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A nurse is caring for a pt who is receiving continuous NGT feedings. Nurse listens to bowel sounds. Which of the following actions should the nurse take? (Has clip for you to listen to) - ANSWERDecrease the rate of feeding A nurse is preparing to to remove client peripheral IV catheter. After hand hygiene and applying don clean gloves, which of the following actions should the nurse take first? - ANSWERclamp the infusion tubing
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A nurse is caring for a pt who is receiving continuous NGT feedings. Nurse listens to bowel sounds. Which of the following actions should the nurse take? (Has clip for you to listen to) - ANSWERDecrease the rate of feeding A nurse is preparing to to remove client peripheral IV catheter. After hand hygiene and applying don clean gloves, which of the following actions should the nurse take first? - ANSWERclamp the infusion tubing a nurse is contributing to the plan of care for a client who has a positive throat culture for streptococci. Which of the following interventions should the nurse recommend to be included in the plan of care? - ANSWEREnsure client wears a surgical mask during transportation throughout facility. A nurse is caring for a pt who has just died and practiced his Islamic faith. Which of the following cultural practices should the nurse expect? - ANSWERThe clients face should be turned towards Mecca. A nurse is preparing to administer oxygen to a pt who has heart failure and is having severe difficulty breathing. Which of the following oxygen delivery equipment should the nurse select to provide highest concentration oxygen to the client? - ANSWERNon-rebreather mask A charge nurse who sells smoke, enters the visitor restroom, and sees flames in the trash can. What is the sequence of actions that the nurse should take? - ANSWER1. Evacuate Clients from area
A client who has advanced cancer tells the nurse they have a difficult time talking to anyone about the illness. Which of the following actions should the nurse take to encourage therapeutic communication? - ANSWERLet the client know, as their nurse, you are available to listen A nurse is preparing to transport a client to an acute care facility to a long term care facility. Which of the following information should the nurse plan to include in the transfer report? - ANSWERResolved health conditions A nurse is contributing to the plan of care for a client who has a prescription for elastic bandages to the lower extremities. Which of the following actions should the nurse recommend for the plan of care? - ANSWERCompare the clients pedal pulses bilaterally every 4 hours A nurse is taking notes of client information on a piece of paper while receiving the report. Which of the following actions should the nurse take while disposing the paper? - ANSWERShred the paper in a secured container A nurse is assisting with care of a recently deceased pt. Which of the following actions should the nurse take prior to the family views the body? - ANSWERClean soiled areas of the body A nurse is preparing to administer an enteral feeding tube to a client who has a NGT in place. Which of the following should the nurse do to verify correct placement of the NG Tube? - ANSWERCheck the pH of the gastric aspirate A nurse i A nurse is caring for a pt who has a terminal illness and the pt family member asks why the pt mouth is continually open. Which of the following should the nurse respond? - ANSWERThe reduced muscle tone has relaxed the jaw muscles. A nurse is caring for a postoperative client who is at risk for thrombus formation. Which of the following interventions should the nurse delegate to an assistive personal (AP)? - ANSWERApply thromboembolic stockings A nurse is preparing to collect data from a client for a health assessment. Which of the following actions should the nurse take? - ANSWERProvide privacy for pt A nurse is planning care for a client who is disorientated and at risk for falls. Which of the following interventions should the nurse include? (SATA) - ANSWER1. Reinforce teaching about call bell
nurse offer to break the pills not smaller pieces. The nurse is demonstrating which of the ethical principals? - ANSWERBeneficence A nurse is caring for a client who has Clostridium Difficile infection. Which of the following solutions should the nurse perform hand hygiene while caring for this client? - ANSWERmild soap A nurse is preparing to palpate a clients pulse. The nurse should recognize that which of the following pulses is located onto of a clients foot? - ANSWERDoralis Pedis A nurse is reinforcing teaching with a client about smoking cessation. Which of the following should the nurse identify the first stage of health behavior change? - ANSWERPrecontemplation A nurse is contributing to a plan of care for a client who has a new perscription for wrist restraint. Which of the following should the nurse include in the plan? - ANSWERPad Bony prominences on the wrist. A nurse is reviewing the medical record of a client who has heart failure. The nurse should identify which of the following laboratory results as an indication that the client hs fluid volume excess? - ANSWERBUN 8mg/dL A nurse is collecting data on four clients. Which of the following findings should the nurse report to the provider? - ANSWERUrine output of over 62/min A nurse is moving a client up in bed with assistance of a second nurse. Which of the following actions should the nurse take? - ANSWERPlace feet apart with the foot nearest the head of the clients bed in front of the other foot. A nurse is reviewing the vital sounds of four adult clients. Which of the following findings require further data collection by the nurse? - ANSWERA person with a pulse rate of 110/min A nurse is reinforcing teaching with an assistive personal (AP) about performing pulse oximetry. Which of the following information should the nurse include in the teaching? - ANSWERRemove polish from clients fingernails before applying oximetry probe A nurse is reinforcing teaching with a client about living wills. Which of the following client statements an understanding of the teaching? - ANSWERThe living wills directs my medical care when I am unable to make decisions. A nurse assisting with the plan of care for four clients. Which of the following tasks should the nurse assign to the assistive personal (AP)? - ANSWERAssist client out of bed after a breathing treatment A nurse is explaining ethics and values to a newly licensed nurse. The nurse should explain that allowing a client to make a decision about a treatment is an example of which of the following ethical principals? - ANSWERAutonomy
A nurse is reinforcing dietary teachings with a client who has chronic kidney disease and requires a low-potassium diet. Which of the following foods choices by the client demonstrated the understanding? - ANSWER1 cup of applesauce A nurse is repositioning a client who has quadruplegia and is in supine position. Which of the following actions should the nurse take to prevent client muscoskeletal injury? - ANSWERInternally rotate the clients hips by using a trochanter roll A nurse is reinforcing preoperative teaching with a client who speaks a different language than the nurse. Which of the following actions should the nurse take? - ANSWERProvide handouts written in the clients primary language to promote learning A nurse is reinforcing teaching with a client who has partial hearing loss about how to modify the home environment. Which of the following is a priority modification that the nurse should include? - ANSWERFlashing smoke alarm A nurse is reinforcing preoperative teaching with a client about how to turn, cough, and deep breathe. Which of the following statements by the client indicate an understanding of teaching? - ANSWERThis can help prevent pneumonia A nurse is assisting with a prescription to a group of older adults at a community enter about hypothermia, and hyperthermia. Which of the following information should the nurse include about age related changes? - ANSWERCirculation becomes less effective with age A nurse is reinforcing teaching about health promotion with a group of young adult client. Which of the following should the nurses include? - ANSWERYoung adults should receive a dental assessment every 6 months. A nurse is assisting with the plan of care for a client who has aphasia following a stroke. Which of the following interventions should the nurse use to assist the client communication? - ANSWERAsk client close ended questions. A nurse is reinforcing teaching about the use of crutches with a client who has fractured right tibia and fibula. Which of the following statements by the clients indicated an understanding of the teaching? - ANSWERI will be shy to keep the crutch tips dry. A nurse is assisting with the admission of a client who has active tuberculosis. Which of the following actions should the nurse plan to take? - ANSWERAssign the client to a negative-pressure airflow room The nurse is assisting with the admission of a client who has bought their medications to the facility. Which of the following actions should the nurse take? - ANSWERCompare the medications the provider has prescribed with clients medication medications from home.