passpoint review- unit 2

Which client is the best candidate for a vaginal birth after a caesarean (VBAC)?

client who had a breech presentation in her last pregnancy, and this pregnancy is a vertex pregnancy

A client with an intravenous line in place states having pain at the insertion site. Assessment of the site reveals a vein that is red, warm, and hard. Which actions would the nurse take? Select all that apply.

Discontinue the infusion at the affected site. Apply warm soaks to the intravenous site. Document the assessment, nursing actions taken, and the client's response.

A client who weighs 187 lb (85 kg) has an order to receive enoxaparin 1 mg/kg. This drug is available in a concentration of 30 mg/0.3 mL. What dose would the nurse administer in milliliters? Record your answer using two decimal places.

0.85

A nurse is caring for a newborn of a mother who is positive for group B streptococcus (GBS). Which interventions will the nurse include in the infant's plan of care? Select all that apply.

Monitor for temperature instability. Watch for apnea lasting longer than 20 seconds. Assess for signs of respiratory distress.

A client comes to the clinic for a routine checkup. To assess the client's gag reflex, the nurse should use which method?

Place a tongue blade lightly on the posterior aspect of the pharynx.

A nurse is caring for a terminally ill cancer client who is being transferred to hospice care. Which information regarding hospice care would the nurse include in the teaching plan? Select all that apply.

The focus of care is on controlling symptoms and relieving pain. A multidisciplinary team provides care. Bereavement care is provided to the family.

A health care provider (HCP) is calling the pediatric unit and asking the nurse to go into the medical record for test results of a fellow pediatrician. How should the nurse respond to this request?

Verify that the caller is the HCP of record or has a need to know.

The triage nurse in the emergency department must prioritize the care of children waiting to be seen. Which child is in the greatest need of emergency medical treatment?

a 6-year-old with a fever of 104° F (40° C), a muffled voice, no spontaneous cough, and drooling

When performing Leopold's maneuvers on a primigravid client, the nurse is palpating the uterus as shown. Which maneuver is the nurse performing?

third maneuver

Which situation demonstrates correct principles of confidentiality?

An emergency department nurse reports suspected child abuse.

A nurse completes an afternoon assessment of a client who is a nurse and who is visiting the area on vacation. The client states that the nurse must be having a busy shift and asks about the maximum number of clients that the nurse is allowed to care for. What is the nurse's best response?

"Some jurisdictions have staffing laws that allow for nurses to be involved in staffing ratios."

A physician orders diazepam, 10 mg I.V., for a client experiencing status epilepticus. Which statement about I.V. diazepam is true?

It should be administered no faster than 5 mg/minute in an adult.

A nurse is accompanying a client to the mall to do some shopping. A neighbor of the nurse approaches and tries to engage the nurse in conversation. What would be the most appropriate response by the nurse to the neighbor?

"Now is not a good time to talk. I will telephone you later."

The nurse manager has assigned a nurse as the circulating nurse for a surgical abortion. The nurse has a religious objection and wishes to refuse to participate in an abortion. What should the nurse manager of the operating room do?

Change the assignment without comment.

A nursing supervisor asks a pediatric nurse to work temporarily (float) in the intensive care unit (ICU) because there are few clients in the pediatric unit. The pediatric nurse has never worked in ICU and has no intensive care experience. Which action should this nurse take?

Notify the nursing supervisor that the pediatric nurse feels unqualified and untrained for the assignment.

Two parents who are arguing in their infant's room, with voices raised and getting louder, start to hit each other. The infant is crying. Which action should the staff nurse take next?

Remove the infant from the room.

Which client would be most appropriate for the nurse to assign to an unlicensed assistive personnel (UAP) for morning care?

an elderly client with chronic obstructive pulmonary disease (COPD) who is receiving oxygen therapy for mild dyspnea

A client hasn't voided since before surgery, which took place 8 hours ago. When assessing the client, a nurse will

palpate the bladder above the symphysis pubis.

