Test 2

Measure the client's apical pulse rate

A nurse is measuring a client's vital signs. The client's resting radial pulse rate is 55/min. Which of the following actions should the nurse take next? a. document the finding. b. measure the client's apical pulse rate c. talk with the client about factors that can affect the pulse rate d. notify the provider about the client's radial pulse rate

Perform a blanch test.

A nurse is performing a physical assessment of a client. Which of the following actions should the nurse take to assess the client's tissue perfusion?

Hold the sterile drape above the waist and away from the body

A nurse is preparing a sterile field for a procedure the provider will perform at the client's bedside. Which of the following actions should the nurse take?

Warm the irrigating solution to 37 C (98.6F)

A nurse is preparing to irrigate a client's wound. Which of the following actions should the nurse take? a. use a 10 mL syringe b. attach a 22 gauge catheter to the syringe c. warm the irrigating solution to 37 degrees celcius (98.6F) d. administer an analgesic 10 min before the irrigation

Place the client in a lateral position with the head turned to the side before beginning the procedure.

A nurse is providing oral care for a client who is unconscious. Which of the following actions should the nurse take?

The client holds the cane on the unaffected side.

A nurse is teaching a client about the use of a straight -legged cane. Which of the following client actions indicates an understanding of the teaching? a. the client holds the cane on the unaffected side b. the client walks by stepping with the unaffected leg before the affected leg c. the client hold the cane directly next to the foot d. the client holds the cane with a straight elbow

Bear weight on both of your legs.

A nurse is teaching a client with lower extremity weakness how to use a 4 point crutch gait. Which of the following instructions should the nurse include in the teaching?

Explain that it is against policy to share access codes and refer the resident to his supervisor.

A new resident provider asks the charge nurse for an access code to review client's online records. The resident is not scheduled to attend the facility's orientation computer class until next week. Which of the following actions should the nurse take? a. explain that it is against policy to share access codes and refer the resident to his supervisor. b. access the client's online data and monitor the resident as he reads them. c. access the online system and allow the resident to locate client's data. d. ask each client to give permission for the resident to access medical records.

Airborne

A nurse is admitting a client who has measles. Which of the following types of transmission precautions should the nurse initiate? a. airborne b. droplet c. contact d. protective environment

Establish client outcomes

A nurse is admitting a client who will undergo a craniotomy. During the planning phase of the nursing process, which of the following actions should the nurse take?

Peripheral pulses bilaterally symmetric, equal, and strong in all 4 extremities

A nurse is assessing a client's peripheral pulses. Which of the following descriptions should the nurse use to document the findings?

Dorsalis Pedis

A nurse is assessing a client's pulse of the lower extremities. The nurse should identify which of the following as the location of the most distal pulse?

Lower the client to the floor.

A nurse is caring for a client who begins having a tonic-clonic seizure while sitting in a chair at the bedside. Which of the following actions should the nurse take first? a. provide oxygen b. place the client is a side-lying position c. provide privacy d. lower the client to the floor

Obtain the apical and radical rates simultaneously.

A nurse is caring for a client who has a dysrhhythmia. Which of the following techniques should the nurse use to access for a pulse deficit?

"What worries you about being without your teeth?"

A nurse is caring for an older adult client who becomes agitated when the nurse requests that the client's dentures be removed prior to surgery. Which of the following responses should the nurse provide?

Excessive wax in the ear canal.

A nurse is caring for an older adult client who has an in the canal hearing aid. The client states that the hearing aid is making a whistling sound. The nurse should identify which of the following factors as the source for this sound? a. low battery power b. excessive wax in the ear canal c. a volume setting that is too low d. a crack in the ear tube

The client has slightly flexed elbows when ambulating with the crutches.

A nurse is evaluating a client's use of crutches. The nurse should identify that which of the following actions by the client indicates safe usage of this equipment?

Remove the sleeve of the gown from the arm without the IV line

A nurse is helping a client change his hospital gown. The client has an IV infusion via an infusion pump. Which of the following actions should the nurse take first? a. remove the sleeve of the gown from the arm without the IV line b. slow the infusion using the roller clamp c. disconnect the IV line from the pump. d. bring the IV solution and tubing from the outside to the inside of the sleeve of the gown

Bounding

After assessing a client's radial pulses, the nurse documents "radial pulses 4+ bilaterally." The nurse should document this finding when a client's pulses have which of the following qualities?