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A postoperative client has three different PRN analgesics prescribed for different levels of pain. The nurse inadvertently administer a dose that is not within the prescribed parameters. What action should the nurse take first? C
A) Determine if the pain was relieved.
B) Complete a medication error report.
C) Assess for side effects of the medication.
D) Document the clients responses.

The unlicensed assistive personnel (UAP) describes the appearance of the bowel movements of several clients. Which descriptions warrant additional follow-up by the nurse? (Select all that apply.) ABDE A) Multiple hard pellets.
B) Brown liquid.
C) Formed but soft.
D) Solid with red streaks. E) Tarry appearance.

An elderly woman comes to the clinic because of vaginal bleeding. The healthcare provider finds a vaginal tear, which the client reports is likely to have occurred during unprotected sexual intercourse. Which content is most important for the nurse to include in this client’s teaching plan? A
A) The importance of using vaginal lubricants.
B) Methods used to practice safe sex.
C) Information about alternative ways to express sexuality.
D) Intercourse positions that help prevent tears.

A male client has right-sided hemiplegia following a left cerebrovascular accident (CVA). His sitting balance has improved, and he is now able to sit In a wheelchair. To assist the client in transferring from the bed to a wheelchair, what action should the nurse take?
A) Have the client put both arms around the nurse’s neck for support. B) Place the wheelchair on the client’s left side.
C) Instruct the client to look at his feet.
D) Instruct the client total slow, deep breaths while transferring.

The nurse observes a newly admitted older adult female take short steps and walk very slowly while pushing a walker in front of her. What action should the nurse take in response to these observations? A
A) Complete a full fall risk assessment of the client.
B) Teach the client to take longer steps at faster pace.
C) Suggest that the the client use a wheelchair instead of a walker.
D) Place client on bedrest until the healthcare provider is notified.

A client is receiving ketorolac (Toradol) IM 45 mg IM 6 hours for postoperative pain. The available 2 ml vial is labeled , Toradol IM 30 mg/ml, How many should the nurse administer?
(Round to the nearest tenth.) 1.5mg

While suctioning a client’s nasopharynx, the nurse observes that the client’s oxygen saturation remains at 94%, which is the same reading obtained prior to starting the procedure. What action should the nurse take in response to this finding? C
A) Reposition the pulse oximeter clip to obtain a new reading.
B) Stop suctioning until the pulse oximeter reading is above 95%. C) Complete the intermittent suction of the nasopharynx.
D) Apply an oxygen mask over the client’s nose and mouth.

An older woman with end stage heart disease is hospitalized for severe heart failure. She is alert, oriented, and requests that no heroic measures are implemented if her breathing stops. What action should the nurse take first? A
A) Discuss with the client her meaning of heroic measures.
B) Obtain a “do not resuscitate” (DNR) prescription.
C) Set up a family conference to discuss the client’s.
D) Consult the palliative care team about client’s care.

A client diagnosed with primary open-angle glaucoma received a prescription for biotic eye drops, pilocarpine HCl (Pilocarpine). What instruction should the nurse plan to include in this client’s teaching? A
A) “Do not allow the dropper bottle to touch the eye.”
B) “Administer the medication directly on the cornea.”
C) “Squeeze your eye closed after administering the drops.”
D) “Wash your hands after each administration of eye drops.”

When assessing a client who starts to wheeze related data should obtain? D
A) Presence of radiation.
B) Heart sounds.
C) Body temperature. D) Precipitating factors.

The home health nurse is reviewing the personal care of an elderly client who lives alone.Which client assessment findings indicate the need to assign an unlicensed assistive personnel. (UAP) to provide routine foot care and file the client’s toenails? Select all that apply.) ABC
A) syncope when bending. B) Hand tremors.
C) Diminished visual acuity.
D) Urinary incontinence.
E) Shuffling gait.

A client is discharged to a long-term care facility with an indwelling urinary catheter. Which nursing action should be included in the plan to reduce the client’s risk for infection related to the catheter? B
A) Flush the catheter daily with sterile saline. B) Encourage increased intake of oral fluids.
C) Administer a PRN antipyretic if a fever develops.
D) Secure the drainage bag at bladder level during transport.

To assess the quality of an adult client’s pain, what approach should the nurse use? C
A) Observe body language and movement.
B) Provide a numeric pain scale.
C) Ask the client to describe the pain.
D) Identify effective pain relief measures.

A client who has been diagnosed with terminal cancer tells the nurse, “The doctor told me I have cancer and do not have long to live.” Which response is best for the nurse to provide?
A) “That’s correct, you do not have long to live” D
B) “Would you like me to call your minister?”
C) “Don't give up, you still have chemotherapy to try.” D) “Yes, your condition is serious.”

When performing blood pressure measurement to assess for orthostatic hypotension, which action should the nurse implement first? C
A) Apply the blood pressure cuff securely.
B) Record the client’s pulse rate and rhythm. C) Position the client supine for a few minutes.
D) Assist the client to stand at bedside.

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