A client complains of a headache, nausea, and vomiting during a blood transfusion. Which one of the following actions should the nurse take immediately? 1. Check the vital signs. 2. Stop the blood transfusion. 3. Slow down the rate of blood flow. 4. Notify the health care provider and blood bank personnel. ANSWER ANS: […]
As a member of the safety committee, the nurse’s task is to identify actions to prevent falls within the organization. Which intervention should the nurse emphasize as important to prevent falls? 1. Display the phone number to the nurses’ station. 2. Keep electrical cords under the bed. 3. Keep the environment tidy. 4. Read label […]
A 73-year-old male client who normally sleeps on his right side recently underwent a right-side hip replacement surgery and now has trouble sleeping. One of the interventions that the nurse might try with this client is to: 1. Request medication to help the client sleep while in the hospital 2. Carefully prop the client on […]
The nurse is using medical asepsis when providing client care. Which action did the nurse demonstrate? 1. Administering parenteral medications 2. Changing a dressing 3. Performing a urinary catheterization 4. Using personal protective equipment ANSWER Correct Answer: 4 Rationale 1: Administering parenteral medications requires surgical asepsis. Rationale 2: Changing a dressing requires surgical asepsis. […]
The nurse working on the cardiac unit notes that the client has an S2 murmur, which the nurse understands is caused by: 1. Pulmonic or aortic valve backflow or regurgitation 2. Mitral valve backflow or regurgitation 3. Tricuspid valve backflow or regurgitation 4. Poor coronary arterial circulation ANSWER ANS: 1 Closure of aortic and […]
The 154-pound adult client has had vomiting and diarrhea for 4 days secondary to a viral infection. What hourly urine measurement would indicate that efforts to rehydrate this client have not yet been successful and should continue? 1. 35 mL per hour 2. 80 mL per hour 3. 50 mL per hour 4. 30 mL […]
The nurse knows that she needs to provide additional teaching to the client who makes which of the following statements? 1. “I’m so glad to find out that this is only a plantar wart—I was afraid it was something contagious like athlete’s foot.” 2. “The health care provider will remove this plantar wart by first […]
What is the correct order for a nursing assistant for putting on the protective equipment when caring for a client in isolation? 1. Wash her hands, apply the mask and eyewear, put on the gown, and then apply gloves 2. Apply the mask and eyewear, put on the gown, wash her hands, and then apply […]
A 44-year-old client shares with the admitting nurse that the client is having epigastric pain that the client identifies as a 7 on a 0 to 10 scale. In order to plan for the pain management of this client, which is the most appropriate response from the nurse? 1. “What would be a satisfactory level […]
At a medical clinic, a client with vascular insufficiency is seen frequently. The nurse will give the client additional instruction about her condition if the client: 1. Walks regularly 2. Wears knee-length stockings 3. Elevates the feet when sitting 4. Alternates periods of sitting and standing ANSWER ANS: 2 The client with risk or […]
