A nurse in an acute care facility is assisting with the development of

226: A nurse in an acute care facility is assisting with the development of an in-service about reducing environmental stressors to improve clients’ sleep. Which of the following instructions should the nurse include?

Ans: Conduct change-of-shift- report near clients’ rooms.

Turn on overhead lights briefly when checking IV lines.

Wear shoes with rubber soles.

Open curtains between clients in semiprivate rooms.

 

227: A nurse is caring for an older adult client who is postoperative following a total hip arthroplasty. The client is incontinent of stool and urine. Which of the following actions should the nurse take to prevent skin breakdown?

Ans: Clean the client’s skin with soap and hot water.

Use a moisture barrier on the client’s skin.

Limit the client’s fluid intake.

Massage the area around the client’s coccyx.

 

228: A nurse is collecting data from a client who has a urinary tract infection and is taking ciprofloxacin. The client reports pain in her calf muscle. Which of the following statements should the nurse make?

Ans: “That reaction means your dose is too high. Cut the pill in half.”

“Discontinue the medication. I will ask your provider for another antibiotic.”

“Continue to take the medication. Calf pain is minor reaction that will resolve itself.”

“This is an allergic reaction. Take the medication with an antihistamine.”

 

229: A nurse is assisting in the care of a client who is in active labor and is to undergo amniotomy. Which of the following actions should the nurse take? (Mark in order)

Ans: Document the procedure in the electronic medical record

Check the fluid for color, odor, and consistency.

Position the client with a rolled towel under her hips.

Obtain a baseline reading of the FHR and contraction pattern.

Pass the sterile hook to the provider.

 

230: A nurse is reinforcing teaching about car seat safety with a parent of a newborn. Which of the following statements by the parent indicates are understanding of the teaching?

Ans: “I should keep my baby rear-facing in the car seat until she is 2 years old.”

“I should position the car seat’s retainer clip at the level of the baby’s belly button.”

“I should place my baby in the car seat at a 90-degree angle.”

“I should enable the airbag when my baby is in the front seat of the car.”

 

231: A nurse is contributing to the plan of care for a client who has a potassium level of 2.9 mEq/L. Which of the following actions should the nurse plan to take?

Ans: Administer furosemide.

Apply a cardiac monitor.

Give a dose of alendronate.

Monitor for Chvostek’s sign.

 

232: A nurse is collecting data from a client about risk factors for cardiovascular disease. The nurse should identify that which of the following findings is a modifiable risk factor?

Ans: Family history of cardiovascular disease

Sex

Cholesterol 240 mg/dL

Age 65

 

233: A nurse is reinforcing teaching with the guardians of a 6-year-old child who has cystic fibrosis. Which of the following information should the nurse include in the teaching?

Ans: ”Provide homeschooling for your child.”

”Do not include your child when making decision about treatment.”

”Have your child wear a medical identification wristband.”

”Ensure that your child does not receive the influenza vaccine annually.”

 

234: A nurse is assisting with developing a plan of care for a client who is immobile. Which of the following interventions should the nurse recommend to reduce the development of pressure ulcers?

Ans: Place a donut-shaped cushion under the client.

Place the client in a 30⁰  lateral position.

Turn the client every 3 hr

Check the client’s skin every 4 hr.

 

235: A nurse is assisting the provider with a lumber puncture for a client who has manifestations of meningitis. Into which of the following positions should the nurse assist the client?

Ans: Trendelenburg with her body in Sims’ position

Prone with her arms at her side and her legs extended

Head flexed to the chest and her knees pulled up to the abdomen

Arms raised above her head with her legs elevated on pillows

 

236: A nurse in a provider’s office is collecting data from a client who was just diagnosed with tuberculosis. Which of the following actions should the nurse take first?

Ans: Communicate with personnel about the need for prophylaxis.

Place a mask on the client.

Notify the local health department.

Contact those who live with the client.

 

237: A nurse is caring for a client who is 2 days postoperative following a total bilateral mastectomy. The client is tearful and looks away when her surgical dressings are removed. The nurse should place the priority on which of the following actions?

Ans: Identifying the client’s perception of the changes in her physical appearance

Providing the client with information on community resources that will strengthen her coping skills

Encouraging the client to write about her feelings in a journal each day

Demonstrating a nonjudgmental attitude toward the client when providing care for her surgical wounds