A nurse is caring for a client who had a partial laryngectomy and is receiving continuous enteral feedings at 65 mL/hr through a gastrostomy tube. Which of the following findings requires immediate intervention by the nurse? - answerThe infusion pump for administering contimuous feeding is turned off. A nurse is assessing a client who has a magnesium level of 4.4 mEq/L. Which of the following findings should the nurse expect? - answerHypotension A nurse is providing dietary teaching to a client who has an increased cholesterol level. Which of the following foods should the nurse recommend? - answerEgg whites A nurse is caring for a toddler who has respiratory syncytial virus. Which of the following actions should the nurse plan to take? - answerUse a designated stethoscope when caring for the toddler. A nurse is assessing a client who has a chest tube following a thoracotomy. Which of the following findings requires intervention by the nurse? - answer1 cm of water present in the water seal A nurse is reviewing the medical history of a client who is taking garlic supplement. The nurse should identify that which of the following findings is a contraindication for taking this supplement? - answerThe client takes aspirin daily. A nurse is planning to provide community education about viral hepatitis. Which of the following should the nurse plan to include in the teaching? - answerseries of four hepatitis vaccines is recommended to prevent viral hepatitis. A nurse is reviewing the history and physical of a client who has right ventricular heart failure. Which of the following is an expected finding? - answerElevated pulmonary artery pressure A home health nurse is conducting an initial home visit for a client who has terminal breast cancer. The client has two school-age children and a limited support system. Which of the following is the priority nursing action? - answerInform the client of available community resources. A nurse is providing postoperative teaching to a client who has a newly-inserted pacemaker. Which of the following statements by the client indicates that the teaching has been effective? - answer"I will use my cell phone on the ear opposite of my pacemaker." A nurse is caring for a client who has heart failure and has started taking a loop diuretic. Which of the following findings indicates the client is experiencing an adverse effect of the medication? - answerDecreased reflexes A nurse is caring for a client who has neutropenia due to HIV. Which of the following precautions should the nurse take while caring for this client? - answerWear an N95 respirator. A nurse manager is presenting information to the nursing staff regarding the appropriate use of client restraints. Which of the following should the nurse include? (Select all that apply.) - answerThe nurse should pad the bony prominences. The nurse should remove the restraints every 2 hr. The provider's prescription should include the A nurse is providing discharge teaching about disease prevention to a client who has active tuberculosis. Which of the following should the nurse include? - answerEducating the client how to cover nose and mouth with tissues when coughing A nurse is caring for a client who reports difficulty falling asleep at night. Which of the following actions should the nurse take? - answerSchedule routine care tasks during hours when the client is awake. A nurse is preparing a client for surgery and has just administered the preoperative injection. Which of the following actions should the nurse take? - answerReview deep breathing and coughing exercises. A nurse suspects another nurse is chemically impaired during their shift. Which of the following is an appropriate action for the nurse to take? - answerReport to the nurse manager. A nurse in the recovery room is assessing a client who has a new chest tube. The nurse finds that the water seal is no longer tidaling. The nurse should identify the finding as resulting from which of the following? - answerThe tubing may be kinked. A nurse delegates tasks to a licensed practical nurse (LPN) and an assistive personnel (AP). When admitting a client who is experiencing acute liver failure and who has ascites and an NG tube, which of the following tasks is most appropriate for the nurse to delegate to the LPN? - answerMeasure the amount of gastric drainage every 2 hr. A nurse is assessing an adult male client who has a BMI of 20. The nurse should identify that the client's BMI falls within which of the following categories? - answerHealthy weight A nurse is assessing a client who has a long arm cast. For which of the following findings should the nurse monitor when assessing for acute compartment syndrome? - answerChange in mental status A nurse is planning care for a newly admitted client. Which of the following interventions should the nurse plan to take first? (Click on the "Exhibit" button for additional information about the client. There are three tabs that contain separate categories of data.) - answerAdminister pain medication to the client. A community health nurse is performing a vision screening on a 4-month-old infant. When shining a light source into the infant's visual field, which of the following is an expected finding? - answerThe infant closes their eyes. A nurse is planning discharge teaching for a client who is scheduled to receive intravenous infusions at home. Which of the following instructions should the nurse plan to include? - answerPlace the infusion pump cord against the baseboards. A nurse is caring for a client who has just returned to the unit following a bronchoscopy. Which of the following actions by the assistive personnel requires the nurse to intervene? - answerOffers oral fluids to the client