plan b

A nurse is performing a fall risk assessment for a client. Which of the following findings should the nurse identify as a fall risk?

-A client who has a history of frequency is at risk for a fall due to frequency getting out of bed at night to go to the bathroom. the nurse should place a commode next the client's bed to reduce the risk for injury.

a nurse is preparing an in-service on different types of pain. Which of the following information should the nurse plan to include as a characteristic of acute pain?

-A key factor that differentiates acute prom from chronic pain is protective. It servers as a warning signal to the client that injury or disease is present.

A nurse is teaching a client about using nicotine chewing gum for smoking cessation. Which of the following instructions should the nurse include?

-Chew a piece of nicotine gym slowly and intermittently they should chew the gum slowly and intermittently for about 30 min to avoid releasing too much nicotine all at once. Fast release can cause effects similar to those that result from excessive smoking, such as throat irritation, headache, dizziness, heartburn and nausea.

A nurse is planning care for a client who has urinary incontinence, Which of the following interventions should the nurse include in the plan?

-Clean the client's perineal area with no rinse cleanser Should clean the perineal area and any skin in contact with urine with commercial no rinse cleaner or wash and rinse the skin with soap and water to prevent irritation and breakdown.

a nurse is submitting dietary request for a client who devoutly follows mormon dietary practice. The nurse should ask wha the client if they would like which of the following foods or beverages excluded from meals?

-Coffee The nurse should be aware that clients who follow Mormon dietary practices often choose not to consume caffeine-containing beverages, such as coffee or tea. The nurse should ask if the client wants to exclude caffeine, and, if so, request that other beverages be provided with the client's meals.

A nurse is teaching a class about documenting client care in paper charts. Which of the following instructions should the nurse include in the teaching?

-Correct charting errors as they occur. to ensure accurate documentation. The nurse should draw a single line through the error then sign or initial it.

A nurse is assessing a 10-month-old infant who has urinary tract infection (UTI). Which of the following findings should the nurse expect?

-Decreased appetite The nurse should expect an infant who has a UTI to have a decrease appetite. Manifestations of a UTI in an infant incline poor feeding, irritability, fever and vomiting.

A community health nurse is teaching a group of older adult clients at a senior center. Which of the following factors should the nurse include as an age-related change that increases their risk for constipation in older adult clients?

-Delay gastric emptying identify that slowed peristalsis and delayed gastric emptying are expected manifestations of aging and can lead to constipation.

A nurse is planning to provide teaching for a client who has fibromyalgia and is experiencing chronic pain. The nurse should expect to teach the client about which of the following medications?

-Duloxetine When prescribe duloxetine the client should prepare to provide information on the medication a serotonin/norepinephrine re uptake inhibitor that decreases pain, fatigue and stiffness in a clients who have fibromyalgia. This medication is also approved for treating depression and general anxiety

A school nurse is providing teaching to the parent of a school-age child who has juvenile idiopathic arthritis (JIA) about pain management which of the following statements should the nurse include?

-Encourage the child to participate in physical play activities. The nurse should instruct the parent to encourage the child to participate in physical activity to maintain joint function. The child should also participate in physical education classes at school

A nurse is providing teaching to the parent of a school-age child who has juvenile idiopathic arthritis about pain management. Which of the following statements should the nurse include?

-Encourage the child to participate in physical play activities. The nurse should instruct the parent to encourage the child to participate in physical activity to maintain joint function. The child should also participate in physical education classes at school.

Nurse is assessing a client who has an infection of the upper urinary tract. In which of the following locations should the nurse expect the client to be experiencing pain?

-Flank or back pain Other manifestations are fever, nausea, vomiting, dysuria, and urinary frequency.

A nurse is teaching the parents of a 5-month-old infant who is breastfed about introduction of complementary foods. Which of the following statements should the nurse make?

-Give your baby iron-fortified infant rice cereals before starting other foods. The nurse should inform the parents that iron-fortified infant cereals are usually the first foods introduce because this cereal is easy digested and the infants is unlikely to be allergic to it. In addition, breastfed infants need iron supplementation. After introducing infants cereal, strained vegetables fruits and meats can be added on at a time.

