Fundamentals Assessment

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

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