The nurse is caring for a client who has as a son with a streptococcus throat infection.
Which nurse recommendation would be best to advise the client to do in order to
prevent acquiring the infection?
ANS-Frequently wash her hands and surfaces of the home.
The nurse is caring for a client infected with Rocky Mountain spotted fever. The nurse
should ask if the client has experienced which of the following?
ANS-Was bitten by a tick
The nurse is caring for a client with a protozoa infection. Which is the most likely mode
of transmission?
ANS-Ingestion of contaminated food or water
The nurse is caring for a client who is recovering from an allergic reaction. Which
leukocyte level would the nurse expect to be the most elevated?
ANS-Eosinophils
The nurse is caring for a client who has an infected wound on the great toe that is red
with a purulent exudate. The nurse expects that this client has which type of infection?
ANS-Localized
The client experienced a fall. Nursing assessment reveals that the client is experiencing
tachycardia, hypotension, confusion, tachypnea, and flat jugular veins. What should be
the nurse's first response?
ANS-Administer oxygen.
The family wants to know why the nurse is putting a urinary catheter in a client
experiencing shock. What is the nurse's best response?
ANS-"It will help monitor how much urine the kidneys are able to produce."
A client experiencing shock has had a urinary output of 250 mL in the last 10 hours.
What is the nurse's most appropriate response?
ANS-Notify the physician.
Which client is most likely to be experiencing hypovolemic shock?
ANS-A client who had surgery 24 hours ago and who also has a nasogastric tube
The physician has ordered arterial blood gases for a client experiencing shock. The
nurse knows that which value indicates shock?
ANS-pH 7.32
A 63-year-old Arab American male states his left leg is "hot." What is the nurse's best
first response?
ANS-Assess for pain
The client is complaining of excruciating pain in a foot that has been amputated. The
family tells the nurse that the client is just addicted to pain medications. What is the
nurse's best response?
ANS-"He is experiencing phantom limb pain."
A client has had abdominal surgery and has orders to be ambulated three times a day.
Oral pain medication has been ordered for the client. What should the nurse do to
facilitate ambulation?
ANS-Mediate 1 hour prior to ambulating the client.
The client reports frequent use of acetaminophen. How should the nurse best respond?
ANS-"Do you drink alcohol?"
A client with chronic pain has been admitted with a fever. The nursing assessment
reveals that the client has a decreased level of consciousness. What should the nurse
ask the family about?
ANS-What medications the client has taken
The practical nurse is reviewing the social history from a client diagnosed with small cell
carcinoma of the lung. Which information is significant for this disease?
ANS-The client has smoked two (2) packs of cigarettes a day for 20 years
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