A nurse is teaching a group of parents and guardians who have toddlers about home safety. Which of the following info should the nurse provide?

-Install deadbolts towards the top of the doors leading outside. Teach the parents and guardians to install deadbolts towers the top of doors leading outside so that they cannot be reached by the toddlers but can easily be opened by an adult incase of fire or other emergency. Toddlers are anxious to experience their environment but are at risk for wandering away or being injured if they are outside alone.

The nurse is teaching an assistive personnel (AP) about manifestations of dysphagia. Which of the following manifestations should the nurse include?

-Storing food in the mouth after swallowing. The nurse should instruct the AP that the presence of food soared in the cheeks, tongue, and palates is a manifestation of dysphagia. Clients who have dysphagia often pocket food in the oral cavity due to inability to swallow.

A charge nurse is supervising a newly licensed nurse who is caring for a group of clients. Which of the following actions by the newly licensed nurse should the charge nurse intervene?

-Uses a square knot to attach a wrist restrain to a client. Using a square knot places the client at risk for injury. Therefore, the charge nurse should intervene, when attaching wrist restraints to a client, the nurse should use a quick-released knot of buckle to secure the restraint incase nit needs to be removed quickly.

An employee health nurse is providing an in-service on infection control procedure. Which of the following infections should the nurse identify as requiring contact isolation precautions. (select all that apply)

-Vancomycin-resistant enterococci (VRE): The nurse should identify VRE as an infection that requires contact precautions. -Methicillin-resistant Staphylococcus Aureus (MRSA): The nurse should identity MRSA as an infection that requires contact precautions. -Clostridium Difficile: The nurse should identity MRSA as an infection that requires contact precautions.

A nurse is taking with the parents of a school-age child about managing enuresis. Which of following parent statements indicates an understanding of the information?

-We will have him help change the bed linens after he has an accident. Positive methods of engage the child and change the enuresis behavior include having the child help change soiled bed clothes ad pajamas and restricting his fluid uptake near bedtime.

A nurse in a long-term care facility is performing an admission assessment on a client who reports that they are currently observing Lent. Which of the following questions should the nurse ask the client to identify ways to accommodate their religious practices in their plan of care?

-Would you like to obtain from meat on Fridays? The nurse should be aware that clients who practice Roman catholicism might choose to attain from meat on Fridays during Lent. The nurse should ask the client if they observe the Roam Catholic practice and then client's choice into their plan of care.

A nurse discovers a medication omission from the previous shifts and notifies the charge nurse. Which of the following statements should the charge nurse make?

-You should monitor the client for injury The nurse should monitor the client for injury following an omission of medication administration.

a nurse is caring for a client who reports nausea. which of the following actions should the nurse take?

Encourage the client to suck on a spoon full of ice chips several times an hour. The nurse should encourage clients who are nauseated to suck on ice chips several times hourly to help prevent dehydration.

A nurse is caring for a client who has clostridium difficile. The nurse should identify that C. diff can be transmitted through contact with which of the following?

Stool the GI tract is the portal of exit from the host C diff, shigella, salmonella, enteritis and hepatitis A

The nurse is updating the plan of care for a client who is experiencing chemotherapy induced nausea and vomiting. Which of the following interventions should the nurse include?

-Provide the client with room-temperature foods. Hot foods can worsen nausea. Therefore, the nurse should chill the client's food or see them at room temperature to make them more palatable.

The nurse is caring for a client who has a pressure ulcer and prescription for a culture to evaluate the effect of antibiotic therapy on wound healing. Which of the following actions should the nurse take first when obtaining the culture?

-Remove dressing covering the wound. According to evidence-base practice, the nurse should first remove dressings covering the wound

A nurse is supervising a newly licensed nurse who is documenting care on four clients in the client's electronic medical records. The nurse should identify that which of the following notations indicates accurate documentation?

-The client is disoriented to place and date. The nurse should identity that this notation reflects objective and accurate information about the client's neurological status.

A charge nurse is providing an educational session to a group of newly licensed nurses about the purpose of the National Patient Safety Goals. Which of the following objectives should the nurse include as a component of the National patient Safety goals?

