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A pregnant client, who is originally from another country, is admitted to the hospital in labor. During the admission process, the spouse tells the nurse that the client will not receive any pain medication during the process. The spouse then waits in the waiting room. As the birthing process continues, the nurse asks the client if she needs pain medication. She declines the offer and reminds the nurse by saying, "My spouse told you I cannot have any pain medicine." What is the nurse's best response to the client?

"I want to advocate for you and assist with the pain during this process."

A client with chronic pancreatitis is discharged with a prescription for pancrelipase. Which instruction must the nurse include when providing discharge instructions regarding this medication?

"Swallow this medication whole. Do not chew it."

The nurse providing health promotion education to the parents of a 6-year-old child should include which statements about 6-year-old children in the education?

"They are very sensitive to criticism."

A 33-year-old client reports never having an orgasm. The client's partner is upset about being unable to meet the client's needs. Which interventions should the nurse implement? Select all that apply.

Ask the client if intercourse is enjoyable and if the client feels there is a problem. Assess the couple's sexual history and their perception of the problem.

A child has just returned to the room with a cast on the leg after open reduction of a fractured femur. The nurse notes a 6 cm by 10 cm area of blood on the cast. What is the most important action by the nurse?

Assess vital signs. The most appropriate action for the nurse to take is to assess the client's vital signs for evidence of hemorrhage, such as tachycardia and hypotension. After the nurse has assessed the client, the provider should be notified with the findings. Gauze pads may be placed over the bloody drainage after the client is assessed and the provider notified. The size of the bloody drainage should be monitored after the client is assessed and the provider notified.

Following a client's total hip replacement, what should the nurse do? Select all that apply.

Encourage the client to use the overhead trapeze to assist with position changes. Use a fracture bedpan when needed by the client. When the client is in bed, prevent thromboembolism by encouraging the client to do toe-pointing exercises.

A nurse is caring for a client of the Buddhist faith who is dying. The client's family is at the bedside. Which intervention would the nurse implement to support the client's death with dignity?

Ensure that the room is calm, dimly lit, and quiet. In the Buddhist religion, death is associated with rebirth. To ensure dignity, the environment surrounding the dying client should be serene. Placing the bed to face east, tying sacred threads on the client's wrists, and straightening the arms are actions appropriate for a dying person who follows Hinduism.

A child has just returned to the pediatric unit following placement of a ventriculoperitoneal shunt for hydrocephalus. The child is placed in a supine position. What is the nurse's priority intervention?

Place the child on the side opposite the shunt. Following shunt placement surgery, the child would be placed on the side opposite of the surgical site to prevent pressure on the shunt valve. Intake and output will also need to be assessed, but that is not the nurse's priority. The child is usually on nothing-by-mouth status until the nasogastric (NG) tube is removed and bowel sounds return. Also, pain medication should be administered by an intravenous route initially postoperatively. Teaching, if able, begins preoperatively. If not, teaching is not the first nursing intervention when returning to the pediatric unit.

When caring for a client with quadriplegia, which nursing intervention is the priority?

Preventing atelectasis Clients with quadriplegia have paralysis or weakness of the diaphragm, abdominal, or intercostal muscles. Maintenance of airway and breathing take top priority. Although forcing fluids, maintaining skin integrity, and obtaining adaptive devices for more independence are all important interventions, preventing atelectasis is the priority.

A community health nurse is caring for a Vietnamese client with a diabetic foot ulcer. The client's children, spouse, and best friend are the only people available that speak English. What should the nurse do to provide optimal client care? Select all that apply.

Request that a health related interpreter to come to the home. Utilize a trained telephone interpreter while providing care.

The nurse institutes measures to prevent accidental injury for a client with neurocognitive disorder due to Alzheimer's disease. Which interventions should the nurse perform? Select all that apply.

Stay with the client when the client is ambulating. Have the client wear a medical identification bracelet. Prevent the client from accessing cigarettes and matches.

A client of Hispanic ethnicity has recently immigrated to this country and has been admitted for depression. The nurse documents that the client has poor eye contact during the medication teaching session. What is the most likely reason for the client's behavior?

The client is demonstrating respect for the nurse.

What information should a nurse include when teaching post-circumcision care to the parents of a neonate prior to discharge from the hospital? Select all that apply.

The infant must void before being discharged. Petroleum jelly should be applied to the glans with each diaper change. The circumcision will require care for 2 to 4 days after discharge.

A young Middle Eastern woman's father and brother arrive at the hospital to learn that the physician arrived early and discussed the results of the client's skin biopsy directly with her. They become agitated and begin yelling. The best action for the nurse to take is to:

ask the the father and brother if they would like the physician to meet with the family.

The nurse is interveiwing an adolescent with a new onset of fatigue. What communication strategies will be least effective for the nurse to establish a therapuetic relationship with the adolescent?

asking personal questions unrelated to the situation writing down everything the client says discussing the nurse's own thoughts and feelings about the situation

The nurse is assessing a 2-year-old child's development. What assessment finding would warrant further investigation by the nurse?

having a vocabulary of 100 words A two-year-old should have a vocabulary of 200 words, so a smaller vocabulary could indicate a development delay.

A nurse has an order to start magnesium sulfate on a preterm labor client. The order reads: administer a 4-g bolus over 15 minutes. The nurse has 50 g of magnesium sulfate mixed in 1000 mL of lactated Ringers on hand. How will the nurse set the pump rate to deliver the 4-g bolus? Record your answer using a whole number.

320 (60 minutes)/(1 hour) × (4 g)/(15 minutes) × 1000 mL/50 g = 240,000/750 = 320 mL/hour

The family of a client receiving hospice care takes a dinner break only to learn that the client died while they were absent from the bedside. What should the nurse do to console the family at this time?

Stay with the family while they view the body.

When planning care for a client with osteoarthritis, the nurse should instruct the client to use:

orthotic devices to support involved joints.

The client is Asian and does not speak English. The nurse arranges for the interpreter who can speak the client's dialect and begins the health assessment. The client is describing symptoms as numbness, feeling "hot under the skin," and thinking too much. The nurse should next ask specific questions about which symptom?

pain