.png){kind=logo}
NCLEX Challenge 8 A nurse in a long-term care facility is caring for an older adult client who has dementia and begins to have frequent episodes of urinary incontinence. After the provider determines no medical cause for the client’s incontinence, which of the following interventions should the nurse initiate to manage this behavior?Take the client to the bathroom every 2 hr.A nurse is completing discharge teaching to a client about nutrition therapy for wound healing following major surgery. Which of the following vitamins that promote wound healing should the nurse include in the teaching? (Select all that apply.) Vitamin A Vitamin B12 Vitamin C Vitamin K A nurse at a community health clinic is caring for a client who reports a headache and stiff neck. Which of the following actions should the nurse take first?Evaluate the client’s neurological status.A nurse is in a client’s room when the client begins having a tonic-clonic seizure. Which of the following actions should the nurse take first?Turn the client’s head to the side.
A nurse is caring for a client who has a history of dementia. The client is alert and oriented to person, place, and time, and has advance directives. The client is scheduled for a procedure that requires informed consent. Which of the following persons should sign the informed consent?The client.A nurse is assessing for cyanosis in a client who has dark skin. Which of the following sites should the nurse examine to identify cyanosis in this client?Conjunctivae.A nurse is caring for a 2-year-old child who has seizures and is receiving phenytoin in suspension form.Which of the following actions should the nurse take before administering each dose?Shake the container vigorously.A nurse is teaching a client about nutritional requirements necessary to promote wound healing. Which of the following nutrients should the nurse include in the teaching?Protein.A nurse is caring for a client who has pruritus following treatment for scabies. Which of the following actions should the nurse take?Provide mittens for the client to wear at night.A nurse is caring for a client who has a suspected diagnosis of myasthenia gravis. The provider prescribes a Tensilon test. Which of the following findings indicates a positive test?Muscle contractions become progressively stronger.
A nurse is preparing a sterile field prior to inserting a urinary catheter for a client. Identify the sequence of steps the nurse should plan to follow.Perform hand hygiene Place package on work surface Open outermost flap away from self Open side flap, pulling to the side Open innermost flap toward self Use inner surface of package as sterile field A nurse in the emergency room is assessing a client who was brought in following a seizure. The nurse suspects the client may have meningococcal meningitis when assessment findings include nuchal rigidity and a petechial rash. After implementing droplet precautions, which of the following actions should the nurse initiate next?Assess the cranial nerves.A nurse is planning care for an older adult client who is at risk for developing pressure ulcers. Which of the following interventions should the nurse use to help maintain the integrity of the client’s skin?Use a transfer device to lift the client up in bed.A nurse working on a medical unit is caring for a client who is prescribed seizure precautions. Which of the following interventions should the nurse include in the client’s plan of care?Obtain IV access.A nurse is teaching a female client who has a new prescription for transdermal sumatriptan to treat migraine headaches. Which of the following instructions should the nurse include?“Use contraception while taking this medication.”
A nurse is caring for a client who reports a throbbing headache after a lumbar puncture. Which of the following actions is most likely to facilitate resolution of the headache?Increase fluid intake.A nurse is assessing a client who has Bell’s palsy. Which of the following findings should the nurse expect? (Select all that apply.) Muscle distortion Pain behind the ear Impaired taste A nurse is caring for a client who has a new diagnosis of myasthenia gravis. For which of the following manifestations should the nurse monitor?Weakness.A nurse is assessing a client’s wound dressing and observes a watery red drainage. The nurse should document this drainage as which of the following?Serosanguineous.A school nurse is performing a routine health assessment for a school-age child. Which of the following findings indicates the nurse should investigate further for pediculosis capitis?Pruritis of the scalp.
.png)