Decrease errors related to invasive procedures. Was developed by the joint commission to address specific areas of concern related to client safety. Decreasing errors related to invasive procedures is a component of the NPSG

a nurse is caring for a client who has an indwelling dinar catheter. Which of the following manifestations should indicate to the nurse that the client is developing a catheter-acquired infection?

Low-back pain the nurse should expect a client who has a urinary catheter-acquired infection to manifest low-back pain due to inflammation from the bladder infection. Other indications of a urinary catheter infection include urinary frequency, hematuria and suprapubic tenderness.

A nurse is providing teaching about negative pressure wound therapy to a client who has chronic pressure ulcer. Which of the following info should the nurse include?

PWT promotes drainage of infectious material from the wound. For wounds to heal adequately, the wound must be free of infection.

A nurse is teaching a client who has a new diagnosis of obstruction sleep apnea. Which of the following statements should the nurse include?

-Obstructive sleep apnea occurs when you stop breathing for at least 10 seconds. is a disorder that causes the cessation of airflow through the mouth and nose for at least 10 seconds. Which obstruction sleep apnea the structures in the mouth or nose relax during sleep causing obstruction.

A nirse is assisting a client who is learning to use a walker following a stroke. the client states, 'I wasn't sure i could do this but i talked to my friend who uses crutches and they think i can' which of the following responses should the nurse make?

-It sounds like your friends encouragement about using a walker was helpful. The nurse recognizes this statement as an expression of hope, which is used to provide encouragement to the client. Praising the clients effort and actions can provide reassurance to the client and promote the clients self-confidence

A nurse in a provider's office is planning medication teaching for a client who has urinary tract infection. The nurse should prepare teaching for which of the following medications?

-Nitrofurantoin The nurse should prepare to provide information to the client on the medication, an anti-infective medication with bacteriostatic and bacterial properties that inhibit the growth of bacteria in the urinary tract.

A nurse is irrigating a client's infected surgical would to promote would haling. Which of the following actions should the nurse take?

Continue irrigating until clear solution drains from the wound The nurse should continue irrigating the wound until clear solution drains from the wound because this is an indication that there is no more debris or exudate to flush from the wound.

A nurse is teaching a group of newly licensed nurses about using abbreviations when transcribing prescription. Which of the following transcripts should the nurse use as an example of the correct usage of abbreviations?

Docusate sodium 100 mg PO bid This entry includes the necessary components of the prescription and uses acceptable abbreviations according to the Joint Commission and the Institute for Safe Medication Practices.

A public health nurse is planning care to meet Healthy People 202 objectives. Which of the following interventions should the nurse include to promote clients access to health care?

Set up a workshop to help people who are uninsured sign up for health coverage. The four main component of access to care under healthy people are timeliness, workforce services and coverage. By setting up workshops to help people who are uninsured sign up for health coverage, the public nurse will improve health care access.

A nurse is assessing a client who has been coughing during meals. The nurses should initiate a referral to which of the following members of the interprofessional care tram to evaluate the client for dysphagia.

Speech language pathologist can perform an in depth assessment of the clients swallowing diff determine if dysphagia is present, can also teach the client straggles for compensating for dysphagia and eating sFETY

A nurse is teaching a client who has acute ulcerative colitis and is prescribe a low-fiber diet. Which of the following foods should the nurse instruct the clients to eat?

Flavored gelatin The nurse should instruct a client who is prescribed a low-fiber diet to choose flavored gelatin because it contains 0 g of fiber. The nurse should identify that a low-fiber diet is usually prescribed on a temporary basis while the client's bowel is acutely inflamed.

A nurse is reviewing the advance directives of a client who is bing sustained on life support. The family disagrees regarding the continuation of life support measures. Which of the following individuals should the nurse identify as having legal ability to determine the clients course of treatment?

The client's younger child, who is the client's health care proxy An individual who is appointed by the client to be a health care proxy has the legal ability to make medical decisions for the client if they are unable to do so on their own. The assignment of a health care proxy is part of a client's advance directives, which can also include a living will.

A nurse on a mental health unit is planning an in-service for newly hired staff about the use of restraints. Which of the following informations should the nurse include?

-Document a client's conditions every 15 min while in restraints.

A nurse is reviewing the urinalysis report for a client who report dysuria. Which of the following findings should the nurse identify as manifestation of a urinary tract infection?

