A nurse is caring for a client who is postoperative following abdominal surgery. Click to highlight the assessment findings below that the nurse should report to the provider. To deselect a finding, click on the finding again.
- Urinary output
- Reported pain level
- Vital signs
Key Terms
A nurse is caring for a client who is postoperative following abdominal surgery. Click to highlight the assessment findings below that the nurse should report to the provider. To deselect a finding, click on the finding again.
- Urinary output
- Reported pain level
- Vital signs
A nurse is caring for a client who reports difficulty falling asleep. which of the following recommendations should the nurse make?
Maintain a consistent time to wake up each day
a nurse is caring for a client who has diarrhea due to shigella. Which of the following precautions should the nurse implement for this client?
wear a gown when caring for the patient
a nurse is assessing a client who reports increased pain following physical therapy. Which of the following questions assess the quality of the clients pain?
"is your pain sharp or dull"
A nurse is caring for a client who has a sodium level of 125 mEq/L. Which of the following findings should the nurse expect?
abdominal cramping
A nurse is admitting a client who has an abdominal wound with a large amount of purulent tissue drainage. Which of the following types of transmission precautions should the nurse initiate?
contact precautions
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| Term | Definition |
|---|---|
A nurse is caring for a client who is postoperative following abdominal surgery. Click to highlight the assessment findings below that the nurse should report to the provider. To deselect a finding, click on the finding again. | - Urinary output |
A nurse is caring for a client who reports difficulty falling asleep. which of the following recommendations should the nurse make? | Maintain a consistent time to wake up each day |
a nurse is caring for a client who has diarrhea due to shigella. Which of the following precautions should the nurse implement for this client? | wear a gown when caring for the patient |
a nurse is assessing a client who reports increased pain following physical therapy. Which of the following questions assess the quality of the clients pain? | "is your pain sharp or dull" |
A nurse is caring for a client who has a sodium level of 125 mEq/L. Which of the following findings should the nurse expect? | abdominal cramping |
A nurse is admitting a client who has an abdominal wound with a large amount of purulent tissue drainage. Which of the following types of transmission precautions should the nurse initiate? | contact precautions |
a nurse is caring for a client with a diagnosis of terminal cancer. which pf the following statements by the client should indicate to the nurse that the client is ready to hear information regarding palliative care? | "i want you to tell me about measures available to keep me comfortable" |
A nurse is caring for a client who has tuberculosis. Which of the following actions should the nurse take? | - place the client in a room with negative-pressure airflow |
A nurse is caring for a client who is postoperative and has signs of hemorrhagic shock. when the nurse notifies the surgeon, he directs her to continue to take the client's vital signs every 15 min and call him back in 1 hr. from a legal perspective, which of the following actions should the nurse take next? | notify the nursing manager |
A nurse on a med-surg unit is caring for a client who has a new prescription for wrist restraints. Which of the following actions should the nurse take? | pad the client's wrist before applying the restraints |
a nurse in a surgical suite notes documentation on a client's medical record that they have a latex allergy. in preparation for the client's procedure, which of the following precautions should the nurse take? | wrap monitoring cords with stockinette and tape them in place |
A nurse is discussing the use of herbal supplements for health promotion with a client. Which of the following client statements indicates am understanding of herbal supplement use? | "i can take echinacea to improve my immune system" |
A nurse is planning care for a client who has had a stroke resulting in aphasia and dysphagia. Which of the following tasks should the nurse assign to an AP? | - assist the client with a partial bed bath |
a nurse is initiating a protective environment for a client who has had an allogeneic stem cell transplant. which of the following precautions should the nurse plan for this client? | make sure the client wears a mask when outside their room if there is construction in the area |
A nurse has just inserted an NG tube for a client. Which of the following assessment findings should the nurse expect to confirm correct tube placement? | an x-ray shows the end of the tube above the pylorus |
A nurse is reviewing the laboratory results of a female client who has hypovolemia. Which of the following laboratory result would be priority for the nurse report to the provider? | potassium 5.8 mEq/L (3.5 to 5 mEq/L) |