A client is receiving 1 L of 0.9% sodium chloride IV to be infused for 12 hours. The IV infusion set has a drop factor of 15 gtt/ml. At how many drops per minute should the nurse set the IV to infuse? Record your answer using a whole number.

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A client is brought to the emergency department with abdominal trauma following an automobile accident. The vital signs are heart rate, 132 bpm; respirations, 28 breaths/min; blood pressure, 84/58 mm Hg; temperature, 97.0° F (36.1° C); oxygen saturation 89% on room air. Which prescription should the nurse implement first?

Administer 1 liter 0.9% saline IV.

A client has a plural chest tube following removal of the lower lobe of the lung. Two days after surgery, the tube is accidentally pulled out of the chest wall. What should the nurse do first?

Apply an occlusive dressing such as petroleum jelly gauze.

A client states, "If my heart stops beating, I do not want to be resuscitated." Which action would the nurse take?

Ask if the client discussed this with the healthcare provider.

A client presents to the emergency department with symptoms of wheezing, coughing, edema of the lips, tongue, and palate. The client's significant other states they decided to try lobster for the first time. The health care provider suspects an immunoglobulin E (IgE) mediated food allergy. Place the steps that the nurse should do in the correct order. All options must be used.

Assess the client's airway. Start an intravenous line. Administer an antihistamine. Document the food allergy. Teach the client how to use an EpiPen autoinjector.

A nurse is caring for a client with type 2 diabetes who has had a myocardial infarction (MI) and is reporting nausea, vomiting, dyspnea, and substernal chest pain. Which is the priority intervention?

Control the pain and support breathing and oxygenation.

Which intervention is essential when performing dressing changes on a client with a diabetic foot ulcer?

using sterile technique during the dressing change

A client with ascites is experiencing severe respiratory distress and refuses endotracheal intubation. What should be the nurse's first action?

Determine whether the client is competent to make the decision.

When providing discharge instructions to a client being discharged from the hospital, the nurse knows that specific interventions can promote cost-effective care. Which intervention(s) is appropriate during discharge teaching? Select all that apply.

Discuss the importance of filling new prescriptions and taking them as prescribed. Ensure that the client has a follow-up appointment scheduled with the primary care provider prior to discharge. Confirm that the client has the means (financial, transportation) to get new prescriptions and to attend appointments. Educate the client on signs and symptoms that may be experienced and which level of care is appropriate for those situations.

A client is diagnosed with herpes simplex. Which statement about herpes simplex infection is true?

During early pregnancy, herpes simplex infection may cause spontaneous abortion or premature birth.

The emergency department nurse is admitting a client who does not speak English. The client is accompanied by the client's adult son, who does speak English. The client appears to be in pain, but the nurse is unable to assess the character or history of the client's pain because of the language barrier. How should the nurse best communicate with the client?

Enlist the help of a hospital interpreter; ask the client's son to translate if none is readily available.

The nurse is assessing the ears of an infant. What will the nurse do to best visualize the tympanic membrane?

Grasp the auricle with the nondominant hand, and pull down and back.

The nurse is caring for a client with a vascular implantable device (VID) or port-a-cath who needs a blood withdrawal for laboratory studies. The VID has been accessed. Place the steps in order that the nurse will perform them to withdraw blood from this client's VID. All options must be used.

Perform hand hygiene and don gloves. Clean the needleless cap with approved antiseptic solution. Connect a sterile syringe and unclamp the catheter. Draw appropriate amount of waste based on facility policy and remove syringe. Connect new sterile syringe and draw minimum amount of blood required for specimen. Flush VID with 0.9% sodium chloride or heparin according to facility policy.

A breastfeeding client is seen at home by the visiting nurse 10 days after a vaginal birth. The client is reporting a warm, red, painful breast, a temperature of 100° F (37.7°C), and flulike symptoms. What should the nurse do?

Refer the woman to her health care provider (HCP).

A registered nurse (RN) instructs the unlicensed assistive personnel (UAP) to check the urine intake and output (I&O;) on clients on the oncology unit at the end of the 8-hour shift. It is important for the nurse to instruct the UAP to do what?

Report back to the nurse immediately if any client has an output less than 240 mL.

