who has slurred speech, which nursing intervention is contraindicated? encouraging the client to speak slowly encouraging the client to speak distinctly asking the client to repeat indistinguishable words asking the client to speak louder when tired

asking the client to speak louder when tired

A competent client in a long-term care facility refuses to take oral diuretic medication. The nurse informs the client that if the medication isn't taken, restraints will be applied, and the medication will be given by injection. Which legal tort best describes this nurse's statement? assault battery negligence autonomy

assault

A client is diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH). The nurse informs the client that the physician will order diuretic therapy, restrict fluid intake, and provide sodium replacement to treat the disorder. If the client does not comply with the recommended treatment, which complication may arise? cerebral edema hypovolemic shock severe hyperkalemia tetany

cerebral edema

A nurse is reviewing the medication list of a client who presents with slow, involuntary muscle spasms of the arms and legs and twisting of the neck. The nurse reviews the client's prescriptions for which medication that could correlate with these symptoms? diazepam haloperidol amitriptyline hydrochloride clonazepam

haloperidol

Which vaccine should a nurse encourage a client with chronic obstructive pulmonary disease (COPD) to receive? Select all that apply. varicella influenza hepatitis B pneumonia pertussis

influenza pneumonia pertussis

A client who was recently hospitalized has constipation related to the medical regimen. Which medication may contribute to this problem? folic acid iron potassium vitamin E

iron

Which statement indicates that the client with diabetes insipidus understands how to manage care? The client will: maintain normal fluid and electrolyte balance. select a diabetic diet correctly. state dietary restrictions. exhibit serum glucose level within normal range.

maintain normal fluid and electrolyte balance.

A full-term client is admitted for an induction of labor. The health care provider (HCP) has assigned a Bishop score of 10. Which drug would the nurse anticipate administering to this client? oxytocin 30 units in 500 ml D5W prostaglandin gel 0.5 mg misoprostol 50 mcg dinoprostone 10 mg

oxytocin 30 units in 500 ml D5W

A client with acquired immunodeficiency syndrome is receiving zidovudine. Which laboratory value indicates an adverse reaction to zidovudine? red blood cell (RBC) count of 1.8 million/μl (1.8 million x 10 to the 12th/L) fasting blood glucose of 104 mg/dl (5.8 mmol/L) serum calcium level of 8.9 mg/dl (2.2 mmol/L) platelet count of 240,000/mm3

red blood cell (RBC) count of 1.8 million/μl (1.8 million x 10 to the 12th/L)

A nurse is caring for a client who had an ileal conduit 3 days earlier. Which assessment finding, if made by the nurse, would indicate a need for a further consultation with the enterostomal nurse? beefy red stoma site stoma site not sensitive to touch red, sensitive skin around the stoma site clear mucus mixed with yellow urine drained from the appliance bag

red, sensitive skin around the stoma site

A young adult is admitted for elective nasal surgery for a deviated septum. Which sign would be an important indicator of bleeding even if the nasal drip pad remained dry and intact? presence of nausea repeated swallowing rapid respiratory rate feelings of anxiety

repeated swallowing

The nurse is suctioning a client's tracheostomy. For what reason during the procedure does the nurse complete the above action? to loosen the client's thick, tracheal secretions to regulate the suction pressure to clear secretions from the tubing to lubricate the outside of the suction catheter

to clear secretions from the tubing

A client is admitted and has a history of combat-related post-traumatic stress. At night the client experiences nightmares and declines anxiolytics, replying that only privacy is needed to perform Reiki treatment. What is the nurse's best response? "Can you explain to me how you use Reiki?" "Reiki cannot help with post-traumatic stress." "You need someone else to perform Reiki." "Research is recommending medical marijuana."

"Can you explain to me how you use Reiki?"

The nurse is caring for a recently circumcised newborn. Based on the progress note, what would be the most appropriate nursing intervention?2/10 0800Progress Note TabThree-day-old male, two days post-circumcision by Mogen clamp. Small amount of yellow-white exudate noted around glans. No bleeding or swelling noted. Axillary temp 36.4° C (97.5° F). Nursing eagerly, latching on well. Voided x4 post-circ. Provide routine care to the circumcised area. Wrap the neonate in two additional blankets. Take the neonate's temperature every hour for the first 24 hours. Give the neonate a pacifier to help soothe the pain

Provide routine care to the circumcised area.

