Four hours following surgical repair of a compound fracture of the right ulna, the nurse
is unable to palpate the client’s right radial pulse. Which action should the nurse take
first \u2714\u2714Elevate the client’s right hand on one or two pillows
After placing a 36- week- gestation newborn in an isolette and drying the infant with
several blankets, what should the nurse implement next? \u2714\u2714Remove the wet blankets
and linen from the isolette
A client in the third trimester of pregnancy complains of frequent nasal stiffness and
occasional nosebleeds. Her chest circumference has increased by 5 cm during the
pregnancy, and she uses thoracic breathing. Her diaphragm is elevated and she has an
increased costal angle. Which intervention should the nurse implement? \u2714\u2714Record the
respiratory finding in the clients chart as normal
A terminally ill male hospice client who is at home is showing decreased awareness of
his surroundings. His appetite is poor and he often refuses oral intake of solids and
liquids. For the past several days he has been unable to get out of bed. Which action
should the hospice nurse implement? \u2714\u2714Instruct family to offer client only soft bland
foods
A woman was admitted yesterday afternoon with severe abdominal pain. Her pregnancy
test and ultrasound were negative, so an exploratory laparotomy was completed during
the night. When coffee ground materials is observed in the drainage from the
nasogastric tube (NGT), which intervention should the nurse implement? \u2714\u2714Verify
correct placement of the nasogastric tube
The nurse is reviewing the laboratory values for a client with acute pancreatitis who
reports of the abdominal pain is not as severe as it was on admission. Which laboratory
test should the nurse review to evaluate the clients clinical recovery? \u2714\u2714Lipase
While assessing a client who had a laparotomy the previous day, the nurse notices that
300 mL of dark red fluid has drained from the nasogastric tube in the last hour. Which
action should the nurse take first? \u2714\u2714take vital signs
The nurse is reviewing the recommended preventative care for clients with asthma,
chronic bronchitis, and emphysema. Which health care measure is most important for
the nurse to recommend to these clients? \u2714\u2714Avoid large crowded areas during the
colder months of the year
The mother of a one-moth-old infant calls the clinic to report that the back of her infant’s
head is flat. How should the nurse respond? \u2714\u2714Position the infant on the stomach
occasionally when awake and active
A woman is brought to the labor and delivery unti after delivering a term infant and the
placenta in the hospital parking lot 10 minutes ago. Which action should the nurse
perform first? \u2714\u2714Perform a fundal massage
A client has a new prescription for the maximum recommended dosage of
pipercillin\/tazobactam for nosocomial pneumonia. The nurse should report which
laboratory finding to the healthcare provider before administering the prescribed dose?
\u2714\u2714Decrease serum creatine
A client who is admitted with diabetic ketoacidosis (DKA) is demonstrating Kussmaul
breathing and has a severe headache along with nausea. Her arterial blood gases
(ABG) are: pH 7.50; PaCO2 30 mmHg; HCO3 24 mEq\/L (24mmol\/L). Which
assessment finding warrants immediate intervention by the nurse? \u2714\u2714Fruity breath
When performing postural drainage on a client with Chronic Obstructive Pulmonary
disease (COPD), which approach should the nurse use? \u2714\u2714Explain that the client may
be placed in five positions
A young male client with testicular cancer has a living will that describes his desire that
no extraordinary measures be taken to save his life. The healthcare provider knows the
client has a good prognosis and refuses to write a “do not resuscitate” (DNR)
prescription. Which action should the nurse take? \u2714\u2714Initiate an ethics committee
review
In observing a clients face, which assessment finding requires the most immediate
intervention by the nurse? \u2714\u2714Oral mucosa is cyanotic Blue lips
The nurse is assessing a client with cirrhosis and notes that the client has a positive
Babinski reflex. Which action should the nurse take in response to the finding?