If a client is receiving rescue breaths, and the chest wall fails to rise during cardiopulmonary resuscitation, what should the rescuer do first?

Reposition the airway.

The nurse is providing discharge teaching for a client with rheumatic endocarditis but no valvular dysfunction. On which nursing diagnosis should the nurse focus her teaching?

Risk for infection

A nursing student sees a nurse self-injecting medication in the nurses' locker room. The nurse tells the nursing student that students are not allowed to be the nursing staff locker room. What are the best actions for the nursing student? Select all that apply.

Talk with the nursing instructor about what happened on that same day. Ask the nurse manager what to do about what happened on that same day.

A student nurse working with a registered nurse is assessing a child with epiglottitis. The student nurse tells the child that she must look into his/her throat. Which intervention by the registered nurse is most appropriate?

Tell the student nurse that the anesthesiologist will visually examine the child's throat.

The registered nurse (RN) is teamed with a licensed practical/vocational nurse (LPN/VN) in caring for a group of cardiac clients on a pediatric unit. Which action by the LPN/VN indicates the nurse should intervene immediately?

The LPN/VN assists a child to the bathroom 2 hours after a cardiac catheterization.

A nurse admitted a client with ulcerative colitis. A case manager is visiting the client and wants to discuss care. What is the nurse's understanding of the case manager?

The case manager collaborates care among all health care partners with the client in the center.

A nurse is working on a medical unit at a hospital with an ethics review board. Which situation(s) would be appropriate for the nurse to forward for ethics committee review? Select all that apply.

The child of Jehovah Witness parents being refused lifesaving blood transfusions. A client whose last drink was 4 months ago placed on the liver transplant list. The comatose client with a feeding tube and no advanced directive whose children want it removed and spouse does not.

A primigravida at 8 weeks' gestation tells the nurse that she wants an amniocentesis because there is a history of hemophilia A in her family. The nurse informs the client that she will need to wait until she is at 15 weeks' gestation for the amniocentesis. Which is the most appropriate rationale for the nurse's statement regarding amniocentesis at 15 weeks' gestation?

The volume of amniotic fluid needed for testing will be available by 15 weeks.

The nurse is planning care for a group of clients. Which client should the nurse identify as needing the most assistance in accepting being ill?

a 60-year-old woman diagnosed with chronic obstructive pulmonary disease who refuses to wear an oxygen mask even though poor oxygenation makes her confused

The nurse would question the prescription for a fetal scalp electrode on which client?

client with an HIV infection

The nurse is planning the care of a client with schizophrenia. The nurse understands that the client will need the most extensive laboratory monitoring regiment if which medication is prescribed?

clozapine

A client with hypertrophic cardiomyopathy (HCM) is experiencing dyspnea, chest pain, syncope, fatigue, and palpitations and has an apical systolic thrill and heave, fourth heart sound (S4), and systolic murmur. Which nursing diagnosis should the nurse use to guide this client's care?

decreased cardiac output

A nurse identifies a client's responses to actual or potential health conditions during which step of the nursing process?

diagnosis

A nurse is developing a nursing diagnosis for a client. Which information should be included?

factors influencing the client's condition

The nurse is educating parents of a child diagnosed with seasonal allergies. The nurse discusses therapeutic management of the child's allergies and works with the parents to set goals that best support a quality childhood experience. Which of the following goals is most important for the nurse to set with the parents?

identifying ways to reduce the child's exposure to the allergens

The nurse is evaluating a client who is using a flow incentive spirometer (see figure) following abdominal surgery 1 day ago. The client is performing the procedure correctly when the client does what? Select all that apply.

inhales for 3 seconds following fully expanding the lungs coughs after using the spirometer exhales passively before using the spirometer again sits upright

Several clients have been admitted to the emergency department. The nurse should assess these clients in which order from first to last? All options must be used.

the client who is 6 months of age with diarrhea and dehydration the client who is 12 years of age with a fractured tibia the client who is 8 years of age with small lacerations to legs and arms the client who is 16 years of age with a "sore throat"

A physical therapist has instructed the nursing staff on how to perform range-of-motion (ROM) exercises for an infant with torticollis. The nurse is uncomfortable when the infant cries and grimaces during the exercises. What is the most important action for the nurse to take?

