A nurse is caring for a client who requires an NG tube forstomach decompression. Which of thefollowing actions should the nurse take when inserting the NG tube?a. position the client with the head of the bed elevated to 30 degrees prior to insertion of the NGtubeb. remove the NG tube if the client begins to gag or chokec. apply suction to the Bg tube prior to insertiond. have the client take sips of water to promote insertion of the NG tube into the esophagus Show A nurse is caring for a client who has asodium level of 125 mEq/L. Which of the followingfindings should the nurse expect? A nurse is preparing to administerenoxaparin subcutaneously to a client/ Which of the followingactions should the nurse take? A nurse is evaluating aclient's use of a cane. Which of the following actions should the nurseidentify as an indication of correct use? A nurse is preparing an education program forstaff about advocacy. which of the followinginformation should the nurse include?a. advocacy ensures client's safety, health, and rightsb. advocacy ensures that nurses are about to explain their own actionsc. advocacy ensures that nurses follow through on their promises to clientsd. advocacy ensures fairness in client care delivery and use of resources Scheduled maintenance: Thursday, December 8 from 5PM to 6PM PST
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Terms in this set (57)A nurse is evaluating a client's use of a cane. Which of the following actions should the nurse identify as an indication of correct use? 3 A nurse receives a report about a client who has 0.9% sodium chloride infusing IV at 125mL/hr. When the nurse performs the initial assessment, he notes that the client has received only 80mL over the last 2 hr. Which of the following actions
should the nurse take first? 4 A nurse is caring for a client who requires an NG tube for stomach decompression. Which of the following actions should the nurse take when inserting the NG tube? 4 A nurse is reviewing a client's fluid and electrolyte status. Which of the following findings should the nurse report to the provider? 4 A nurse is providing discharge instructions to a client who will be using a walker. Which of the following client statements indicates an understanding of the teaching? 2 A nurse is planning care for a client who has had a stroke, resulting in aphasia and dysphagia. Which of the following tasks should the nurse assign to an assistive personnel? SATA 1, 2, 4 A nurse is caring for
a client who is expressing anger about his diagnosis of colorectal cancer. Which of the following actions should the nurse take? 4 A nurse is preparing to apply a dressing for a client who has a stage 2 pressure injury. Which of the following types of dressings should the nurse use? 4 A nurse is administering an otic medication to an older adult client. Which of the following actions should the nurse take to ensure the medication reaches the inner ear? 1 A nurse is using an open irrigation technique to irrigate a client's indwelling urinary catheter. Which of the following actions should the nurse take? 3 A nurse is initiating a protective environment for a client who had an allogeneic stem cell transplant. Which of the following precautions should the nurse plan for this client? 2 A nurse is planning strategies to manage time effectively for client care. Which of the following strategies should the nurse implement? 3 A nurse caring for a client who is postoperative following a knee arthroplasty and requires the use of thigh-length sequential compression sleeves. Which of the following actions should
the nurse take? 3 A nurse is caring for a client who has a respiratory infection. Which of the following techniques should the nurse use when performing nasotracheal suctioning for the client?
2 A nurse is assessing a client who reports increased pain following physical therapy. Which of the following questions should the nurse ask when assessing the quality of the clients pain? 4 A nurse is providing discharge teaching to a client about self-administering heparin. Which of the following
instructions should the nurse include in the teaching? 3 A nurse in a long-term care facility is caring for a client who dies during the nurses shift. Identify the sequence in which the nurse should perform the following steps 2,3,4,5,1 A nurse is teaching a client and his family how to care for the client's tracheostomy at home. Which of the following instructions should the nurse include in the teaching? 2 A nurse is caring for a client who has a terminal illness and is approaching death. The client is short of breath and has noisy respirations from secretions. Which of the actions should the nurse take? 1 A nurse is caring for a child who has a prescription for a blood transfusion. The child's parents have refused the treatment due to their religious beliefs. Which of the following actions should the nurse
take? 1 A nurse is
preparing to administer enoxaparin subcutaneously to a client. Which of the following actions should the nurse take? 1 A nurse is admitting a client who is having an exacerbation of heart failure. In planning this clients care, when should the nurse initiate discharge planning? 1 A nurse is assessing a client who has required bed rest for the past month. Which of the following findings should the nurse identify as an indication that the client has developed thrombophlebitis? 3 A nurse is caring for a client who has dementia. Which of the following interventions should the nurse take to minimize the risk for injury to the client? 1 A nurse is assessing
an older adult client's risk for falls. which of the following assessments should the nurse use to identify the clients safety needs? 2,4,5 A nurse is caring for a client who has pharyngeal diptheria. Which of the following types of transmission precautions should the nurse initiate? 2 A nurse is caring for a client who has
herpes zoster and asks the nurse about the use of complementary and alternative therapies for pain control. The nurse should in form the client that this condition is a contraindication for which of the following therapies? 4 A nurse is admitting a client who has an abdominal wound with a large amount of purulent drainage. Which of the following types of transmission precautions should the nurse initiate? 4 A nurse is educating a client who has a terminal illness about declining resuscitation in a living will. The client asks what would happen if i arrive at the emergency department and I had difficulty breathing? Which of the following responses should the nurse make? 2 A nurse is performing a skin assessment
for a client who expresses concern about skin cancer. Which of the following findings should the nurse identify as a potential indication of skin malignancy? 3 A nurse is reviewing evidence based practice principles about administration of oxygen therapy with a newly licensed nurse. Which of the following actions should the nurse include? 2 A nurse is performing a home safety assessment for a client who is receiving supplemental oxygen.
