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1. a client with stage IV bone cancer is admitted to the hospital for a 1 to 10 scale. Which intervention should the nurse implement Answer: administer opioid and non-opioid medication simultaneously 2. During spring break, a young adult presents at the urgent care clinic and report headache. Which intervention is most important for the nurse to implement? Answer: initiate isolation precautions 3. After a colon resection for colon cancer, a male client is moaning while being transported to the unit (PACU). Which intervention should the nurse implement first? Answer: determine clients pulse, blood pressure, and respiration 4. Which nursing problem has the highest priority when planning care for a client with osteomalacia? Answer: risk for injury 5. A client who took a camping vacation two weeks ago in a country with a tropical climate comes symptoms and diarrhea for the past week. Which finding is most important for the nurse report? Answer: jaundice sclera 6. a client admitted to a surgical unit is being evaluated for an intestinal obstruction. The healthcare prescribed nasogastric tube (NGT) to be inserted and placed to intermittent low wall suction. Which intervention –to facilitate proper tube placement? Answer: elevate the head of bed 60 to 90 degrees 7. when explaining dietary guidelines to a client with acute glomerulonephritis (AGN), which instruction should the nurse include in the dietary teaching? Answer: restrict sodium intake 8. a client with chronic kidney disease is started on hemodialysis, during the first treatment the client’s blood pressure 150/90 mm hg to 80/30 mm hg. Which action should the nurse take first? Answer: lower the head of the chair and elevate feet 9. a client with urolithiasis is preparing for discharge after lithotripsy. Which intervention should the nurse postoperative discharge instruction? Answer: monitor urinary stream for decrease in output 10. a client with sickle cell anemia develops a fever during the last hour of administration of a unit of packed red blood notifying the healthcare provider, what information should the nurse provide first using the SBAR (situation, background, assessment, and recommendation ) communication process? Answer: preface the report by stating the clients name and admitting diagnosis 11. Intermittent claudiation with leg pain… Answer: Encourage progressive exercise. 12.Three months after Dx of T2DM pt and noncompliance to Tx regimen….. Answer: Check A1c. 13. Client with SIADH complains of dry mouth and thirsty…. Answer: Give hard candy. 14. Client with emphysema with CT drain change from green to clear liquid. Answer: Tx is effective, document, continue to monitor pt. 15. Pt with multiple transplant reaction to report to HCP (healthcare professional) Answer: Lower back pain and hypotension. 16. Fracture of left femur + fixation complain of pain. Answer: Assess peripheral pulse. 17. Nursing care goal for preop client. Answer: A physical and emotional preparedness. 18. Iron deficiency anemia client selected food requiring further teaching. Answer: Orange. Help in iron absorption but not reach in iron. 19. CVA client with expressive aphasia frustrated. Answer: Use communication board. 20. 2hrs Post op laparoscopy client demanding for food.
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