-Presence of crystals The nurse should identify that crystalluria is a manifestation of a UTI or kidney stones. The nurse should report this finding and monitor the client for other manifestations of infection.

A nurse is obtaining signatures on informed consent forms from a group of clients who are schedule for surgery. Which of the following individuals should the nurse identify as legally unable to provide informed consent?

-A young child who received morphine for pain A client who has received opioid analgesics is legally unable to provide informed consent because of the sedative effects of the medication and the impact this has on the client's ability to reason and make judgment.

A nurse is teaching an in-service about applying the National Patient Safety Goals when taking a verbal prescription for a client. Which of the following instructions should the nurse include?

-Read back the prescription to the provider. The nurse should include in the teaching to read back all prescriptions to the provider to reduce the risk for a medication error.

A home health nurse is planning care for an older adult client who live alone and reports having adhering to their medications...The nurse should include which of the following interventions in the plan?

organize daily medications in a divided pill box assist the client with remembering to take their daily medications and reduce the risk for medication error.

A nurse is discussing the healthy People 2020 initiative with a group of newly licensed nurses. The nurse should identify that which of the following nursing interventions meets on the healthy people 2020 objectives?

organizing an exercise program for a group of older adults in an independent living facility Healthy People 2020 objectives include promoting a variety of wellness behaviors for clients across the life span, including increasing physical activity. Offering an exercise program for older adult clients can prevent social isolation and help them maintain both physical and emotional health.

A nurse is using the SOAP format to document in the electronic medical record of a client who is 2 days postoperative following an open cholecystectomy. Which of the following entires should the nurse place in the A portion of the SOAP progress note?

"Ineffective airway clearance due to inadequate use of spirometer." The nurse should place this in the "A" portion of the SOAP progress note, which states the nurse's interpretation of assessment data.

A nurse is teaching about applying the National Patient Safety Goals to reduce health care-associated infections in clients. Which of the following information should the nurse include in the teaching?

-Bathe clients using a chlorhexidine solution. The nurse should include in the teaching to bathe clients using CX antimicrobial solution to reduce the amount of bacteria on client's skin that can cause an infection.

A nurse is planning to tech a class about standard precautions and preventing pucker injuries. Which of the following information should the nurse include in the plan?

-Recap needles using the one-handed scoop method. The nurse should instruct the participants to recap needles that have not been inserted into a client using the one-handed scoop method to reduce the risk for a puncture injury

A home health nurse is teaching a client about fire extinguishers. Which of the following instruction should the nurse include in the teaching?

-Call the fire department before using a fire extinguisher. The nurse should instruct the client to ensure that every person is out of the home and call the fire department before attempting to extinguish a fire to reduce the risk of injury.

A nurse is preparing to administer acetaminophen drops 60 mg PO to an infant who has a fever. The amount available is 160mg/5 ml. How many ML should the nurse administer?

-Have/DesiredX -1.9 ML 60/160 X 5

A nurse is performing a health screening assessment on a client. Which of the following findings should the nurse identify as a risk factor for developing colorectal cancer?

-History of polys The client who has polyps or who has a family history of certain types of pulps is a risk for developing colorectal cancer because polyps can develop into malignant tumors.

A nurse is providing teaching to a group pf newly license nurses about the legal scope of practice of nurses. Which of the following statements by a newly licensed nurse indicates an understanding of the teaching?

-I can reposition a client who has tetraplegia without a provider's prescription. Repositioning a client is an independent intervention that is within the scope of practice of a nurse. This intervention helps prevent skin breakdown and decreases the clients risk for developing complications of immobility, such as pneumonia.

A nurse is providing teaching to a client who has a prescription for risedronate to treat postmenopausal osteoporosis. Which of the following clients statements indicates an understanding of the teaching?

-I won't lie down for 30 min after I take my medication ensure the client understands that they should remain upright for at least 30 min after taking risedronate to reduce the risk for esophageal injury.

A nurse is teaching a client to self-administer 8 units of NPH insulin and 2 units of regular insulin in the same syringe. Which of the following client statements indicates an understanding of the teaching?

-I'll draw up regular insulin into the syringe before the NPH insulin.

