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The nurse manager of a medical-surgical intensive care area is identifying clients who can be transferred to a general medicine unit. Which client condition supports being transferred to a less acute care area at this time?
The nurse admits a female client to the emergency department who arrives with a black eye and reports of headache, chronic pain, GI problems, menstrual irregularities, and anxiety. A previous physical workup was negative. The nurse should assess the client for which priority problems? Select all that apply.
The nurse is assessing a school-age child. Which finding by the nurse may indicate physical neglect?
The nurse is treating a client who continues to return to a violent relationship saying, “There is nothing I can do.” What is the nurse’s best response?
A young man is brought to the emergency department as a victim of a multivehicle accident that caused multiple casualties. The man is awake and alert. He has a fracture of his right tibia and several small lacerations on his face. How will the triage nurse categorize this client?
The nurse is providing preoperative teaching to a teenaged client with appendicitis. Which information should the nurse include about postoperative activity?
A major portion of a construction project has collapsed. The emergency department (ED) has been notified that numerous victims are being transported to the ED. What should be the first action of the ED nurses?
The nurse would take which actions to comply with the principles of medical asepsis? Select all that apply.
The client has been diagnosed with Trichomonas vaginitis. The nurse explains during client teaching that this infection can affect fertility by which mechanism?
During a prenatal visit in the second trimester, which item reported by the client should be a cause for concern?
When beginning to present information about heart disease to a newly diagnosed client, what is most important for the nurse to do first?
A Native American client who has a low-grade fever tells the nurse on the reservation that he will only use a sweat lodge to treat his illness. Which approach by the nurse would be most therapeutic?
The nurse is teaching an adolescent client who is preparing for a long-distance running event about eating for competition. Does the nurse explain which type of meal is most appropriate before the competition?
The nurse who has completed an assessment of a Hispanic client determines that some cultural food practices place the client at risk for cardiovascular disease. Which suggestion by the nurse is appropriate?
The nurse is preparing to administer a watery medication via intramuscular injection into the deltoid muscle of a 73-kg (160-lb) male. What is the preferred needle size for the medication, muscle, and weight of the client?
A 4-month-old client has D 5 1 / 2 D512 NS IV prescribed to run at a rate of 40 mL/hr. While the unlicensed assistant obtains an infusion pump, the nurse sets the drip rate at how many drops/minute, using a Soluset with micro drip tubing (drop factor of 60 gtt/mL)? Provide a numerical answer. Record your answer rounding to the nearest whole number.
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The family of a home infusion client calls the home health nurse one night to report that the electronic infusion pump alarm is sounding. What should the nurse anticipate as the cause of the infusion pump alarming? Select all that apply.
The nurse is teaching a client recovering from staphylococcus food
poisoning on ways to prevent this infection from occurring in the future.
What should the nurse include when providing these instructions to the
client? (Select all that apply.)
Which clients can be appropriately assigned to a newly graduated RN who has recently completed orientation? Select all that apply.
A client’s family member comes to the nurse’s station and says, “He needs more pain medicine. He is still having a lot of pain.” What is the nurse’s best response?
Pain disorder and depression have been diagnosed for a client. He reports chronic low back pain and states, “None of these doctors has done anything to help.” Which client statement is cause for greatest concern?
A patient has been taking prednisone 20 mg orally each day for 10 days for a severe allergic skin reaction. The patient tells the nurse that she no longer needs to take the prednisone because she is feeling better and the reaction has cleared up. What is the nurse’s best response?
A patient visits the urgent care clinic with a bacterial respiratory infection. The nurse will anticipate the need for patient teaching about which medication?
Which intervention can facilitate healing and humanization of the critical care environment?
A patient with facial trauma is unable to eat after surgery. His albumin level is 1.5. Which nutritional alteration is the patient experiencing?
A patient has low albumin, prealbumin, and transferrin levels with a decreased total lymphocyte count. Which nursing diagnosis is a priority for this patient?
The nurse is providing dietary education for the patient with hypertension. The patient asks what the DASH diet is. Which comment is appropriate for the nurse to make?
The patient is complaining of chest pain (9 of 10 on the pain scale) that has continued for 20 minutes without relief from rest or nitroglycerin. What is the primary nursing diagnosis?
A postoperative patient with a history of intractable pain is receiving fentanyl IV. The nurse is preparing to suction the patient’s endotracheal tube and notes that the high-pressure alarm is sounding. When the nurse attempts to ventilate with a bag-valve-mask, it suddenly requires a lot more effort to ventilate the patient. What do these findings suggest about the fentanyl?
The nurse is explaining to the student nurse why pain assessment is known as the “fifth vital sign.” Which statements indicate an understanding of this concept? (Select all that apply.)
The nurse is assessing a patient with a patient-controlled analgesic device (PCA) who is receiving morphine. The nurse notes that the patient has made 20 attempts but has only received four doses from the drug. What does this finding suggest? (Select all that apply.)
Which snack selection would be most appropriate for the nurse to make for a client with cancer who has stomatitis?
Public health nurses have been activated to open a shelter due to an approaching hurricane. What most important items should families be encouraged to take to the emergency shelter?
The nurse has applied elbow splints on a confused client to prevent the client from removing the intravenous (IV) line. Which of the following interventions is required?
A client who is lactose intolerant is recovering from a surgical procedure. What impact should the nurse expect this to have on progression of diet as tolerated?
A Code Red (fire) has been announced on the hospital unit. What is the nurse’s first response?
Which information would the nurse omit from written documentation when a reportable incident has occurred?
A client is placed on enteral feedings via nasogastric tube to meet nutritional goals. Which intervention should the nurse include in the plan of care to help maintain fluid balance?