An Orthodox Jewish pregnant woman comes to the labor and birth suite with her birth attendant. Her partner is also present in the room. The woman is about to give birth when the nurse observes the partner move to the head of the bed outside the view of the birth. The nurse interprets this action as: reflecting of the couple's religious beliefs and practices. demonstrating a lack of interest in the birth of the baby. indicating the husband's anxiety related to the process of labor and birth. reflecting the cultural position of the husband as the head of the house.

reflecting of the couple's religious beliefs and practices.

A client's arterial blood gas analysis reveals an excess of carbon dioxide. The nurse should recognize that this is consistent with which condition? metabolic acidosis metabolic alkalosis respiratory acidosis respiratory alkalosis

respiratory acidosis

A client who survived a hemorrhagic stroke now demonstrates a speech disability. What is the best response when the home care nurse observes the spouse speaking for the client and finishing the client's sentences? "Although it takes time for your spouse to communicate to you and to others, it is important not to speak for your spouse." "Remember to use a regular tone of voice when you help your spouse speak so your spouse can clearly understand the answers." "I am wondering if you are concerned about your spouse's cognitive ability, as you seem to frequently speak for your spouse." "Today I noticed that you are speaking for your spouse, and it would be helpful to have practice conversations with your spouse."

"Although it takes time for your spouse to communicate to you and to others, it is important not to speak for your spouse."

A school nurse is conducting a seminar for parents of preschool children on the prevention of head injuries. What is the most appropriate information for the nurse to give the parents? Children should always be supervised by an adult when playing. Safety gates should be installed at staircases at home. Children should always wear helmets when riding bicycles. Children should be accompanied by an adult when crossing the street.

Children should always wear helmets when riding bicycles.

A registered nurse is staff-shared to the maternal-neonatal unit where the RN has never worked before. How can this nurse be best employed? Assign the RN to the labor and delivery area. Assign the RN to the nursery. Use the RN as a nursing assistant in the postpartum unit. Assign the RN a client care assignment in the postpartum unit.

Assign the RN a client care assignment in the postpartum unit.

The chare nurse is observing care for a client on a psychiatric floor diagnosed with suicidal ideations. The client is lying in bed in the hospital room. Which observation would cause the charge nurse to intervene? Unlicensed assistive personnel closing the client's door to allow for uninterrupted rest. Licensed practical nurse documenting the client's whereabouts every 15 minutes. Security personnel inspecting all items visitors bring to the client's room. Registered nurse asking to inspect the client's mouth after taking oral medications.

Unlicensed assistive personnel closing the client's door to allow for uninterrupted rest.

The nurse observes that the client's total parenteral nutrition (TPN) solution is infusing too slowly. The nurse calculates that the client has received 300 mL less than was prescribed for the day. The nurse should: increase the flow rate to infuse an additional 300 mL over the next hour. maintain the flow rate at the current rate and document any discrepancy in the chart. assess the infusion system, note the client's condition, and notify the health care provider. discontinue the solution and administer dextrose in 5% water until the infusion problem is resolved.

assess the infusion system, note the client's condition, and notify the health care provider.

After a 3-month trial of dietary therapy, a client with type 2 diabetes still has blood glucose levels above 180 mg/dl (9.99mmol/L). The physician adds glyburide, 2.5 mg P.O. daily, to the treatment regimen. The nurse should instruct the client to take the glyburide: at breakfast. in mid-morning. 30 minutes after dinner. at bedtime.

at breakfast.

When instructing a client about the proper use of condoms for pregnancy prevention, the nurse should include which instructions to ensure maximum effectiveness? Place the condom over the erect penis before coitus. Withdraw the condom after coitus when the penis is flaccid. Ensure that the condom is pulled tightly over the tip of the penis before coitus. Obtain a prescription for a condom with nonoxynol 9.

Place the condom over the erect penis before coitus.

A client has an open cholecystectomy with bile duct exploration. Following surgery, the client has a T tube. What should the nurse do to determine the effectiveness of the T tube? Irrigate the tube with 20 mL of normal saline every 4 hours. Unclamp the t-tube and empty the contents every day. Assess the color and amount of drainage every shift. Monitor the incision sites for bile drainage.

Assess the color and amount of drainage every shift.