Call the physical therapist.

Using the nursing process to make ethical decisions involves following several steps. Which step is the nurse implementing when the nurse reflects on the decision-making process and the role it will play in making future decisions?

evaluating

Which is an advantage of using biologic burn grafts such as porcine (pigskin) grafts? Porcine grafts:

promote the growth of epithelial tissue.

A client is refusing to take the prescribed oral medication. Which measure by the nurse can be used to get the client to take the medication? Select all that apply.

suggesting a liquid form of the medication instead of a pill asking the client the reason for not taking the medication explaining the purpose of the medication to the client

A client in a long-term care facility signed a form requesting not to be resuscitated. The client develops pneumonia, and the client's health rapidly deteriorates. The client is no longer competent, but the family wants everything possible done for the client. When the family asks the nurse what will be done, what is the best response by the nurse?

"We will continue to use antibiotics to treat the pneumonia."

Ear drops have been prescribed to be instilled in the adult client's left ear to soften cerumen. To position the client, what should the nurse do?

Pull the auricle lobe up and back.

A nurse is caring for a client with advanced heart failure. The client can't care for themself and hasn't been able to eat for the past week because of dyspnea. The client doesn't want a feeding tube inserted and expresses their desire for "nature to take its course." The client's family is pleading with the client to have a feeding tube inserted. What is the most appropriate action for the nurse to take?

Talk with the client's family about the client's right to decide for themself.

A triage nurse is completing an initial assessment of several clients in the waiting room. Which client would the nurse see first?

a client with uterine contractions who reports "they are getting stronger and closer now"

There has been a car accident involving four vehicles on a remote highway. The nearest emergency department is 15 minutes away. Which victim should be transported by helicopter rather than an ambulance to the nearest hospital?

a middle-aged female with cold, clammy skin; heart rate of 120 bpm; and is unconscious

An apartment fire spreads to seven apartment units. Victims suffer burns, minor injuries, and broken bones from jumping from windows. Which client should be transported first?

a middle-aged man with no injuries who has rapid respirations and coughs

Which guidelines define and regulate what the nurse may and may not do as a professional?

nurse practice act

A child is admitted to the pediatric unit with a fracture of the hip. The physician orders Russell traction. This type of traction is

skin traction applied to a lower extremity, with the extremity suspended above the bed.

The nurse is prioritizing care for several clients. Which client should the nurse assess first?

the client with stridor who just received the first dose of an antibiotic

The nurse is suctioning a client's tracheostomy. For what reason during the procedure does the nurse complete the above action?

to clear secretions from the tubing

A primigravid client with diabetes at 38 weeks' gestation asks the nurse why she had a fetal acoustic stimulation during her last nonstress test. Which should the nurse include as the rationale for this test?

to startle and awaken the fetus

The unlicensed assistive personnel (UAP) approaches the nurse and states, "The client doesn't know what caused him to be so depressed. He must not want to tell me because he doesn't trust me yet." In responding to this staff member, which statement by the nurse will help the UAP understand the client's illness?

"Endogenous depression is biochemical and isn't caused by an outside stressor or problem. The client can't tell you why he's depressed because he really doesn't know."

The neonate has a prescribed IV rate of 8 mL/h. Fluid totals are recorded every 2 hours on the even hours. There is a new prescription written at 1030 to decrease the IV rate to 6 mL/h. How many mL will be added to the recorded total at 1200? Record your answer using a whole number.

13

The client's order is for 5 units of regular insulin and 10 units of NPH (neutral protamine Hagedorn) insulin given as a basal dose. The client also is to receive an amount prescribed from the medium-dose sliding scale (shown image) based on morning blood glucose levels. The current bedside blood glucose measurement is 264 mg/dL (14.7 mmol/L). How many total units of insulin would the nurse administer to the client? Record your answer using a whole number.