A nurse in a provider's office is caring for a client who has a new prescription for an opioid analgesic. The client states that they are concerned about developing constipation. Which of the following actions should the nurse take first?

-Identify the client's usual bowl elimination pattern. The first action the nurse should take when use the nursing process is to assess the client. The nurse should first identify the client's usual bowel elimination pattern and the plan care based on the clients individual needs.

A nurse is teaching a class about cultural and religious differences in values and believes related to death. Which of the following information should the nurse include in the teaching regarding postmortem clients who devoutly practice orthodox Judaism?

- Client's body should not be left alone until after the funeral. The nurse should instruct the class that the bodies of clients who practice orthodox Judaism are often not left alone until after the funeral. which often occurs within 24 hr of the client's death.

A nurse is caring for a client who has a history of depressive disorder. The client states "it feels pointless to get up in the morning." which of the following responses should the nurse make?

- It sounds as if life seems meaningless to you now This respond is therapeutic because it reflects the clients feelings and encourages the client to verbally express their concerns.

The nurse is preparing to administer Enoxaparin to a client via a subcutaneous injection. Which of the following actions should the nurse take?

-Administer the medication in the clients abdomen. The nurse should administer the medication deeply into the clients subcutaneous tissue. Recommended sites for administering the medication can include the left or right side of the abdomen 5 cm or 2 in from the umbilicus, upper thigh or buttocks. Sites should be rated frequently.

A nurse is caring for a client who has anew diagnosis of diabetes mellitus and states that they cannot afford the prescribed insulin . The nurse offers to refer the client to the facility social worker. Which of the following principles is the nurse demonstrating?

-Advocacy Advocacy is the principle of acting on behalf of the client to promote clients right.

A nurse is teaching a group of newly licensed nurses about providing emotional support to a client who has experience a loss. Which of the following information should the nurse include in the teaching?

-Allow the client to express a negative response. The nurse should teach the newly license nurses to encourage clients to express all feelings, both positive and negative in order to alleviate distress and anxiety.

A nurse is planning care for a client who has dementia and continues to get out of bed without assistance. Which of the following actions should the plan to take?

-Apply an electronic safety to the bed. The nurse should apply an electronic safety device to the bed for an older adult client who has dementia. The device lets the staff when the client tries to get out bed without assistance.

A nurse is monitoring a client who is 3 days postoperative following amputation and reports phantom lim pain (PLP). Which of the following actions should the nurse take first?

-Ask the client to describe the pain sensations. The first action the nurse should take when using nursing process is to assess the client to determine the type of pain. The nurse can then request a prescription to manage the client's pain. Depending on the manifestations, treatment of PLP includes beta-blockers, antiepileptics, antispasmodics or antidepressants.

A nurse is administering a liquid medication from a multi dose bottle to a client. The nurse calculates that the dose to be administer is 4 Ml. Which of the following actions should the nurse take?

-Label the medication after measuring the dose. draw the medication into needles-less syringe and label with the name of the medication and route.

An operating room nurse is teaching an in-service about standardized procedures to reduce the risk for client injury during surgery. Which of the following information should the nurse include?

-Mark the operative site prior to surgical procedure. The nurse should include the instruction to mark the surgical site prior to the surgical procedure to prevent injury to the client from the operating on the wrong site.

A public health nurse is preparing to care for a community that has a large population of clients who practice the Islamic faith. Which of the following practice should the nurse anticipate when caring for clients in this community.

-Moving to the floor to pray The nurse should identify that many clients who practice the islamic faith get on the floor and face towards Mecca when praying. If the client is physically unable to het to the floor due to illness, then Muslim tradition permits prayer while in bed.

A nurse is reviewing the facility policy about occurrences that require an incident repair with a newly licensed nurse. Which of the following examples should the nurse include?

-Omission of a laboratory test The nurse should instruct the newly licensed nurse that an incident reports is completed following omission of laboratory test. Other situations that required incident report include medication errors, falls omission of a medication and needle sticks injuries.

Food that islam can have

-Pizza Dietary laws related to islam do not restrict consumption of dairy. Therefore, cheese pizza is an appropriate choice to offer clients who follow dietary laws for islam.

