EVOLVE QUESTIONS

The parents of a 16-year-old child tell the nurse that they are concerned because the child sleeps until noon every weekend. Which is the most appropriate nursing response?

"Adolescents love to sleep late in the morning."

The nurse has reinforced instructions to the client returning home after arthroscopy of the knee. The nurse determines that the client understands the instructions if the client makes which statement?

"I'll report fever or site inflammation to the primary health care provider."

A client is seen in the health care provider's office for a physical examination after experiencing unusual fatigue over the last several weeks. Height is 5 feet, 8 inches, with a weight of 220 pounds. Vital signs are temperature 98.6° F oral, pulse 86 beats per minute, respirations 18 breaths per minute, and blood pressure 184/96 mm Hg. Random blood glucose is 110 mg/dL. In order to best collect relevant data, which question should the nurse ask the client first?

"When was the last time you had your blood pressure checked?"

Abdominal ultrasonography is prescribed for a client who is pregnant. The nurse provides information to the client regarding the procedure and makes which statement?

"You will be positioned on your back and turned slightly to one side with your head elevated."

A primary health care provider prescribes atenolol 0.05 g orally daily. The label on the medication bottle states, atenolol 50-mg tablets. How many tablet(s) will the nurse administer to the client? Fill in the blank.

1 tablet

An adult client trapped in a burning house suffered burns to the back of the head, the upper half of the posterior trunk, and the back of both arms. Using the rule of nines, the nurse determines the extent of the burn injury to be which percentage?

22.5%

The nurse is preparing to provide mouth care to an unconscious client. The nurse collects which items to perform this procedure? Select all that apply.

A soft toothbrush Irrigation syringe Bite stick or a padded tongue blade Suction with oral suction catheter attached

The nurse is monitoring the daily weight of an infant with heart failure (HF). Which finding alerts the nurse to suspect fluid accumulation and thus the need to notify the registered nurse?

A weight gain of 1 lb in 1 day

The nurse is reviewing the prescriptions of a client diagnosed with diabetes mellitus who was admitted because of an infected foot ulcer. Which primary health care provider's prescription supports the treatment of this condition?

An increased amount of NPH daily insulin

A client arrives at the emergency department for treatment of an injury to the eye after being hit by a baseball bat. On data collection, the nurse notes that the eye is bleeding. Which nursing action is appropriate?

Cover the eye with cold, sterile saline gauze.

An adolescent client with type 1 diabetes mellitus is admitted to the emergency department for treatment of diabetic ketoacidosis. Which assessment findings should the nurse expect to note?

Fruity breath odor and decreasing level of consciousness

The nurse assists a primary health care provider (PHCP) with the insertion of a nasogastric tube. Which positions should the nurse place the client in to prepare for the procedure? Select all that apply.

High fowlers position. slight flexion of neck.

The nurse is caring for a neonate that is 3 hours old and should assess for which signs of cold stress? Select all that apply.

Increased respirations with apnea. Mottling of skin

The client with spinal cord injury is prone to experiencing autonomic dysreflexia. The least appropriate measure to minimize the risk of autonomic dysreflexia is which action?

Limiting bladder catheterization to once every 12 hours

The nurse reviews a plan of care for a postoperative client following a thyroidectomy and notes that the client is at risk for breathing difficulty. Which nursing intervention should the nurse include in the plan of care?

Monitor neck circumference frequently.

The nurse is caring for the client who has skeletal traction applied to the left leg. The client complains of severe left leg pain. The nurse checks the client's alignment in bed and notes that proper alignment is maintained. Which action should the nurse take next?

Notify the registered nurse.

The nurse is reinforcing instructions to a group of female clients about breast self-examination (BSE). When should the nurse instruct the pre-menopausal client to perform this examination?

One week after menstruation begins

The nurse is evaluating the effectiveness of meperidine hydrochloride for pain management for a client in labor. The client describes her pain level as "9" during contractions. The nurse determines that the medication was effective if the client exhibited which reasonable goal for pain relief?

Pain level is "4" while a progressive labor pattern continues.

A client is complaining of skin irritation from the edges of a cast applied the previous day. The nurse should plan for which intervention?

Petaling the cast edges with adhesive tape

The nurse has a prescription to give a dose of Rho(D) immune globulin to a client who has delivered an infant. Which criteria need to be met in order to administer this medication? Select all that apply.

Rh negative mother Negative Coombs' test

The nurse is reviewing a chart of a child with a head injury. The nurse notices that the level of consciousness has been documented as obtunded. Which observation should the nurse expect to make during data collection of the child?

The child sleeps unless aroused and, once aroused, interacts poorly with the environment.

A primary health care provider has prescribed phenobarbital sodium 25 mg orally twice daily for a child with febrile seizures. The child's weight is 7.2 kg. The safe pediatric dosage is 1 to 6 mg/kg/day. What should the nurse determine about the medication dosage?

The dosage is too high.

An older client with a history of hyperparathyroidism and severe osteoporosis is hospitalized. The nurse caring for the client plans to address which problem first?

The possibility of injury

The nurse is assisting with caring for a client who is receiving intravenous fluids and who has sustained full-thickness burn injuries of the back and legs. The nurse understands that which would provide the most reliable indicator for determining the adequacy of the fluid resuscitation?

Urine output

The nurse is caring for a client scheduled for a cesarean delivery. The nurse reviews the client's health record, knowing that which finding needs to be further investigated before delivery?

White blood cell count of 35,000 mm3