A client receives a new prescription for simvastatin (Zocor) 5 mg PO daily at bedtime. What action should the nurse take? (correct Answer- Administer the medication as prescribed with a glass of water
Which client should the nurse assess frequently because of the risk for overflow incontinence? A client Who is confused and frequently forgets to go to the bathroom
While monitoring a client during a seizure, which interventions should the nurse implement? (Select all that apply) (correct AnswerMove obstacle away from client Monitor physical movements Observe for a patent airway Record the duration of the seizure
A male client with a long history of alcoholism is admitted because of mild confusion and fine motor tremors. He reports that he quit drinking alcohol and stopped smoking cigarettes one month ago after his brother died of lung cancer. 1 / 4 Which intervention is most important for the nurses to include in the client’s plan of care? (correct Answer- Observe for changes in level of consciousness.
An older adult female admitted to the intensive care unit (ICU) with a possible stroke is intubated with ventilator setting of tidal volume 600, PlO2 40%, and respiratory rate of 12 breaths/minute. The arterial blood gas (ABG) results after intubation are PH 7.31. PaCO2 60, PaO2 104, SPO2 98%, HCO3 23. To normalize the client’s ABG finding, which action is required? correct Answer- Increase ventilator rate.
The mother of the 12- month-old with cystic fibrosis reports that her child is experiencing increasing congestion despite the use of chest physical therapy (CPT) twice a day, and has also experiences a loss of appetite. What instruction should the nurse provide? (correct Answer- CPT should be performed more frequently, but at least an hour before meals.
The nurse is evaluating the diet teaching of a client with hypertension. What dinner selection indicates that the client understands the dietary recommendation for hypertension? (correct Answer- Baked pork chop, applesauce, corn on the cob, 2% milk, and keylime pie
A client with type 2 diabetes mellitus is admitted for frequent hyperglycemic episodes and a glycosylated hemoglobin (HbA1c) of 10%. Insulin glargine 10 units subcutaneously once a day at bedtime and a sliding scale with insulin aspart q6h are prescribed. What action should the nurse include in this client’s plan of care? (correct Answer- Fingerstick glucose assessment q6h with meals Review with the client proper foot care and prevention of injury Coordinate carbohydrate controlled meals at consistent times and intervals Teach subcutaneous injection technique, site rotation and insulin management
Which problem reported by a client taking lovastatin requires the most immediate fallow up by the nurse? 2 / 4 (correct Answer- Muscle pain
While assessing a client’s chest tube (CT), the nurse discovers bubbling in the water seal chamber of the chest tube collection device. The client’s vital signs are: blood pressure of 80/40 mmHg, heart rate 120 beats/minutes, respiratory rate 32 breaths/minutes, oxygen saturation 88%. Which interventions should the nurse implement? (correct Answer- Provide supplemental oxygen Auscultate bilateral lung fields Reinforce occlusive CT dressing
Before leaving the room of a confused client, the nurse notes that a half bow knot was used to attach the client’s wrist restraints to the movable portion of the client’s bed frame. What action should the nurse take before leaving the room? (correct Answer- Ensure that the knot can be quickly released.
Oral antibiotics are prescribed for an 18-month-old toddler with severe otitis media. An antipyrine and benzocaine-otic also prescribed for pain and inflammation. What instruction should the nurse emphasize concerning the installation of the antipyrine/benzocaine otic solution? (correct Answer- Have the child lie with the ear up for one to two minute after installation.
An older adult male is admitted with complications related to chronic obstructive pulmonary disease (COPD). He reports progressive dyspnea that worsens on exertion and his weakness has increased over the past month. The nurse notes that he has dependent edema in both lower legs. Based on these assessment findings, which dietary instruction should the nurse provide? (correct Answer- Restrict daily fluid intake.
The nurse inserts an indwelling urinary catheter as seen in the video what action should the nurse take next? (correct Answer- Leave the catheter in place and obtain a sterile catheter. 3 / 4
A client with coronary artery disease who is experiencing syncopal episodes is admitted for an electrophysiology study (EPS) and possible cardiac ablation therapy. Which intervention should the nurse delegate to the unlicensed assistive personnel (UAP)? (correct Answer- Prepare the skin for procedure.
Fallowing an outbreak of measles involving 5 students in an elementary school, which action is most important for the school nurse to take? (correct Answer- Restrict unvaccinated children from attending school until measles outbreak is resolved.
A preeclamptic client who delivered 24h ago remains in the labor and delivery recovery room. She continues to receive magnesium sulfate at 2 grams per hour. Her total input is limited to 125 ml per hour, and her urinary output for the last hour was 850 ml. What intervention should the nurse implement? (correct Answer- Continue with the plan of care for this client
The nurse is planning care for a client who admits having suicidal thoughts. Which client behavior indicates the highest risk for the client acting on these suicidal thoughts? (correct Answer- Begin to show signs of improvement in affect
When assessing a multigravida the first postpartum day, the nurse finds a moderate amount of lochia rubra, with the uterus firm, and three fingerbreadths above the umbilicus. What action should the nurse implement first? (correct Answer- Check for a destined bladder
A 12 year old client who had an appendectomy two days ago is receiving 0.9% normal saline at 50 ml/hour. The client’s urine specific gravity is 1.035. What action should the nurse implement? (correct Answer- Encourage popsicles and fluids of choice
An older male client arrives at the clinic complaining that his bladder always feels full. He complains of weak urine flow, frequent dribbling after voiding, and
