Fundamentals Assessment – Flashcards
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Healthcare provider
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The nurse overhears the healthcare provider explaining to the client that the tumor removed was non-malignant
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I will ask one of the female nurses to bathe you
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A male nurse is assigned to care for a female Muslim client
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Assist and support the client in establishing short-term goals
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A client has a nursing diagnosis of, "Spiritual distress related to a loss of hope, secondary to impending death."
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Analysis
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Prior to administering a newly prescribed medication to a client
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Sensory pattern, area, intensity, and nature of the pain
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A female client who has breast cancer with metastasis to the liver and spine is admitted
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Flush the lumen with the saline solution and administer the medication through the lumen
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When preparing to administer an intravenous medication through a central venous catheter,
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What is concerning you this morning?
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When the nurse enters a client's room to do an initial assessment the client shouts "Get out of my room! I'm tired of being bothered!"
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Notify family members of the client's condition
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In providing care for a terminally ill resident of a long-term care facility
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Wet to moist dressing
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A client is admitted with a stage four pressure ulcer that has a black, hardened surface
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Foods and liquids consumed during the past 24 hours
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A 73-year-old Hispanic client is seen at the community health clinic with a history of protein malnutrition
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As a tool to organize thinking and clinical decision making about clients' healthcare needs
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What is the rationale for using the nursing process
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Obtain a prescription for removal of the catheter as soon as possible
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Which nursing intervention is most beneficial in reducing the risk of urosepsis
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Use reflective listening techniques when the client expresses spiritual doubt
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A male client has a nursing diagnosis of "spiritual distress"
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Determine if the expected outcomes of care were achieved
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In evaluating client care, which action should the nurse take first?
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Risk for aspiration
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The nurse nots that a client consistently coughs while eating and drinking
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Respiratory rate
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Which client assessment data is most important for the nurse to consider before ambulating a postoperative client
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As the client to relax and run a small amount of fluid into the rectum
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The nurse encounters resistance when inserting the tubing into a client's rectum
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Drape the top sheet and covers loosely over the bed cradle
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When making the bed of a client who needs a bed cradle
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What activities during a routine ay are impacted by your pain
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To obtain the most complete assessment data for a client with chronic pain, which information should the nurse obtain
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Tell me what you would like to see happen with your children in the future
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A single mother of two teenagers, ages 16 and 18,
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Inform the family that death is imminent
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A client in hospice care develops audible gurgling sounds on inspiration
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Upon discharge, the client will list three ways to protect the feet from injury
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Which statement correctly identifies a written learning objective
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Pulse rate decreases from 78 to 52 beats/min
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The nurse is digitally removing a fecal impaction for a client
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Examine one's own culturally based values, beliefs, attitudes, and practices
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A nurse is becoming increasingly frustrated by the family members' efforts
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Ask the client about numbness or tingling in the hands
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A client is demonstrating a positive Chvostek's sign
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Continue the gabapentin
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A client who has moderate, persistent, chronic neuropathic pain due to diabetic neuropathy
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Ask the client if this decision has been discussed with his healthcare provider
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A male client with acquired immunodeficiency syndrome (AIDS) develops cryptococcal meningitis
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Reposition the client's arm
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The nurse is administering an intermittent infusion of an antibiotic to a client
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Combination of plant proteins to provide essential amino acids
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A male client with an infected wound tells the nurse that he follows a macrobiotic diet
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Vitamin B12
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The nurse is discussing dietary preferences with a client who adheres to a vegan diet
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1) Ask the client to push the IV pole to the chair 2) Pre-medicate client with an analgesic 3)Inform the client of the plan for moving to the chair 4) Assess the client's blood pressure
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A nurse is preparing a male client who has an indwelling catheter and an IV infusion to ambulate
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Eats anything and does not think diet makes a difference in health
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The nurse formulates the nursing diagnosis of, "Ineffective health maintenance related to lack of motivation"
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Slow the IV infusion to keep vein open rate
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The nurses determine a client's IV solution is infusing at 250ml/hr
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Continue the planned nursing interventions to restore the client's fluid volume
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When assessing a client with a nursing diagnosis of fluid volume deficit
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Generativity
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A middle-aged woman who enjoys being a teacher and mentor feels that she should pass down her legacy
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Herbs should be obtained from manufacturers with a history of quality control of their supplements
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A female client informs the nurse that she uses herbal therapies to supplement her diet and manage common ailments
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Ineffective coping related to response to positive biopsy test results
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Which statement is an example of a correctly written nursing diagnosis statement
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Asks permission before touching a client
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What action by the nurse demonstrates culturally sensitive care
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Locate the perineum
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When teaching a female client to perform intermittent self-catheterization
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Biofeedback allows the client to control involuntary responses to promote peripheral vasodilation
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A client with Raynaud's disease asks the nurse about using biofeedback
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Ask the mother to be present to soothe the child
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As the nurse prepares the equipment to be used to start an IV on a 4-year-old boy
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A consistent, systematic approach
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Which technique is most important for the nurse to implement when performing a physical assessment
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Examine the effectiveness of nursing interventions toward meeting client outcomes
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What activity should the nurse use in the evaluation phase of the nursing process
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The client signs a document that designates another person...