Which of the following observations should the nurse identify as proper safety protocol? 2 A nurse is caring for a client who has a terminal illness and is at the end of life. The nurse should recognize which of the following statements by the client's partner indicates effective coping? 2 A nurse is talking with an older adult client who is contemplating retirement. The client states, "I keep thinking about how much I enjoy my job. Im not sure I want to retire." Which of the following responses should the nurse
make? 3 A
nurse is caring for a group of clients. Which of the following actions should the nurse take to prevent the spread of infection? 2 A nurse is admitting a new client. Which of the following actions should the nurse take while performing medication reconciliation? 3 A nurse is lifting a bedside cabinet to move it closer to a client who
is sitting in a chair. To prevent self-injury, which of the following actions should the nurse take when lifting this object? 4 A nurse is
talking with the partner of a client who has dementia. The client's partner expresses frustration about finding time to manage household responsibilities while caring for their partner. The nurse should identify that the partner is experiencing which of the following types of role-performance stress? 3 A nurse is caring for a client who is postoperative and is exhibiting signs of hemorrhagic shock. The nurse notifies the surgeon, who tells the nurse to continue to measure the client's vital signs every 15 min and to report back in 1 hr. Which of the following actions should the nurse take next? 4 A nurse is preparing a change of shift report.
Which of the following tools or documents should the nurse use to communicate continuity of care? 2 A nurse is
planning to insert a peripheral IV catheter for an older adult client. Which of the following actions should the nurse plan to take? 2 A nurse is caring for a client who is postoperative and refuses to use an incentive spirometer following major abdominal surgery. Which of the following actions is the nurses priority? 2 A nurse manager is preparing to review medication documentation with a group of newly licensed nurses. Which of the following statements
should the nurse manager plan to include in the teaching? 1 A nurse responds to a call light and finds a client lying on the bathroom floor. Which of the following actions should the nurse take first? 1 A nurse on a medical-surgical unit is caring for a client who has a new prescription for wrist restraints. Which of the following actions should the nurse take? 1 A home health nurse is performing a follow-up visit for a client who has a gastrostomy tube through which they receive intermittent feedings and medications. The client recently developed diarrhea.
Which of the following findings should the nurse identify as a possible cause of the diarrhea? 3 A nurse is caring for a client who is postoperative. When the nurse prepares to change her dressing, she says, "every time you change my bandage, it hurts so much." Which of the following interventions is the nurse's priority action? 4 A nurse is caring for a client who has diarrhea due to shigella. Which of the following precautions should the nurse implement for this client? 4 A nurse is administering 1L
of 0.9% sodium chloride to a client who is postoperative ans has fluid volume deficit. Which of the following changes should the nurse identify as an indication that the treatment was successful? 3 A nurse is preparing to administer an injection of an opioid medication to a client. The nurse draws out 1 mL of the medication from a 2mL vial. Which of the following actions should the nurse take? 1 A nurse is caring for a client who has a sodium level of 125mEq/L. Which of the following findings should the nurse expect? 4 A nurse is preparing an education program for staff about advocacy. Which of the following information should the nurse include? 1 A nurse is caring for a client who has an aggressive form of prostate cancer. The
provider briefly discusses treatment options and leaves the client's room. When the nurse asks if the client would like to discuss any concerns, the client denies. Which of the following statements should the nurse make?
3 A nurse is assessing a client's readiness to learn about insulin self administration. Which of the following statements should the nurse identify as an indication that the client is ready to learn? 1 A nurse is caring for a client who asks about the purpose of advance directives. Which of the following statements should the nurse make? 2 A nurse is assessing four adults. Which of the following physical assessment techniques should the nurse use? 2 A client who is postoperative is verbalizing pain as a 2 on a scale of 0-10. Which of the following statements should the nurse identify
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