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A maleclient whois admitted to the mental health unit for treatment of bipolardisorder has a
slightlyslurred speech pattern and an unsteady gait. Which assessment finding ismost
important for the nurse to report to the healthcare provider? (ANS- Serum lithiumlevelof 1.6 mEq/L or mmol/l (SI)—Rationale:
The therapeutic level of
Serum lithium is 0.8 to 1.5 mEq/Lor mmol/l (SI). Slurred speech and ataxia aresign of
lithium toxicity.
A client was admitted to the cardiac observation unit 2 hours ago complaining ofchest pain.
On admission, the client's EKG showed bradycardia, ST depression, but noventricular
ectopy. Theclient suddenlyreports a sharp increasein pain, telling the nurse, "Ifeel like an
elephant just stepped on mychest" TheEKG now shows Q waves and ST segmentelevations
in the anterior leads. What intervention should the nurse perform? (ANS- Administer prescribed morphinesulfateIV and
provideoxygen at 2 L/min pernasal
The nurseis developing a teaching program for thecommunity. What populationcharacteristic is most influential when choosing
strategies for implementing a teaching plan? (ANS- Literacy level
A client is being discharged with a prescription for warfarin (Coumadin). Whatinstruction
should the nurse providethis client regarding diet? (ANS-Eat approximated thesame amountof leafy green vegetables daily
so the amount of
vitamin K consumed is consistent.
A client who had a small bowel resection acquired methicillin resistantstaphylococcus
aureus (MRSA) while hospitalized. Hetreated and released, but is readmittedtoday because
of diarrhea and dehydration. It is most important for the nurse toimplement whichintervention. (ANS- Maintain contact
transmission precaution
A postoperative femaleclient has a prescription for morphine sulfate10 mg IV q3hours for
pain. One doseof morphine was administered when theclient was admitted tothepost
anesthesia care unit (PACU) and 3 hours later, the client is again complaining ofpain. Her
current respiratoryrateis 8 breaths/minute. What action should the nurse take?(ANS- Administer Naxolone IV
Which intervention is most important for the nurse to includein the plan of careforan older
woman with osteoporosis? (ANS- Placetheclient on fall precautions
Based on theinformation provided in thisclient's medical record during labor,which should
the nurseimplement? (Click on each chart tab for additional information. Please besure to
scroll to the bottom right cornerofeach tab toview all information contained intheclient's
medical record.) (ANS- Continueto monitor the progress of labor.
An unlicensed assistive personnel UAP leavesthe unit without notifying thestaff.
In what
order should the unit manager implement this intervention to addressthe UAPsbehavior?
(Place the action in order from first on top to last on bottom.) (ANS- 1. Note dateand time of the behavior.
2. Discusstheissue privately with the UAP.
3. Plan for scheduled break times.
4. Evaluatethe UAP for signs of improvement.
Following discharge teaching, a male client with duodenal ulcer tells the nurse hewill
drink plentyof dairy products, such as milk, to help coat and protect his ulcer.
What is the
best follow-up action bythe nurse?
(ANS- Review with theclient the need to avoid foods that are rich in milk andcream
A maleclient with hypertension, who received new antihypertensive prescriptionsat his last
visit returns to theclinictwo weeks later to evaluate his blood pressure (BP). HisBP is
158/106 and he admits that he has not been taking the prescribed medicationbecause the
drugs make him "feel bad". In explaining the need for hypertension control, thenurseshould
stress that an elevated BP placestheclient at risk for which pathophysiologicalcondition?
(ANS- Strokesecondaryto hemorrhage
The nurse observes an unlicensed assistive personnel (UAP) positioning a newlyadmitted
client who has a seizure disorder. Theclient is supine and the UAP is placing softpillows
along thesiderails. What action should the nurse implement?
(ANS- Instruct the UAP to obtain soft blankets to secure to the side rails instead ofpillows.
An adolescent with major depressive disorder has been taking duloxetine(Cymbalta) for the
past 12 days. Which assessment finding requires immediate follow-up?(ANS- Describes life without purpose
A 60-year-old female client with a positive family history of ovarian cancer hasdeveloped an
abdominal mass and is being evaluated for possibleovarian cancer. HerPapanicolau (Pap)
smear results are negative. What information should the nurseinclude in theclient's teaching
(ANS-Furtherevaluation involving surgery may be needed
A client who recently underwear a tracheostomyis being prepared for dischargetohome.
Which instructionsis most important for the nursetoinclude in the discharge plan?(ANS- Teach tracheal suctioning techniques
In assessing an adultclient with a partial rebreather mask, the nurse notes that theoxygen
reservoir bag does not deflatecompletely during inspiration and theclient'srespiratoryrate is
14 breaths/ minute. What action should the nurse implement?
(ANS- Document the assessment data — Rational: reservoir bag should notdeflate
completely during inspiration and theclient's respiratoryrateis within normallimits.
During shift report, thecentralelectrocardiogram (EKG) monitoring systemalarms. Which
client alarm should the nurseinvestigate firs?(ANS- Respiratory
apnea of30 seconds
During a home visit, the nurse observed an elderly client with diabetes slip andfall. What
action should the nursetakefirst?
(ANS- Check theclient for lacerations or fractures
At 0600 while admitting a woman for a schedulerepeat cesarean section (CSection), the
client tells the nurse that she drank a cup a coffee at 0400 because she wanted toavoid
getting a headache. Which action should the nurse takefirst?(ANS- Inform the anesthesia
care provider
After placing a stethoscope as seen in the picture, the nurse auscultates S1 and S2heart
sounds. To determine if an S3 heart sound is present, what action should the nursetake first?
(ANS-Listen with the bell at thesamelocation

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