A nurse in a pediatric unit is preparing to insert an IV catheter for 7-yearold. Which of the following actions should the nurse take? A. (Unable to read) B. Tell the child they will feel discomfort during the catheter insertion. C. Use a mummy restraint to hold the child during the catheter insertion. D. Require the parents to leave the room during the procedure.
A nurse is caring for a client who has arteriovenous fistula Which of the following findings should the nurse report? A. Thrill upon palpation. B. Absence of a bruit. C. Distended blood vessels D. Swishing sound upon auscultation.
A nurse is providing discharge teaching for a client who has an implantable cardioverter defibrillator which of the following statements demonstrates understanding of the teaching? A. “I will soak in the tub rather and showering” B. “I will wear loose clothing around my ICD” C. “I will stop using my microwave oven at home because of my ICD” D. “I can hold my cellphone on the same side of my body as the ICD”
A nurse is caring for a client who is at 14 weeks gestation and reports feelings of ambivalence about being pregnant. Which of the following responses should the nurse make? A. “Describe your feelings to me about being pregnant” B. “You should discuss your feelings about being pregnant with your provider” C. “Have you discussed these feelings with your partner?” D. “When did you start having these feelings?”
A nurse is planning care for a client who has a prescription for a boweltraining program following a spinal cord injury. Which of the following actions should the nurse include in the plan of care? A. Encourage a maximum fluid intake of 1,500 ml per day. B. Increase the amount of refined grains in the client’s diet. C. Provide the client with a cold drink prior to defecation. 3 / 4 D. Administer a rectal suppository 30 minutes prior to scheduled defecation times.
A nurse is caring for a client who is in active labor and requests pain management. Which of the following actions should the nurse take? A. Administer ondansetron. B. Place the client in a warm shower. C. Apply fundal pressure during contractions. D. Assist the client to a supine position.
a nurse in an emergency department is performing triage for multiple clients following a disaster in the community. To which of the following types of injuries should the nurse assign the highest priority? A. Below-the knee amputation B. Fractured tibia C. 95% full-thickness body burn D. 10cm (4in) laceration to the forearm
a nurse manager is updating protocols for the use of belt restraints. Which of the following guidelines should the nurse include? A. Remove the client’s restraint every 4hr B. Document the client’s condition every 15 min C. Attach the restrain to the bed’s side rails D. Request a PRN restrain prescription for clients who are aggressive
A nurse is teaching an in-service about nursing leadership. Which of the following information should the nurse include about an effective leader? A. Acts as an advocate for the nursing unit. B. (Unable to read) for the unit C. Priorities staff request over client needs. D. Provides routine client care and documentation.
A nurse is reviewing the laboratory findings of a client who has diabetes mellitus and reports that she has been following her (unable to read) care. The nurse should identify which of the following findings indicates a need to revise the client’s plan of care. A. Serum sodium 144 mEq/ B. (Unable to read) C. Hba1c 10 %