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Which statement best describes durable power of attorney
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Provide warm prune juice before the client goes to bed at night
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On the third postoperative day following thoracic surgery
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Witness the client's signature on the consent form
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A male client arrives at the outpatient surgery center for a schedule needle aspiration of the knee
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0800, 1200, 1600, 2000
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A medication is prescribed to be given QID
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Cradle the client's heel
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The nurse is providing passive range of motion (ROM) exercises to the hip and knee
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Determine who is legally empowered to make decisions
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A 75-year-old client who has a history of end stage renal failure and advanced lung cancer, recently had a stroke
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Drape the sheets over the footboard of the bed
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An older female client with rheumatoid arthritis is complaining of severe joint pain
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Place the soiled linens in a pillow case and deposit them in the dirty linen hamper
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How should the nurse handle linens that are soiled
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Refuse to perform the task that is beyond the nurse's experience
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The charge nurse assigns a nursing procedure to a new staff nurse
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Advise the client to sit on the sit of the bed for a few minutes before standing again
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A client who has been on bedrest for several days now has a prescription to progress activity as tolerated
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Assault and battery with deliberate intent to deviate from the consent form
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A signed consent form indicated a client should have an electromyogram
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It's highly likely that she will recover and return to her pre-illness state
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The daughter of an older woman who became depressed following the death of her husband asks
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Consider the sterile field contaminated if it becomes wet during the procedure
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What action should the nurse implement when adding sterile liquids
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Explain that the records are hospital property and may not be removed
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A nurse observes a student nurse taking a copy of a client's medication administration record
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Place a transfer belt around the client, assist to stand, and pivot to a chair that is placed at a right angle to the bed
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An older client who is able to stand but not to ambulate receives a prescription
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Check capillary refill of toes on lower extremity with Unna's paste boot
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What intervention should the nurse include in the plan of care for a client who is being treated with an Unna's paste boot
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Accused of diversion
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A female nurse who sometimes tries to save time by putting medications in her uniform pocket
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Instruct the client to take slow deep breaths and stop bearing down
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While preparing to insert a rectal suppository in a male adult client
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Turn the client q2h
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The nurse assesses an immobile, elderly male client and determines that his blood pressure is 138/60
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Draw up the irrigating solution into the syringe
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The nurse is preparing to irrigate a client's indwelling urinary catheter using an open technique
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Document the events that occurred in the nurses' notes
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Before administering a client's medication, the nurse assesses a change in the client's condition
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Complains of inability to empty bladder
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The nurse is completing the plan of care for a client who is admitted for benign prostatic hypertrophy
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One-inch pressure sore draining serous fluid
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The nurse removes the dressing on a client's heel that is covering a pressure sore
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Bend at the knees when lifting heavy objects
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The charge nurse observes an unlicensed assistive personnel (UAP) bending at the waist
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Emptying the urinary catheter drainage bag for a client with Alzheimer's disease
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Which client care requires the nurse to wear barrier gloves
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Fluid volume imbalance
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The home health nurse visits an elderly client who lives at home with her husband
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Serum albumin
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A client with chronic renal disease is admitted to the hospital for evaluation prior to a surgical procedure
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Elicit specific facts about past hospitalizations with direct questions
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A client provides the nurse with information about the reason for seeking care
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The nurse notes that there are numerous scatter rugs throughout the house
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A home health nurse visits an elderly female client who had a brain attack three months ago
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Impaired gas exchange
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When caring for an immobile client what nursing diagnosis has the highest priority
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Withhold the administration of the suppository until contacting the healthcare provider
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A nurse is preparing to insert a rectal suppository and observes a small amount of rectal bleeding
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Raise the bed to a waist-high working level
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What action is most important for the nurse to implement when placing a client in the Sim's position
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Speak initially with the oldest family member to show respect
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While caring for a child and mother from Cambodia
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Increase in pulse rate
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A male client with venous incompetence stands up and his blood pressure subsequently drops
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Cassette infusion pump
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The nurse is preparing to give a client with dehydration IV fluids delivered at a continuous rate of 175ml/hr
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A 55-year-old woman who has had moderate low back pain for three months
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The nurse working in the emergency department is assessing four clients' ability to tolerate pain
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Document the presence and volume of the pulse palpated
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In assessing a client's femoral pulse
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I don't understand why i'm so weak and tired
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What client statement indicates to the nurse that the client requires assistance with bathing
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Take measures to promote as much comfort as possible
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A client is admitted to the hospital with intractable pain
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Position prone with a small pillow below the diaphragm
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What action should the nurse implement to prevent the formation of a sacral ulcer
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Active ROM exercises to both arms and legs two or three times a day
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The nurse is caring for a client who is weak from inactivity because of a 2-week hospitalization
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The clamp on the urinary drainage bag is open
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When assessing a client with an indwelling urinary catheter
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Notify the surgeon that the consent form has not been signed
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After a client has been premedicated for surgery with an opiod analgesic
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It may hurt but we'll give you medicine to help you feel better
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A 4-year-old boy who is schedule for a tonsillectomy and adenoidectomy
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Identify the break in surgical asepsis and provide another set of sterile supplies
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A healthcare provider is performing a sterile procedure at a client's bedside
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1) Bedtime snack of crackers and milk 2)Breakfast of eggs, bacon, toast, and coffee 3) Lunch of tuna fish sandwich, carrot sticks, fresh fruit, and coffee 4) Snack of potato chips, and diet soda
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A low-sodium, low-protein diet is prescribed for a 45-year-old client
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Evaluate the client's mental status for competence to refuse treatment
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A 35-year-old female client with cancer refuses to allow the nurse to insert an IV
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Discontinue the administration of the bolus feeding
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While the nurse is administering a bolus feeding to a client via nasogastric tube
