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204 term lzb During a home health assessment the nurse witnesses a school age child fall from a second story window. Which is the priority action?Tell the child not to move Do not rule out spinal cord injury A unit manager observes several nurses working throughout the day.. Which action represents a breach in client confidentiality ?Posting positive information about a client on social media website.A client who is newly admitted requests information about advanced directives. The nurse should include which of the following statements in discussion ?I will give you a pamphlet with written information about advanced directives.A nurse completes a home health assessment on an older adult who has a broken arm and burns to the chest. Which action is needed at this time?Contact adult protective services.A client arrives to the ED and reports HA, neck stiffness and sensitivity to light. Which is the priority nursing action?Implement droplet precautions- possible meningitis (highly contagious if bacterial) A bladder irrigation is prescribed for a client who has an occluded indwelling cath. Which action should nurse take when unsure of how to perform this procedure?Refer to the policy and procedure manual
A charge nurse reviews abbreviations in client documentation. Which is an approved entry?Furosemide 60 mg PO daily A nurse participates in quality improvement to decrease hospital readmissions for clients who have heart failure. .Which action should the nurse expect to perform?Compare performance to current practice standards A nurse assigns care for client who has DM to an LPN and a UAP. Which task should be given to the LPN?Obtain capillary glucose A client with a stage IV pancreatic cancer decides to DC all treatment. Which action should the nurse take?Ask client to discuss decision A nurse receives a client's medication over the telephone from the provider. Which action should the nurse take?Repeat the prescription back to the provider A nurse receives end of shift report. Which of the following client assessment findings should nurse address first ?New onset of confusion in client with L femur fracture ( Fat emboli risk/ Hypoxia) A nurse should notify public health about which infections?-gonorrhea -hep C -Chlamydia -Meningococcal A client with a new diagnosis of stage IV lung cancer, when partner requests the dx be withheld from the client, which action should the nurse take ?Request additional information from partner A nurse reviews the plan of care for client who has myasthenia gravis. Which intervention requires a revision?Assist with daily activities prior to medication admin A client who has COPD is prescribed ipatropium. The nurse should instruct the client to report which sx immediately ?Eye pain An older adult client who is receiving a blood transfusion develops an increased BP and crackles bilaterally. Which medication should nurse administer?Furosemide ( fluid overload)
A nurse provides teaching to a client who is prescribed spironolactone. Nurse should limit the intake of which foods?Bananas Tomatoes Avocados Sweet potatoes A client is prescribed acetaminophen 650 mg PO every 4 hours PRN. which finding should alert the nurse to question this prescription ?reports drinking 6 beers daily A school age child with ADHD is observed having increased concentration and ability to complete tasks. Nurse recognizes which medication may contribute to this?Methylphenidate An unresponsive client is brought in with a RR of 8 with pinpoint pupils. Which med should be given?Naloxone A nurse providing discharge instructions to a client who is newly prescribed lisinopril. Which statement indicates teaching was effective?-it is an emergency if mouth begins to swell -if I develop a cough my doctor will be notified -my K level will need to be monitored -getting up quickly may cause me to feel dizzy A nurse provides care to client receiving chemo. Which action is appropriate if it spills on the floor?Use a spill kit A client has a sulfamethoxazole allergy, the nurse should question which medication ?Glipizide A nurse prepares to administer morphine 2mg IV. The vial available has 4mg per 2 ml. Which action should be taken?Waste 1 mL with another nurse The electronic medication list is different from the client's medication. Which action should the home health nurse perform?Clarify the prescription with the provider An older adult receiving TPN states, I am having trouble breathing. " The nurse should perform which action?Evaluate fluid volume status
A client who has cellulitis reports a pain level of 2. The nurse should plan to administer which medication ?Ibuprofen PO A client is prescribed sulcrafate for treatment of a duodenal ulcer. Which statements indicate effective teaching ?-I should drink 2000 mL of water each day -This will turn into a paste and cover the ulcer -My diet will include more fruits + vegetables -This medication will be taken 1 hr before meals A client with a DVT is receiving heparin, current labs show a aPTT of 40 seconds. Which action should the nurse implement ?Increase the infusion A young adult is prescribed levetiracetam for seizure disorder. Which information should the nurse discuss ?Mild periods of drowsiness may occur during the day A client is prescribed clozapine. The nurse should monitor for which complication ?Dyslipidemia A client is prescribed aldendronate tablets. Which information should be included in the teaching ?Sit upright for 30 min after taking A client prescribed phenelzine asks Why must I stop adding parmesan cheese to pasta. The nurse understands which complication may occur with this ?HTN Crisis A nurse should take which action before administering levothyroxine to a client on continuous enteral tube feeding.Pause infusion pump for 30 minutes A nurse is caring for a client with an implanted venous port, which action should be implanted prior to administering medication?Access port using a non coring needle Prior to administering scheduled enoxaparin, which lab should the nurse evaluate ?Plts