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The nurse makes out assignments for nursing staff. How should the nurse position the chair to help transfer the client with a surgical repair of a fractured hip from the bed to a chair?
A client who has degenerative arthritis is admitted for a total hip replacement. When the client identifies an allergy to latex during admission, what is the best method for alerting all health care workers?
The nurse observes the unlicensed assistive personnel ambulating a blind client. What instruction to the unlicensed assistive personnel is best for maintaining the client’s safety and security?
The client has type A, Rh-positive blood. The licensed practical nurse is delegated by the registered nurse to obtain the blood from the facility laboratory. The nurse who is monitoring the administration of a unit of blood is concerned about the time it is taking for the blood to infuse. What is the maximum amount of time that a unit of blood is safe to infuse?
The registered nurse (RN) starts an infusion of whole blood and asks the licensed practical/vocational nurse (LPN/LVN) to continue monitoring the client during the blood transfusion. 17. According to the Joint Commission’s National Patient Safety Goals, what nursing action regarding blood administration is most appropriate?
Bladder retraining is progressing slower than expected due to the client’s mental and physical limitations. An indwelling catheter is inserted. A nurse must collect a sterile urine specimen from a client with an indwelling catheter. What nursing action is appropriate?
A client presents to the clinic in the last month of pregnancy. The client has significant anxiety regarding invasive procedures such as an I.V. line and internal fetal monitoring that may be required during labor and birth. The health care provider, nurses, and client prepare a plan limiting invasive procedures yet maintaining appropriate fetal monitoring and an acceptable pain level for the client. Just before inserting the needle into the muscle for a Z-track injection, the nurse appropriately pulls the tissue at the injection site in what direction?
The newborn is recovering postoperatively from surgical repair of a cleft lip when the nurse assesses frequent movement of the arms and legs. What restraint is best for the nurse to obtain at this time?
Two parents express frustration because their child has frequent outbreaks of impetigo. The nurse assesses their knowledge of the disease process. What statement by a parent indicates a need for additional teaching?
Approximately 36 hours after admission, the client with alcohol use disorder becomes restless and shouts that, “The bugs in this room are disgusting!”. In this situation, what nursing action is most appropriate?
A client with a fractured femur is in skeletal traction with a pin through the distal femur. The affected leg is supported by balanced suspension. What material is best for the nurse to use to cover the tips of the pin to prevent injuries?
The nurse interacts with a client who has developed a type of conjunctivitis, commonly called pinkeye. What health teaching is appropriate for the nurse to provide? Select all that apply.
The discharge instructions indicate that the client must temporarily wear a metal shield over the operative eye while sleeping. When the client asks the nurse about the purpose of the eye shield, what explanation is best?
The client has type A, Rh-positive blood. The licensed practical nurse is delegated by the registered nurse to obtain the blood from the facility laboratory. The nurse prepares to discontinue the transfusion tubing and empty container of blood when the transfusion is completed. What nursing action is best for disposing the equipment?
While the tube-feeding formula is infusing, the client tells the nurse about feeling full and nauseated. What nursing action is best for preventing bacterial contamination of tube-feeding formula?
A client with type 1 diabetes mellitus reports having urinary problems. When the nurse interviews the client, what symptom(s) will the client most likely report if a bladder infection has been acquired? Select all that apply.
A 30-year-old primigravid client is admitted to the labor, delivery, recovery, and postpartum (LDRP) unit of a local hospital. The health care provider plans to perform a vaginal examination to determine the status of labor. How can the nurse best prepare to assist with the vaginal examination?
The newborn is recovering postoperatively from surgical repair of a cleft lip when the nurse assesses frequent movement of the arms and legs. When developing a nursing intervention for a newborn who has undergone surgery to correct a cleft lip, how frequently should the nurse plan to remove and reapply the restraints?
Two parents express frustration because their child has frequent outbreaks of impetigo. The nurse assesses their knowledge of the disease process. The nurse is caring for an adolescent who developed this rash immediately after clearing brush. What statement, made by the client, requires clarification?
A 68-year-old client who is currently being treated for major depression is transferred to a medical unit after an episode of acute abdominal pain. What nursing action is especially important when administering medications to a client with depression?
A spinal tap will be performed to confirm a diagnosis of meningitis. While awaiting the diagnostic test results for a client with possible meningitis, what transmission-based precautions are best to implement?
A 35-year-old seeks medical attention to determine the reason menstruation has ceased. A radioactive iodine uptake test is prescribed. After the radioactive iodine uptake test, what nursing instruction is most accurate?
When checking the label on the blood, what blood type would the nurses identify as being incompatible?
The nurse reviews the hereditary implications and precipitating factors of sickle cell anemia with the client. How can the nurse be best protected from acquired immunodeficiency syndrome (AIDS) when caring for a client with an unknown infectious status?
Internal radiation therapy is used to treat the client who has been diagnosed with advanced cervical cancer. An applicator containing radioactive material is inserted into the client’s vagina. Because the client is receiving this type of radiation therapy, what nursing intervention(s) should the nurse include in the care plan? Select all that apply.
