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A client admitted to the maternity unit is at 38 week of gestation and has bright red vaginal bleeding . It would be most important for the nurse to assess which of the following?
- history of bleeding at any other time during the pregnancy.
- complains of abdominal pain.
- temperature.
- length of time of the bleeding
The nurse is receiving a prescription of a client who has acute renal failure. Which of the following prescription should the nurse clarify?
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- urine specimen for urinalysis (UA).
- blood specimen for the arterial blood gases (ABG).
- referral to register dietitian for parenteral nutrition evaluation.
The nurse in a same-day surgical center has receive a change of shift report on the following client. The nurse should first see the client who had.
- closed reduction of a fracture tibia with cast application 1 hour ago and is reporting that the cast leg feels hot.
- extraction of the cataract lens 2 hours ago in reporting nausea.
- An arthroscopy of the right knee 3 hours ago and is preparing me pain related as 4 on a scale of (no pain) 0 to 10.
- a laparoscopy colostomy 4 hours ago and Reporting right shoulder pain.
The nurse is teaching a client how to ambulate using crutches. Which of the following information should the nurse include?
- use your hands and arm to support your body weight.
- where sleepers when ambulating with a crutches in your home.
- Maintaining the crutches 12 in (30cm) in front of your feet while standing.
- adjust the hand grip all the crutches so that you elbows are fully extended.
The nurse in a community-based setting is teaching clients over 65 years old of age about health promotion activities. Which of the following information should the nurse include?
- Purchase all your prescription medication at the same pharmacy.
- schedule an appointment for a vision screening every 3 years.
- participate in a deli aerobic exercise for 60 Minutes.
- increase your intake of fat soluble vitamin.
The nurse is assessing a client with suspected endometriosis. Which of the following findings
would support a diagnosis of endometriosis?
- dyspareunia
- hot flashes.
- Weight gain
- amenorrhea
The nurse has been made aware of the following client situation. The nurse should first assess the client with
1. heart failure who has a productive cough and is anxious
2. original enteritis (Crohn’s disease) who is reporting cramping abdominal pain and diarrhea.
3. idiopathic thrombocytopenic purperia (ITP) who has petechia on the trunk and is reporting heavy menses.
4. chronic obstructive pulmonary disease (COPD) who has dyspnea with exertion it is using accessory muscles
The nurse is teaching a client who is scheduled for 24 hour urine collection. Which of the following information should the nurse include? Select all that apply.
- you will be asked to urinate when starting the collection, and the initial ring will be discarded.
- A sign will be posted on the bathroom door as remember to save the urine.
- you will be asked to void at the end of the designated time period to complete the urine collection.
- you should discard urine that is dark or pink in color.
- the collected urine will be sent to the laboratory at the end of each shift
The nurse has taught a client with diabetes mellitus (type 2) about food care. Which of the following statement by the client indicate correct understanding of the teaching? Select all that apply
- I will check my shoes for any foreign object prior put in them on.
- I should use a large coarse file to remove dry skin from bunion.
- I will apply petroleum-based oatmeal between my toes after bathing.
- I should avoid crossing my legs to prevent decreased circulation to my feet.
- Why I should wear a new shoe for few hours for several days until they fit well.
The nurse is screening client for those at increased risk for developing cancer. At highest risk for developing leukemia is the client who.
- received more than 3 blood transfusions.
- Has magnetic resonance imaging (MRI) scan annually.
- Has polycythemia vera and requires phlebotomy treatment.
- had colon cancer and receive prescribed chemotherapy treatments.
The charge nurse has received change-of-shift report on the following clients in labor. The change nurse should ask a staff member to first see the client in the.
- first stage labor who has an oral temperature of 99.7 F (37.6 C)
- first stage labor who has contractions are occurring every 30 seconds.
- second stage labor who has respiratory of 26.
- Second stage labor whose contractions are lasting for 60 seconds.
The nurse is observing a staff member caring for a client who has chickenpox. Which of the following action by the staff member will require the nurse to intervene?
- Placing the client and a private room with monitored negative air pressure.
- Placing the box of disposable face shield outside the client’s room.
- Placing an alcohol base hand rough in the client’s room for hand hygiene.
- placing a surgical mask on the client during transport out the client’s room.
The nurse on the pediatric unit is preparing to admit a client with rubella (merasles). The nurse should assign the client to a.
- private room at the end of the hallway.
- private a room with monitored negative air pressure.
- room with a client who has chickenpox.
- room with a client who has atopic dermatitis (eczema).
The nurse is planning care for a client with moderate Alzheimer’s disease (AD). Which of the following interventions should the nurse include in the clients plan of care?
- encourage the client to reminisce about happy memories.
- Confront the client when inappropriate or agitated behavior occurred.
- Administration to the client the prescribed cholinesterase inhibitor course of AD.
- provide the client with information about activity choices in the morning so the client can make plans for the next day.
The nurse is planning a staff education conference about prevention of urinary tract infection (UTI) in children. Which of the following information should the nurse include? Select all that apply.
- Teach the child to perform Kegel exercise.
- Encourage the child to empty their bladder completely.
- Encourage the child how to maintain an adequate fluid intake.
- Teach the how to properly cleanse their perineal area.
- offer the child noncarbonated, caffeinated beverage choices.
The charge nurse is observing the following client situation. It will require intervention if a.
- client with hepatitis B (HBV) is eating food brought into the facility by a visitor.
- Visitor is sitting on the side of the bed a client with a acute pancreatitis.
- staff members is entering the room of a client with hemophilia influenzae meningitis wearing a protective gown and gloves.
- family member of a child with mycoplasma pneumonia leaves. the door of the client room open.
The nurse is assessing a client’s respiratory system. Select in the correct order the stpes nurse should take. All options must be used.
Inspect the shape
Auscultate the breath sounds.
Palpate the chest.
Percuss the posterior aspect the chest