A nurse is caring for a client who requires a 24-hr urine collection. Which of the following statements by the client indicates an understanding of the teaching? | "i flushed what i urinated at 7:00a a.m. and have saved all urine since." |
A nurse is caring for a client who is refusing a blood transfusion for religious reasons. The client's partner wants the client to have a blood transfusion. Which of the following actions should the nurse take? | withhold the blood transfusion |
A charge nurse is discussing the responsibility of nurses caring for clients who have Clostridium difficile infection. Which of the following information should the nurse include in the teaching? | have family members wear a gown and gloves when visiting |
A nurse is assessing a client who received an IV fluid bolus for dehydration. Which of the following findings should the nurse identify as an indication of fluid volume excess? | distended neck veins |
A nurse is administering 1 L of 0.9% sodium chloride to a client who is postoperative and has fluid volume deficit. Which of the following changes should the nurse identify as an indication that the treatment was successful? | decrease in heart rate |
A nurse is preparing to delegate client care tasks to an assistive personnel(AP). Which of the following tasks should the nurse delegate? | ambulating a client who is postoperative |
A nurse is caring for a client who has a terminal diagnosis and whose health is declining. The client requests information about advance directives. Which of the following responses should the nurse make? | "we can talk about advance directives, and i can also give you some brochures about them" |
A nurse is preparing to apply a dressing for a client who has a stage 2 pressure injury. Which of the following types of dressing should the nurse use? | hydrocolloid |
A nurse is admitting a client who has been having frequent tonic-clonic seizures. Which of the following actions should the nurse add to the client's plan of care? | wrap blankets around all four sides of the bed |
A client who is nonambulatory notifies the nurse that his trash can is on fire. After the nurse confirms the presence of the fire, which of the following actions should the nurse take next? | evacuate the client |
A nurse in a long-term care facility is caring for a client who dies during the nurse's shift. Identify the sequence in which the nurse should perform the following steps. | 1) obtain the pronouncement of death from the provider |
A nurse is planning care of an adolescent who is postoperative following a lumbar laminectomy. Which of the following interventions should the nurse include in the plan of care? | allow the adolescent to make decisions regarding their daily routine |
A nurse is completing an admission assessment for a client who reports vomiting and diarrhea for the past 3 days. Which of the following assessment findings should the nurse expect? | rapid heart rate |
a nurse enters a clients room and finds her on the floor. the clients roommate reports that the client was trying to get out of bed and fell over the side rail onto the floor. which of the following statements should the nurse document about this incident? | "client was trying to get out of bed" |
a nurse is caring for a client who has limited mobility in their lower extremities. which of the following actions should the nurse take to prevent skin breakdown? | have the client use a trapeze bar when changing position |
A nurse is preparing to administer 750 mL of 0.9% sodium chloride IV to infuse over 7 hr. The nurse should set the infusion pump to deliver how many mL/hr? (Round to the nearest whole number.) | 107 mL/hr |
a nurse is performing a home safety assessment for a client who is receiving supplemental oxygen. which of the following observations should the nurse identify as proper safety protocol? | the client identifies the location of a fire extinguisher |
A nurse is assessing a client's readiness to learn about insulin administration. Which of the following statements should the nurse identify as an indication that the client is ready to learn? | "i can concentrate best in the morning" |
A nurse is caring for a client who has an indwelling urinary catheter. Which of the following findings indicates that the catheter requires irrigation? | bladder scan shows 525 mL of urine |
A nurse is caring for a client who is receiving pain medication through a PCA pump. Which of the following actions should the nurse take? | instruct the family to refrain from pushing the button for the client while the client is asleep |
A nurse is caring for a client who has an NG tube and is receiving intermittent feedings through an open system. Which of the following actions should the nurse take first? | tell the client to keep the head of the bed elevated at least 30° |
A middle adult client tells the nurse, "I feel so useless now that my children do not need me anymore." which of the following responses should the nurse make? | "people in middle adulthood often find satisfaction in nurturing and guiding young people" |