A cooling blanket is prescribed to reduce the fever of a client with meningitis. When implementing this medical prescription, what nursing action is most appropriate?
A client who develops a benign parathyroid tumor manifests signs of hyperparathyroidism. The unlicensed assistive personnel assigned to this client asks why the plan of care indicates that the client is at risk for falls and injury. What is the best nursing explanation?
A high school student presents with fatigue and a low-grade fever. The nurse includes health teaching on transmission precautions when caring for the client with infectious mononucleosis. What information is most appropriate?
The client returns from surgery, which was performed under spinal anesthesia. When the nurse is reviewing postoperative prescriptions, what prescription should the nurse question?
Following the nephrectomy, the client has been receiving morphine sulfate regularly for pain. During a nurse’s shift on the urology unit, the nursing supervisor notifies the nursing personnel that a tornado warning has been issued. What action is appropriate at this time?
A nurse volunteers to do blood pressure screenings at a local community hospital’s annual health fair. As the nurse prepares to take a person’s blood pressure, what observation indicates that the current aneroid sphygmomanometer will not measure the blood pressure accurately?
The nurse in a long-term care facility is required by the state’s law to test all newly admitted clients for tuberculosis. The policy of the agency is to administer a Mantoux skin test. When a previously negative client has a positive reaction to a tuberculin skin test, what action is taken next?
The college student is diagnosed with hepatitis A. When the client asks the nurse how the hepatitis A was acquired, what is the best answer?
The nurse is brushing the teeth of a client who is unconscious. How should the client be positioned?
Internal radiation therapy is used to treat the client who has been diagnosed with advanced cervical cancer. An applicator containing radioactive material is inserted into the client’s vagina. If the nurse finds the radioactive insert in the client’s bed, what nursing action is most appropriate?
The health care provider arrives for birth and requests that the client be prepared for epidural anesthesia. What sequence should the nurse follow when cleaning the client’s perineum in preparation for birth of the newborn?
The health care provider prescribes an I.V. infusion of dextrose 2.5% in normal saline solution. The nurse is assessing the intravenous site of the infant pictured. When assessing the lower extremity, which indicates an early sign of infiltration?
Before leaving the clinic, the client asks the nurse, “When can I be certain that I am no longer infectious?”. The nurse correctly advises the client that she is still considered infectious until she:
A 70-year-old client with dementia removes clothing and walks naked through the halls of a long-term care facility. What nursing action is best when caring for clients in a nursing facility when there is a community outbreak of influenza?
A 15-year-old adolescent who has a history of truancy and shoplifting has been referred for care in an adolescent treatment center with a diagnosis of conduct disorder. What nursing action should the nurse take initially when the adolescent displays cues of becoming violent?
A 23-year-old client who experienced a generalized seizure while at work is admitted to the hospital for diagnostic testing. When the client tells the nurse about being allergic to kiwifruit, to what other hospital substance should the nurse anticipate the client may develop an allergic reaction?
Enalapril, an angiotensin-converting enzyme (ACE) inhibitor, is prescribed to a client’s medication regimen. The nurse documents the following morning assessment: What nursing measure should the nurse include initially when a client begins treatment with an antihypertensive medication?
A 79-year-old client is admitted for treatment of multiple myeloma. What type of infection control measure is appropriate when providing nursing care for this client?
A 52-year-old client is admitted to the ambulatory surgery department for the repair of an inguinal hernia. The nurse takes the signed operative consent form to the client to confirm the procedure. The form states that the surgical procedure will be a right inguinal herniorrhaphy. According to the patient safety goals, surgical site verification and time-out processes must be performed. Place the statements in the order in which they should occur. Use all the options.
1. Time-out is done immediately before starting the procedure in the location where the procedure will be performed.
2. The surgeon verifies the surgical site with the client, initialing the correct site with an appropriate marking pen.
3. The nurse reviews the surgical consent, noting the correct procedure and site.
4. The procedure begins after the time-out when staff is confident the correct procedure is being performed on the correct client.
5. Before positioning the client on the operating room table, the nurse identifies the client using the client’s name and birth date on the identification band.
6. All staff stops what they are doing and participates in the final verification, answering verbally when verifying the surgical site.
An infection control nurse is consulted on measures for reducing the potential transmission of the hepatitis A virus to others. On the basis of the routes of transmission for this disease, what infection control measure is essential to include in the client’s care plan?
When the nurse cares for the client with an indwelling retention catheter, what action(s) is helpful for preventing catheter-associated urinary tract infections (CAUTIs)? Select all that apply.
In the labor and delivery suite, the health care provider prescribes meperidine 100 mg intramuscularly. The nurse chooses to inject the meperidine via the Z-track (zigzag) method. What muscle is best for the nurse to select when administering the meperidine to the client?
What statement by the child indicates a need for further teaching about bicycle safety?
What type of precautions should the nurse implement to prevent the transmission of hepatitis B to others?
The client’s husband states that he has been diagnosed with a low sperm count. To improve sperm production, the nurse should instruct the client’s husband to avoid which activity(ies)? Select all that apply.