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A nurse is caring for a client who has bipolar disorder and is experiencing acute mania. The nurse obtained a verbal prescription for restraints. Which of the following should the actions the nurse take?
A. Request a renewal of the prescription every 8 hr.
B. Check the client's peripheral pulse rate every 30 min
C. Obtain a prescription for restraint within 4 hr.
D. Document the client's condition every 15 minutes
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Terms in this set (14)
A nurse is caring for a client who has bipolar disorder and is experiencing acute mania. The nurse obtained a verbal prescription for restraints. Which of the following should the actions the nurse take?
A. Request a renewal of the prescription every 8 hr.
B. Check the client's peripheral pulse rate every 30 min
C. Obtain a prescription for restraint within 4 hr.
D. Document the client's condition every 15 minutes
D. Document the client's condition every 15 minutes
A nursing planning care for a school-age child who is 4 hr postoperative following perforated appendicitis. Which of the following actions should the nurse include in the plan of care?
a. Offer small amounts of clear liquids 6 hr following surgery (assess for gag reflex first)
b. Give cromolyn nebulizer solution every 6 hr (for asthma)
c. Apply a warm compress to the operative site every 4 hr
d. Administer analgesics on a scheduled basis for the first 24 hr
d. Administer analgesics on a scheduled basis for the first 24 hr
A nurse is receiving change-of-shift report for a group of clients. Which of the following clients should the nurse plan to assess first?
a. A client who has sinus arrhythmia and is receiving cardiac monitoring
b. A client who has diabetes mellitus and a hemoglobin A1C of 6.8% c. A client who has epidural analgesia and weakness in the lower extremities
d. A client who has a hip fracture and a new onset of tachypnea
d. A client who has a hip fracture and a new onset of tachypnea
A nurse is preparing to apply a transdermal nicotine patch for a client. Which of the following actions should the nurse take?
a. Shave hairy areas of skin prior to application (apply to hairless, clean & dry areas to promote absorption; avoid oily or broken skin)
b. Wear gloves to apply the patch to the client's skin
c. Apply the patch within 1 hr of removing it from the protective pouch (apply immediately)
d. Remove the previous patch and place it in a tissue (fold patch in half with sticky sides pressed together)
b. Wear gloves to apply the patch to the client's skin
A nurse is caring for a client who is at 33 weeks of gestation following an amniocentesis. The nurse should monitor the client for which of the following complications?
A. Vomiting
B Hypertension
C Epigastric pain
D Contractions
D. Contractions
A nurse is providing teaching to an older adult client about methods to promote nighttime sleep. Which of the following instructions should the nurse include?
A Stay in bed at least 1 hr if unable to fall asleep
B Take a 1 hr nap during the day
C Perform exercises prior to bedtime
D Eat a light snack before bedtime
D. Eat a light snack before bedtime
A nurse on a telemetry unit is caring for a client who becomes unconscious and whose monitor displays ventricular tachycardia. Which of the following actions should the nurse take first after determining the client does not have a palpable pulse?
•A. Assess heart sounds
•B. Defibrillate
•C. Establish IV access
•D. Administer epinephrine
B. Defibrillate
A nurse is admitting a client who 1 week postpartum and reports excessive vaginal bleeding. The nurse does not speak the same language as the client. The client's partner and 10-year-old child are accompanying her. Which of the following actions should the nurse take to gather the client's admission data?
•A. Have the client's child translate
•B. Allow the client's partner to translate
•C. Request a female interpreter through the facility
•D. Ask a nursing student who speaks the same language as the client to translate
C. Request a female interpreter through the facility
A nurse is caring for a client who is febrile (High fever). To reduce the client's fever, the nurse applies a cooling blanket. Which of the following findings indicates the client is having an adverse reaction to the cooling?
•A. Flushing
•B. Tachycardia
•C. Restlessness
•D. Shivering (Hypothermic)
D. Shivering (Hypothermic)
A nurse is reviewing assessment data from several clients. For which of the following clients should the nurse recommend referral to a dietitian?
A. An older adult client who has a BMI of 24(18.5-24.9)
B. A client who has a non-healing leg ulcer (diet isn't good)
C. An older adult client who has presbyopia (age related far-sightedness)
D. A client who has an albumin level of 3.7 g/dL (normal 3.4-5.4)
B. A client who has a non-healing leg ulcer (diet isn't good)
A nurse is providing discharge teaching to a client who has a chronic kidney disease and is receiving hemodialysis. Which of the following instructions should the nurse include in the teaching? a. Eat 1 g/kg of protein per day b. Take magnesium hydroxide for indigestion c. Drink at least 3 L of fluid daily d. Consume foods high in potassium- restricta. Eat 1 g/kg of protein per dayA nurse is caring for a client who is receiving intermittent enteral tube feedings. Which of the following places the client at risk for aspiration? a. Sitting in a high-Fowler's position during the feeding b. A history of gastroesophageal reflux disease c. Receiving a high osmolarity formula d. A residual of 65 mL 1 hr postprandial?b. A history of gastroesophageal reflux diseaseA nurse is providing prenatal teaching to a client who is at 12 weeks of gestation. The nurse should tell the client that she will undergo which of the following screening tests at 16 weeks of gestation? a. Chorionic villus sampling b. Cervical cultures for chlamydia c. Non-stress test d. Maternal serum alpha-fetoprotein- 16 to 18 weeksd. Maternal serum alpha-fetoprotein- 16 to 18 weeks. A nurse is caring for a client who is on bed rest. The nurse should recognize that which of the following findings is a complication of immobility? a. Decreased serum calcium levels- increased serum calcium b. Increased blood pressure- hypotension c. Swollen area on calf d. Urinary frequencyc. Swollen area on calf