A nurse is planning an educational program for a group of older adults at a senior living center. Which of the following recommendations should the nurse include? | "you should receive a pneumococcal vaccine when you are 65 years old" |
a nurse is lifting a bedside cabinet to move it closer to a client who is sitting in a chair. to prevent self-injury, which of the following action should the nurse take when lifting this object? | stand close to the cabinet when lifting it |
A nurse is caring for a client who is scheduled to be transferred to a long-term care facility. The client's family questions the nurse about the reasons for the transfer. Which of the following responses made by the nurse is appropriate? | "would you like it if we discussed the transfer with your family member?" |
A nurse is using an open irrigation technique to irrigate a client's indwelling urinary catheter. Which of the following actions should the nurse take? | subtract the amount of irrigant used from the client's urine output |
A nurse is caring for a client who is having difficulty breathing. The client is supine and is receiving supplemental oxygen via a nasal cannula.Which of the following interventions should the nurse take first? | assist the client to an upright position |
A nurse is assessing four adult clients. Which of the following physical assessment techniques should the nurse use? | ensure the bladder of the blood pressure cuff surrounds 80% of the client's arm |
A nurse is planning care for a client who has vision loss. Which of the following interventions should the nurse include in the plan of care to assist the client with feeding? | arrange food in a consistent pattern on the client's plate |
A nurse is talking with the partner of a client who has dementia. The client's partner expresses frustration about finding time to manage household responsibilities while caring for their partner. The nurse should identify that the partner is experiencing which of the following types of role-performance stress? | role overload |
A nurse is admitting a new client. Which of the following actions should the nurse take while performing medication reconciliation? | compare the client's home medications with the provider's prescriptions |
A client who is postoperative is verbalizing pain as a 2 on a pain scale of 0 to 10. Which of the following statements should the nurse identify as an indication that the client understands the preoperative teaching they received about pain management? | "it might help me to listen to music while i'm lying in bed" |
A nurse is admitting a client who has rubella. Which of the following types of transmission-based precautions should the nurse initiate? | droplet |
A nurse manager is preparing to review medication documentation with a group of newly licensed nurses. Which of the following statements should the nurse manager plan to include in the teaching? | "use the complete name of the medication magnesium sulfate" |
A nurse is admitting a client who is having an exacerbation of heart failure. In planning this client's care, when should the nurse initiate discharge planning? | during the admission process |
A nurse is caring for a client who is postoperative. When the nurse prepares to change the client's dressing, they say, "Every time you change my bandage, it hurts so much." Which of the following interventions is the nurse's priority action? | administer pain medication 45 min before changing the client's dressing |
A nurse is caring for a client in a medical-surgical unit. After reviewing the assessment findings, which of the following actions should the nurse plan to take?Select the 3 actions that the nurse should plan to take. | - assist the client to dangle their legs at the bedside prior to standing |
A nurse is caring for a client who has a new diagnosis of seizure disorder. | the nurse should first address the client's physical safety followed by the client's PRN medication |
A nurse in an emergency department is caring for a client. | the nurse should first review medications that might cause confusion followed by using other methods to keep the client safe |
A nurse is admitting a client. The nurse is reviewing the client's medical record. Which of the following actions should the nurse take? | - place the client on droplet isolation precautions |
A nurse in a providers clinic is caring for a client who has diarrhea the nurse is providing teaching for a client who has diarrhea select the floor instructions the nurse should include in teaching | - eat probiotic foods, such as yogurt |
A nurse in a providers clinic is caring for a client who has heart failure a nurse is evaluating teaching for a client who has heart failure which of the following through statement by the client indicates an understanding of the teaching | - "i am limiting my sodium intake to 2 grams daily" |
a nurse in the emergency department (ED) is caring for a client. click to highlight the findings that indicate the client is malnourished. | - cachectic, with flaccid muscle tone |
a nurse is caring for a client who has a pressure injury. click to highlight the findings that the nurse should report to the provider | - temperature |