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A 9-year-old is brought to the emergency department with extensive burns sustained in a restaurant fire. What is the nurse's most important intervention?

Conduct a wound assessment.

The nurse meets with the family of a 3-year-old child who is seriously ill. What is the most important role of the nurse as collaborator?

Coordinates the multidisciplinary services and provides information about them.

A client is stabilized in the emergency department and moved to the neurologic intensive care unit with a diagnosis of spinal cord injury at level C4-C5. The nurse is working with an experienced unlicensed assistive personnel (UAP). Which items can the nurse delegate to the UAP? Select all that apply.

Ensure that oxygen is flowing at 5 liters per minute by nasal cannula. Check the client's pulse oximetry reading every 1 hour.

A client with cancer of the stomach tells the nurse, "I cannot bear the pain anymore. Please give me some poison to free myself from this agonizing pain." The nurse faces a value conflict. Which is true in such a condition?

Human need may affect the values conflict.

A nurse working in the operating room is assigned to the suite where therapeutic abortions are to be performed throughout the day. The nurse feels that participation in these procedures conflicts with personal religious beliefs. What should the nurse do after notifying the operating room supervisor?

Remain in the operating room suite until another nurse arrives to take that assignment.

The nurse is working in a hospital. Which examples of a nurse executing a healthcare provider's orders are correct? Select all that apply.

The nurse repeats back the healthcare provider telephone order. The nurse accepts a fax order for bisacodyl 10mg suppository now. The nurse clarifies a medication dose of metoprolol 200mg intravenous as needed for systolic blood pressure > 160mmHg.

A student nurse is questioning a nursing instructor about the responsibility to have malpractice insurance. The nursing instructor confirms the safeguard of malpractice insurance by emphasizing which points regarding student liability? Select all that apply.

The student nurse is responsible for the student nurse's actions. The student nurse is held to the same standard of care as a nurse. The nursing instructor can be liable if the assignment is above the student's competency.

A nurse is planning care for a hospitalized school-age child and is delegating care to a pediatric care assistant. When a nurse delegates a task to an unlicensed assistive personnel (UAP), which factor is most important?

The task is appropriate for that individual's preparation.

A client has just undergone a bronchoscopy. Which nursing interventions are appropriate after this procedure? Select all that apply.

Withhold food and fluids until the client's gag reflex returns. Assess for hemoptysis and frank bleeding. Monitor the client's vital signs.

The health care provider (HCP) is calling in a prescription for ampicillin for a neonate. What should the nurse do? Select all that apply.

Write down the prescription. Repeat the prescription to the HCP over the telephone. Ask the HCP to confirm that the prescription is correct.

A healthcare agency has set a plan to apply for accreditation. A nurse on the accreditation committee has been assigned to audit clients' medical records for appropriate documentation. What information would the nurse assess in the audit?

evidence that nursing interventions have been evaluated in terms of the client's response

A nurse manager is implementing a plan to improve the use of standard precautions by the staff on the unit. After collecting observational data on the staff's use of personal protective equipment, which behavior would the nurse manager identify as an indication of the need for education? Select all that apply.

use of gowns when caring for every client use of sterile gloves for urine specimen collection recapping of needles after use

A nurse is caring for a client who is at high risk for developing pneumonia. Which intervention should the nurse include on the client's care plan?

using strict hand hygiene

The nurse working in a critical care unit is a caring for a client that experiences respiratory arrest. In what order will the nurse respond? All options must be used.

Call for emergency help. Begin emergency resuscitation. Document the resuscitation. Complete an incident report. Alert the family to the event. Restock the room with emergency equipment.

A client with a long history of paranoid schizophrenia is readmitted voluntarily after missing his last two injections of haloperidol. He reports, "I'm not sleeping much, and my friend says I smell from not showering. God is telling me to protect myself from others. My parents are sick and tired of me and my illness. They wish I were dead." Which admission notes by the nurse contains assumptions and potentially false accusations? Select all that apply.