\u2714\u2714Complete a thorough neurological assessment
Which action should the nurse take first after obtaining a urine specimen for culture and
sensitivity from an indwelling urinary catheter? \u2714\u2714Ensure continued sterility of the
specimen container
The home health nurse observes an older client with unilateral weakness place the
walker in front of the chair for support while rising to a standing position. Which action
should the nurse take? \u2714\u2714Hold the walker securely to prevent slipping while the client
raises
A client with cancer complains of fever, chills, malaise, and headache following
administration of a colony-stimulating factor. Which nursing intervention is most
beneficial in helping to reduce the flu like symptoms? \u2714\u2714Monitor lab values for an
increase in WBCs
Which laboratory value should the nurse review prior to administering the initial dose of
a statin medication? \u2714\u2714Serum liver enzymes
Following a lumbar puncture, a client voices several concerns. Which concern indicates
to the nurse that the client is experiencing a complication of the procedure? \u2714\u2714I have a
headache that gets worse when I sit up
The nurse is caring for a client withdrawing from a fentanyl citrate addiction. The client
receives a prescription for clonidine 0.2 mg PO taken twice daily. Which action should
the nurse take? \u2714\u2714Advise to sit up slowly from a reclining position
A 7-year-old child is admitted to the hospital with a diagnosis of acute rheumatic fever.
In obtaining a health history form the child’s mother, the recent occurrence of what
illness is most significant? \u2714\u2714Sore throat
Following discharge teaching, a client with a duodenal ulcer tells the nurse of plans to
eat plenty of dairy products, such as milk, to help coat and protect their ulcer. Which is
the best follow-up action by the nurse? \u2714\u2714Review with the client the need to avoid
foods that are rich in milk and cream
The nurse is caring for an adolescent client with an intestinal obstruction who presents
with severe, colicky abdominal pain, nauseas, vomiting, and abdominal distention.
Which pathophysiological mechanism supports the client’s clinical presentation? \u2714\u2714A
weakened diaphragm with high abdominal pressure
The nurse assesses a client with cirrhosis and find 4+ pitting edema of the feet and
legs, and massive ascites. Which mechanism contributes to edema and ascites in
clients with cirrhosis? \u2714\u2714Hypoalbuminemia that results in a decreased colloidal oncotic
pressure
An adult who was recently diagnosed with glaucoma tells the nurse, “it feels like I am
driving through a tunnel.” The client expresses great concern about going blind. Which
nursing instruction is most important for the nurse to provide to this client? \u2714\u2714Maintain
prescribed eye drop regimen
The charge nurse is making assignments on a cardiac unit. Which client is best to
assign to a new graduate who is orienting to the unit? \u2714\u2714With atrial fibrillation whose
saline lock is infiltrated
Penicillin G procaine 2,400,000 units intramuscularly is prescribed for a 4-year-old child
who has streptococcal respiratory infection. The medication vial is labeled 1,200,000
units\/2mL. How many mL should the nurse administer? \u2714\u27144 ML D\/HX2ml
A client in labor states, “I think my water just broke!” The nurse notes that the umbilical
cord is on the perineum. What action should the nurse perform first? \u2714\u2714Trendlenburg
A client who was recently diagnosed with anorexia nervosa collapses at an outpatient
clinic. While taking the blood pressure, the client begins to demonstrate cloudy
consciousness, stupor, and has slurred speech. The nurse obtains blood glucose of 50
mg\/dL, heart rate of 116 beats\/minute, and blood pressure of 88\/50 mmHg. Which
intervention is most important for the nurse to implement? \u2714\u2714Position client with head
flat and feet elevated
The nurse is planning care for a 16-year-old, who has juvenile idiopathic arthritis (JIA)>
the nurse includes activities to strengthen and mobilize the joints surrounding muscle.
Which physical therapy regimen should the nurse encourage the adolescent to
implement? \u2714\u2714Exercise in the swimming pool
The nurse is educating a client with end-stage kidney failure who requires dialysis three
times a week. Which information is important for the nurse to include about the clients
daily diet? \u2714\u2714The protein intake should be decreased to prevent nitrogenous waste
Buildup
A client is admitted to the hospital with symptoms consistent with a right hemispheric
stroke. Which neurovascular assessment requires immediate intervention by the nurse?
