A nurse is an emergency department is preparing a client for emergency surgery. The clients blood alcohol level is 180mg/dL. Which of the following actions is the nurse’s priority?
A. Obtain consent for surgery
B. Insert an indwelling urinary catheter
C. Insert an NG tube
D. Apply anti-embolic stoking’s
A nurse is caring for a client who has an IV in the left forearm and whose infusion pump has alarmed several times. Which of the following actions should the nurse take first?
A. Ensure the tubing connections are secure
B. Reposition the client’s left arm
C. Flush the IV catheter
D. Check the IV site for redness
A nurse is caring for a client following a total knee arthroplasty. The client reports a pain level on a pain scale of 0 to 10. Which of the following interventions should the nurse take?
A. Place pillows under the client’s knee
B. Gently massage the area around the client’s incision
C. Apply an ice pack to the client’s knee
D. Perform range-of-motion exercises to the client’s knee
A nurse is caring for a client in diabetic ketoacidosis (DKA). Which of the following is the priority intervention by the nurse?
A. Administer 0.9% sodium chloride
B. Initiate a continuous IV insulin infusion
C. Check potassium levels.
D. Begin bicarbonate continuous IV infusion
A nurse is caring for a client who has amnesia. Which of the following assessment findings should the nurse anticipate with the clients’ conditions?
A. Flushed skin color
B. Bradycardia
C. Heat intolerance
D. Headache
A nurse is talking to a group of clients who have cancer about radiation therapy. Which of the following activities should the nurse include in the teaching?
A. Limit engaging in sport activities that can cause bruising
B. Decrease intake of fresh fruits and vegetables
C. Limit socializing in large crowds
D. Decrease time spent outdoors
A nurse caring for a client who has cervical and a sealed radiation implant. Which of the following actions should the nurse take?
A. Attach a dosimeter badge to the client’s gown.
B. Place long handled forceps at the client’s bedside
C. Leave unused equipment in the client’s room until discharged
D. Move the client’s soiled linens to a designated container outside the room.
A nurse is assessing a client who has a pressure ulcer. Which of following findings should the nurse expect as an indication that the wound is healing?
A. Light yellow exudate
B. Dry brown eschar
C. Dark red granulation tissue
D. Wound tissue firm to palpation
A nurse is providing teaching to a client who has left sided heart failure. Which of the following manifestations should the nurse include in the teaching?
A. Hacking cough
B. neck vein distention
c. ankle edema
d. Anorexia
A nurse is caring for a client who is experiencing an acute asthma attack .Which of the following should the nurse identify as a contributing factor to the clients’ manifestations?
A. Decreased responsiveness of airways to allergens
B. Acute loss of alveolar elasticity
C. Suppressed Bronchiolar inflammatory response
D. Inability to exhale retained carbon dioxide
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