Client has been noncompliant with his medications, causing decreased sleep and activities of daily living, increased auditory hallucinations, and paranoid delusions about his parents harming him. Client has missed two doses of haloperidol. He is not sleeping and showering. Has a strained relationship with his parents and delusions that they want him dead. Voluntary admission to restart haloperidol. Client admitted for noncompliance with haloperidol injections, sleep disturbance, poor hygiene, auditory hallucinations, and suspiciousness of his parents. Needs to be monitored for suicidal and homicidal ideation. Client admitted because of hallucinations and delusions. His parents may be abusing him. He states he has not taken his medications for 2 days.

A nurse is caring for a 9-year-old child who is scheduled for surgery. The parents ask the nurse not to tell the child about the surgery until leaving for the operating room. What response best demonstrates the nurse's role in supporting the child's rights?

"It's important to tell your child about the surgery to allow time for any questions to be answered."

The nurse is called to the telephone to answer questions regarding a client's condition. The facility has a policy about one designated person who is the client's point of contact. How should the nurse respond to the caller? Select all that apply.

"Please tell me the established password for communication." "Why don't you call the family about your questions?" "If you are not the designated person for communication, then I cannot give you information now."

An anxious client who suffered an acute myocardial infarction is transferred from the coronary care unit to the telemetry unit. The client asks the charge nurse if they can have the same nurse care for them every day. How should the charge nurse respond?

"We will try to assign you the same nurse as often as possible."

The nurse is making assignments for the next shift. Which client can be assigned to a licensed practical nurse/licensed vocational nurse (LPN/LVN)? Select all that apply.

A client who needs assistance with colostomy irrigation A client who is receiving glargine subcutaneously

A nurse is taking care of two clients who have a prescription to receive a blood transfusion of packed red blood cells at the same time. The first client's blood pressure dropped from the preoperative value of 120/80 mm Hg to a postoperative value of 100/50 mm Hg. The second client is hospitalized because he developed dehydration and anemia following pneumonia. After checking the patency of their IV lines and vital signs, what should the nurse do next?

Call for and hang the first client's blood transfusion.

A nurse is caring for a woman who gave birth to her baby boy 2 hours ago. The nurse notes the woman's perineal pad contains some small clots and a moderate amount of lochia has accumulated under her buttocks. What is the first action the nurse should take at this time?

Check fundus for position and consistency.

The nurse is administering a medication to a client with myeloid leukemia and does not know the use, dose, or side effects. To obtain the most up-to-date information about this drug, what should the nurse do?

Consult the drug guide provided by the clinical agency.

A nurse is caring for a client who has several medications ordered to treat the diagnosed condition. The client is refusing the medications, stating that the benefits do not outweigh the side effects. What is the nurse's best response to this situation?

Consult with the prescribing physician.

A nurse is caring for a newborn who has developed sepsis. The health care provider has given the following orders. Which order will the nurse implement first?

Obtain blood cultures.

While receiving phototherapy, a neonate begins to have frequent, loose, watery, green stools and is very irritable. The nurse interprets this as which situation?

This is a normal adverse effect of phototherapy.

The nurse is working on a birthing unit that has several unlicensed assistive personnel (UAP). The nurse should instruct the UAP assigned to several clients in labor to notify the nurse if the UAP notes any of the clients have which finding?

evidence of spontaneous rupture of the membranes

A client who is 16 weeks pregnant has an elevated alpha-fetoprotein (AFP) level. The nurse understands that the physician is likely to refer this client to

a perinatologist.

A surgeon is discussing surgery with a client diagnosed with colon cancer. The client is visibly shaken over the possibility of a colostomy. Based on the client's response, the surgeon should collaborate with which health team member?

enterostomal nurse

The charge nurse is transcribing an order into the electronic medical record (EMR). The order is written atorvastatin 20mg PO QOD x 3. How should the order be written to prevent a medication error?

every other day x 3

When performing cardiopulmonary resuscitation on a 7-month-old infant, which location would the nurse use to evaluate the presence of a pulse?

brachial artery

When teaching the parents about an echocardiogram scheduled for their child, the nurse should explain that the primary reason for this procedure is to determine which factor?