\u2714\u2714Unequal bilateral hand grip strengths
As part of the treatment plan for a client diagnosed with acute pancreatitis, the nurse
plans to withhold oral fluids on which pathophysiological process? \u2714\u2714Decreasing the
formation and secretion of pancreatic enzymes
A male client being treated for testicular cancer with chemotherapy has decreased
alpha fetoprotein radioimmunoassay (AFP). Which nursing intervention should the
nurse implement? \u2714\u2714Advise the client that the treatment is having beneficial effect
The nurse plans to administer a bolus dose of IV heparin based on the clients weight.
The prescribed bolus dose is 100 units\/kg. The client weighs 198 pounds. How many
units of Heparin should the nurse administer? \u2714\u27149000
A successful businessman presents to the community mental health center complaining
of sleeplessness and anxiety over his financial status. What action should the nurse
take to assist this client in diminishing his anxiety? \u2714\u2714teach him to limit sugar and
caffeine
A 6-year old child who has a medical diagnosis of attention deficit hyperactivity disorder
ADHD has been talking has been taken the psychostimulant methylphenidate Ritalin for
two weeks which assessment finding providing by the child mothers most significant in
planning nursing care for this child \u2714\u2714has not had a bm in 2 days<\/p>\n","protected":false},"excerpt":{"rendered":"
Four hours following surgical repair of a compound fracture of the right ulna, the nurseis unable to palpate the client’s right radial pulse. Which action should the nurse takefirst \u2714\u2714Elevate the client’s right hand on one or two pillowsAfter placing a 36- week- gestation newborn in an isolette and drying the infant withseveral blankets, what […]<\/p>\n","protected":false},"author":1,"featured_media":0,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"site-sidebar-layout":"default","site-content-layout":"","ast-site-content-layout":"default","site-content-style":"default","site-sidebar-style":"default","ast-global-header-display":"","ast-banner-title-visibility":"","ast-main-header-display":"","ast-hfb-above-header-display":"","ast-hfb-below-header-display":"","ast-hfb-mobile-header-display":"","site-post-title":"","ast-breadcrumbs-content":"","ast-featured-img":"","footer-sml-layout":"","ast-disable-related-posts":"","theme-transparent-header-meta":"","adv-header-id-meta":"","stick-header-meta":"","header-above-stick-meta":"","header-main-stick-meta":"","header-below-stick-meta":"","astra-migrate-meta-layouts":"default","ast-page-background-enabled":"default","ast-page-background-meta":{"desktop":{"background-color":"","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""},"tablet":{"background-color":"","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""},"mobile":{"background-color":"","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""}},"ast-content-background-meta":{"desktop":{"background-color":"var(--ast-global-color-5)","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""},"tablet":{"background-color":"var(--ast-global-color-5)","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""},"mobile":{"background-color":"var(--ast-global-color-5)","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""}},"footnotes":""},"categories":[25],"tags":[],"class_list":["post-120655","post","type-post","status-publish","format-standard","hentry","category-exams-certification"],"_links":{"self":[{"href":"https:\/\/www.learnexams.com\/blog\/wp-json\/wp\/v2\/posts\/120655","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/www.learnexams.com\/blog\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/www.learnexams.com\/blog\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/www.learnexams.com\/blog\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/www.learnexams.com\/blog\/wp-json\/wp\/v2\/comments?post=120655"}],"version-history":[{"count":0,"href":"https:\/\/www.learnexams.com\/blog\/wp-json\/wp\/v2\/posts\/120655\/revisions"}],"wp:attachment":[{"href":"https:\/\/www.learnexams.com\/blog\/wp-json\/wp\/v2\/media?parent=120655"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/www.learnexams.com\/blog\/wp-json\/wp\/v2\/categories?post=120655"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/www.learnexams.com\/blog\/wp-json\/wp\/v2\/tags?post=120655"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}