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A nurse is assisting with the care of a client who has a femur fracture and is in skeletal traction. Which of

the following actions should the nurse take?

1) Loosen the knots on the ropes if the client is experiencing pain.

2)Ensure the client’s weights are hanging freely from the bed.

3) Check the client’s bony prominences every 12 hr.

4) Cleanse the client’s pin sites with povidone-iodine.

A nurse in a provider’s office is reinforcing teaching with a client who has anemia and has been

takingferrous gluconate for several weeks. Which of the following instructions should the nurse include?

1) Take this medication between meals.

2) Limit intake of Vitamin C while taking this medication.

3) Take this medication with milk.

4) Limit intake of whole grains while taking this medication.

A nurse in a provider’s office is reinforcing teaching with a client who has anemia and has been

takingferrous gluconate for several weeks. Which of the following instructions should the nurse include?

1) Take this medication between meals.

2) Limit intake of Vitamin C while taking this medication.

3) Take this medication with milk.

4) Limit intake of whole grains while taking this medication.

A nurse is reviewing the plan of care for a client who has cellulitis of the leg. Which of the following

interventions should the nurse recommend?

1) Apply topical antifungal agents.

2) Apply fresh ice packs every 4 hr.

3) Wash daily with an antibacterial soap.

4) Keep draining lesions uncovered to air dry.

A nurse is reinforcing teaching with a client who is postoperative after having an ileostomy

established.Which of the following instructions should the nurse include in the teaching?

1) Empty the pouch immediately after meals.

2) Change the entire appliance once a day.

3) Limit fluid intake.

4) Avoid medications in capsule or enteric form.

A nurse is caring for a client with severe burns to both lower extremities. The client is scheduled for an

escharotomy and wants to know what the procedure involves. Which of the following statements is

appropriate for the nurse to make?

1) "An escharotomy surgically removes dead tissue."

2) "A cannula will be inserted into the bone to infuse fluids and antibiotics."

3) "A piece of skin will be removed and grafted over the burned area."

4) "Large incisions will be made in the burned tissue to improve circulation."

A nurse is collecting data from a client who has a possible cataract. Which of the followingmanifestations

should the nurse expect the client to report?

1) Decreased color perception

2) Loss of peripheral vision

3) Bright flashes of light

4) Eyestrain

A nurse is contributing to the plan of care for a client who has an intestinal obstruction and is receiving

continuous gastrointestinal decompression using a nasogastric tube. Which of the following interventions

should the nurse include in the plan of care?

1) Measure abdominal girth daily.

2) Use sterile water to irrigate the nasogastric tube..

3) Maintain the client in Fowler’s position.

4) Moisten the client’s lips with lemon-glycerin swabs.

A nurse is caring for a client who has Cushing's syndrome. Which of the following clinical

manifestationsshould the nurse expect to observe? (Select all that apply.)

1) Buffalo hump

2) Purple striations

3) Moon face

4) Tremors

5) Obese extremities

A nurse is caring for a client who is in the oliguric phase of acute kidney injury. Which of the following

actions should the nurse take?

1) Provide a diet high in protein.

2) Provide ibuprofen for retroperitoneal discomfort.

3) Monitor intake and output hourly

4) Encourage the client to consume at least 2 L of fluid daily.

A nurse is reinforcing teaching about an esophagogastroduodenoscopy with a client who has

uppergastric pain. Which of the following statements should the nurse include in the teaching?

1) "A flexible tube is introduced through the nose during the procedure."

2) "During the procedure you are in a sitting position."

3) "You will remain NPO for 8 hours before the procedure."

4) "You will be awake while the procedure is performed."

A nurse is caring for a client who is difficult to arouse and very sleepy for several hours following a

generalized tonic-clonic seizure. Which of the following descriptions should the nurse use when

documenting this finding in the medical record?

1) Aura phase

2) Presence of automatisms

3) Postictal phase

4) Presence of absence seizures

A nurse is reinforcing teaching with a client who reports right shoulder pain following a laparoscopic

cholecystectomy. Which of the following statements should the nurse make?

1) "The pain results from lying in one position too long during surgery."

2) "The pain occurs as a residual pain from cholecystitis."

3) "The pain will dissipate if you ambulate frequently."

4) "The pain is caused from the nitrous dioxide injected into the abdomen."

A nurse is checking the suction control chamber of a client's chest tube and notes that there is

nobubbling in the suction control chamber. Which of the following actions should the nurse take?

1) Notify the provider.

AnswerRationale:

The nurse should check for kinks and take other measures before notifying the

provider.

2) Verify that the suction regulator is on.

3) Continue to monitor the client because this is an expected finding.

4) Milk the chest tube to dislodge any clots in the tubing that may be occluding it.

A nurse is assisting with the care of a client immediately following a lumbar puncture. Which of thefollowing

actions should the nurse take? (Select all that apply.)

1) Encourage fluid intake.

2) Monitor the puncture site for hematoma.

3) Insert a urinary catheter.

4) Elevate the client’s head of bed.

5) Apply a cervical collar to the client.

A nurse is assisting with the care of a client who is postoperative following surgical repair of a fractured

mandible. The client’s jaw is wired shut to repair and stabilize the fracture. The nurse should

recognizewhich of the following is the priority action?

1) Relieve the client's pain.

2) Check the client’s pressure points for redness.

3) Provide oral hygiene.

4) Prevent aspiration.

A nurse is collecting data from a client who has scleroderma. Which of the following findings should

thenurseexpect?

1) A dry raised rash

2) Excessive salivation

3) Periorbital edema

4) Hardened skin