A nurse is initiating droplet precaution for a newly admitted client. Which of the following actions should the nurse take?

-Place the client in a private room (to prevent the spread of infection) -Ensure the client wears a face mask for transport to x-ray (it is essential client care the nurse should ensure the client wears a face mask to decrease the risk for speeding the infection)

A nurse is participating in a community health screening. Which of the following information should the nurse include about the risk factors for breast cancer?

-The use of hormone replacement therapy increases the risk for breast cancer. The nurse should inform the participants that the use of someone replacement therapy increase the risk for breast cancer.

A nurse is providing dietary teaching to a client who has diarrhea. Which of the following items should the nurse include in the teaching as an appropriate dietary choice?

-Tomato Juice because it is high in potassium, which is lost with diarrhea. Tomato juice also contains no pulp which indicates it is low in fiber. Therefore, it will no contribute to increase bowel motility.

A nurse is part of an informatics committee to improve safety with medication and administration. Which of the following recommendations should the nurse make to decrease the risk of errors at the bedside.

-Use an electronic medication administration record for documentation. The nurse should recommend he use if an electronic medication administration record for documentation at the time medications are given to decrease the risk for medication errors.

A nurse is applying a bed safety monitoring device for a client. Which of the following actions should the nurse take?

Connect the sensor pad to the call system. connect the sensor pad to the control unit and the nurse cal system to alert the nurse if the client is about to get out of bed.

A nurse is assessing a client who has received laboratory confirmation of a clostridium difficile infection. Which of the flowing finding should the nurse expect?

Abdominal pain C. difficile, a bacterium that causes diarrhea and potentially life-threatening colon inflammation, typically causes fever, abdominal pain and cramping, and three or more watery stools daily.

A nurse is providing change-of-shift report on a client using the situations background assessment recommendations. (SBAR) communications tool. The nurse should identify that which of the following information in included in the background step?

Admission diagnosis admission diagnosis, medical history and outline of previous treatment provided are included in the background steps of the SBAR communication tool.

A home health nurse is making an initial visit to a client who reports fecal incontinence. Which of the following actions should the nurse take first?

Ask questions about the client's typical dietary intake. The first action the nurse should take when using Maslow's hierarchy of needs is to meet the client's physiological needs, which include nutrition, elimination, and oxygenation. By asking about the client's dietary intake, the nurse might discover foods in the client's diet that increase the risk for diarrhea, which alters the client's elimination patterns and increases the risk for incontinence.

A nurse is documenting information in a client's medical record. Which of the following entries should the nurse make?

Client reports no pain while ambulating in the hallway this entry is client centered specific and clearly address client assessment data.

A nurse is planning care for a client who is actively dying and has previously expressed a desired to adhere to Buddhist practices related to death. Which of the actions should the nurse anticipate and confirm with the client to accommodate their preferences?

Ensure that there is room for the family to stand at the head of the client's bed. when a client who practices buddhism is actively dying the nurse should ensure that there is room available form family members to stand by the client's head and say prayers after the client's death

A nurse is assisting a client who has urolithiasis and is experiencing acute pain. Which of the following manifestation should the nurse expect. Select all

Flank pain is correct. The nurse should identify that a client who has urolithiasis can experience acute pain in the flank area of the client's upper back and abdomen, which can extend to the ribs or pelvis area as the stone moves down the client's ureter. Fever is correct. The nurse should identify that a client who has urolithiasis can experience a fever, along with elevated blood pressure, pulse, and respirations, as a result of the pain and the stone obstructing the ureter and causing infection. Hematuria is correct. The nurse should identify that a client who has urolithiasis can experience blood in the urine due to the stone causing trauma to the bladder, ureter, and urethra. This can also be an indication that infection is occurring and bacteria is present.

A nurse is teaching a newly licensed nurse about the Patient self-determination act (PSDA) Which of the following actions should be nurse include as an example of PSDA?

Informing clients they can decline any treatment provider prescribe. should include in the teaching that the PSDA mandates that health care workers inform, clients of their rights, which includes the right to refuse treatment.

A nurse is discussing a wellness approaches to preventing excessive nutrition intake with a group of clients. Which of the following statements should the nurse make?