cardiac muscle structure

The nurse on a surgical unit has been assigned five clients. Place the clients in order of priority of care. All options must be used.

client rating pain as 9 out of 10 client 1-day postoperative transurethral resection of the prostate (TURP) client with a postoperative infection due to receive oral antibiotics client being discharged to home in 2 hours client with a fever documented at 99°F (37.2°C)

What is the best way for the nurse to position a chest tube for a client to prevent dislocation?

coiled flat on the bed and secured without putting tension on the tube

The nurse is designing a benchmarking study to gather information about nursing care practices for wound care. Which sources of information are used for benchmarking? Select all that apply.

government reports literature reviews standard-setting organizations databases

A nurse at a community event is called to an unresponsive 3-year-old. The parent states the child was eating a hot dog. The nurse determines the child has an obstructed airway. After instructing an observer to call 911, what intervention should happen first?

performing chest compressions with the heel of one hand 30 times

The basis for building a strong, therapeutic nurse-client relationship begins with a nurse's:

self-awareness and understanding.

When a client cannot read or write but is of sound mind, the nurse should read the informed consent to the client in the presence of two witnesses and do what next?

Have the client put an "X" on the signature line.

A nurse is discussing end of life care with a client's family in a skilled nursing facility. The client's advanced directive states the client wants no life support treatments. What are important nursing considerations to determine the efficacy of the advanced directive? Select all that apply.

The client signed the form. The advanced directive has two signatures. The advanced directive has a durable power of attorney.

A client undergoing chemotherapy after a modified radical mastectomy asks the nurse questions about breast prosthesis and wigs. After answering the questions directly, what additional information should the nurse provide?

contact information for the breast cancer support group

The nurse is caring for a client who has a prescription for thigh high antiembolism stockings. The client's left thigh measures 3 in (7.5 cm) larger than the client's right thigh. What is the next action by the nurse?

Order two different sizes of stockings and use one from each package.

The nurse observes a new parent give an oral medication to a 4-month-old infant. The parent instills the medication directly in the back of the infant's throat. Which choice is the nurse's best action?

Instruct the parent to instill a small amount of the medication inside the baby's cheek.

The nurse notes that the sterile, occlusive dressing on the central catheter insertion site of a client receiving total parenteral nutrition (TPN) is moist. The client is breathing easily with no abnormal breath sounds. The nurse should perform the actions in order of what priority from first to last? All options must be used.

Notify the health care provider. Position rolled towel under client's back, parallel to the spine. Obtain a culture from the drainage at the insertion site. Change dressing per institutional policy.

For a client who has had a stroke, which nursing intervention can help prevent contractures in the lower legs?

attaching braces or splints to each foot and leg

When bandaging a client's ankle, the nurse should use which technique?

figure-eight

A nurse is required to irrigate a client's nasogastric tube, a procedure the nurse has not performed before. What is the most appropriate action by the nurse?

Contact the nurse educator for an in-service and support in performing the skill.

The nurse is caring for a client who has just had an upper GI endoscopy. The client's vital signs must be taken every 30 minutes for 2 hours after the procedure. The nurse assigns an unlicensed assistive personnel (UAP) to take the vital signs. One hour later, the UAP reports the client, who was previously afebrile, has developed a temperature of 101.8°F (38.8°C). What should the nurse do next?

Promptly assess the client for potential perforation.

A client is admitted to a mental health unit with a diagnosis of depression and is participating in group sessions. The client asks a nurse if they are married or in a romantic relationship. What is the best response by the nurse to maintain a therapeutic relationship?

"I'm curious about your question but I want to know how you are feeling today."

A client with asthma has been prescribed fluticasone, one puff every 12 hours per inhaler. Place in correct order the nurse's statements when teaching the client how to properly use the inhaler with a spacer.

"Take off the cap and shake the inhaler." "Attach the spacer." "Breathe out all of your air. Hold the mouthpiece of your inhaler and spacer between your teeth with your lips closed around it." "Press down on the inhaler once and breathe in slowly." "Hold your breath for at least 10 seconds, then breathe in and out slowly." "Rinse your mouth."