Keep a record of cues that trigger a desire to eat By assisting the client to identify triggers to eating the nurse can promote behavior modifications that fosters client control over these triggers.

A nurse is providing teaching about a mechanically altered or level 2 int to the caregiver of a client who has dysphagia. Which of the following food selections should the nurse include?

Mashed bananas avoid serving other raw fruits and vegetables due to the risk of choking.

A nurse is discussing informed consent with a group of newly licensed nurses. Which of the following actions is the responsibility of the nurse when obtaining informed consent?

Verify that the client voluntarily gave consent for the procedure It is the responsibility of the nurse to verify that the client understand that they have the right to decline any prescribed treatment and should not feel forced or obligated to sings a consent form.

A nurse is assessing a client who has a rash on their hands and forearms after working with a garden. The nurse should Identify that which of the following findings indicates contract dermatitis?

Well-defined margins of the erythematous area Contact dermatitis appears as an erythematous, eczema-like rash that occurs following contact with an irritant, such as poison oak or poison ivy. Streaks of vesicles and papules can occur as an inflammatory response to plants. To best detect areas of redness in clients who have darker skin pigmentation, the nurse can compare the skin on one side of the body to the other and palpate the skin to detect warmth or edema, because inflamed skin can appear purple-gray rather than reddened.

A nurse is caring for a client who uses a fentanyl transdermal patch to threat chronic pain and is experiencing breakthrough pain following a surgical procedure. Which of the following medications should the nurses expect to administer?

- Oxycodone The nurse should expect to administer oxycodone to a client who is receiving an extended-release medication an is experiencing breakthrough postoperative pain. Oxycodone is a rapid-acting opioid, which can be given with a long-acting opioid.

A nurse is applying a belt restraint to a client. Which of the following actions should the nurse take?

tie the restraint to a moveable part of the client's bed frame. The nurse should secure the restraint to a moveable part of the bed frame to prevent injury to the client when the bed is raised or lowered.

A nurse at a mental health clinic is interviewing a client who has depressive disorder and identified as religious during intake. Which of the following client statements should the nurse identify as indicating spiritual distress?

"I am not even sure why I exist." Spiritual distress refers to feeling disconnected from the world or questioning the purpose of one's existence in the world. The nurse should encourage the client to further explore these feelings and discuss past methods of feeling connected to the world and others.

A nurse is providing teaching about nutrition to the guardian of a 1-month-old infant who is formula fed. Which of the following statements should the nurse include?

-Your baby should be consuming 18-21 ounces of formula per day. the nurse should instruct the guarding that a 1 month old infant should consume 540-630 ml. (19-21 oz) of formula per day. This amount will increase during the first 6 months and the slightly decrease once the infant is eating solid foods.

A nurse is providing teaching to the guardians of a preschooler about preventing contact dermatitis. Which of the following guarding statements indicates an understanding the teaching?

- Plants are among themes common cause of contact dermatitis. The should inform the guarding that contact with plants, such as vision ivy, sumatriptans, and oak is a common cause of dermatitis. Removing irritants from the environment is on intervention to prevent contact dermatitis.

A nurse is caring for an unconscious client who was brought into the emergency department by a law enforcement agent. The law enforcement agent request that the nurse obtain a blood sample for toxicity screening. Which of the following actions should the nurse take?

- Refuse to provide a blood sample. In the role of a patient advocate, the nurse should act to protect the rights of the client. Because this client is unable to give consent and there is no client proxy present, the nurse should refuse to obtain the blood sample at this time. Legal proceeding might deem a client incompetent or that someone else can make this choice. However, until this occurs, the nurse should not obtain the sample.

A nurse is teaching a group of assistive personal about expected physical changes associated with aging. Which of the following info should the nurse include?

Decreases in sense of taste expected physical change, caused by the decrease in the number of taste buds on the tongue.

A nurse is preparing to calculate the medication dosage for an adult client who has a prescription for a weight-base medication. Which of the following actions should the nurse plan to take?

Divide the client's weight in pounds by 2.2 to obtain their weight in kilograms. To calculate dosage for weight-based medications, the nurse should divide the client's weight in pounds by 2.2 to determine their weight in kilograms. It is safest to weigh the client using a kilogram measure to avoid having to convert the weight figure.