Reposition the infant every 2 hours.

Encourage him to use an electric razor

Prepare a woman for a bone density screening

A family member of a client with dementia who has been missing for fivehour

While monitoring a client during a seizure, which interventions should the nurse implement? (SATA) ITS All

Monitor physical movements, Record the duration of the seizure, Observe for a patent airway, Move obstacle away from client

The nurse is assessing a client’s nailbeds. Witch appearance indicates further follow-up is

., ., the pic is the right one.., .

measles outbreakis resolved., Restrict unvaccinated children from attending school until

Persistent coughing while drinking

When planning care for a client with acute pancreatitis, which nursing intervention has the highest priority?

Withhold food and fluid intake.

Completely stop cigarette/ cigar smoking.

Initiate the dosage lockout mechanism on the PCA pump

Encourage popsicles and fluids of choice

Recommend weigh bearing physical activity

Ensure that the knot can be quickly released.

Continue with the plan of care for this client

Notify healthcare provider to prepare for pericardiocentesis

Her mother and sister have a history of breast cancer

To reduce staff nurse role ambiguity, which strategy should the nurse manager implemented?

accurate, andrecurrent., Review the staff nurse job description to ensure that it is clear,

The client’s previous GCS score

The nurse inserts an indwelling urinary catheter as seen in the video what action should the nurse take next?

Leave the catheter in place and obtain a sterile catheter.

i think its a SATA/// all correct

Leakage of CSF from the incisional site, Abdominal distention, Poor feeding and vomiting

Mashed, potatoes, pudding, milk., Pasta, noodles, rice., Egg, tofu, ground meat.

Raise the client’s legs and feet

Review the client’s serum calcium level

Have the child lie with the ear up for one to two minute after installation

....hemoconcentration of serum solutes, Insensible loss of body fluids contributes to the ...

it all but agian didnt think ita was a SATA

Provide supplemental oxygen, Auscultate bilateral lung fields, Reinforce occlusive CT dressing

Avoid all isometric exercises, but walk regularly.

Respiratory apnea of 30 seconds

Place cardiac monitor leads on the client’s chest.

They decrease the risk for joint trauma

Brain damage with CP is not progressive but does have a variable course

Based on principles of asepsis, the nurse should consider which circumstance to be sterile?

An open sterile Foley catheter kit set up on a table at the nurse waist lev

Remove sequential compression devices.

Send family to the waiting area while the client’s history is taking

Send stool sample to the lab for a guaiac test

Three days postoperative colon resection receiving ...

Teach tracheal suctioning techniques

Provide an opportunity for him to clarify his values related to the decisio

Ask the new person to move belonging to accommodate others

Which client should the nurse assess frequently because of the risk for overflow incontinence? A client

Who is confused and frequently forgets to go to the bathroom

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Answers

1
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Reposition the infant every 2 hours.
Feed the infant every 4 hours.
Perform diaper changes under the light.
Cover with a receiving blanket.
2
.
Encourage him to use an electric razor
Asses him for adventitious lung sounds
Initiate contact isolation
Cluster care to conserve energy
3
.
Encourage the woman at risk for cancer to obtain colonoscopy.
Explain the follow-up need it for a client with prehypertension.
Prepare a woman for a bone density screening
Present a class of breast-self examination
4
.
.
A family member of a client with dementia who has been missing for fivehour
.
.
5
While monitoring a client during a seizure, which interventions should the nurse implement? (SATA) ITS All
Monitor physical movements
Record the duration of the seizure
Observe for a patent airway
Move obstacle away from client
6
The nurse is assessing a client’s nailbeds. Witch appearance indicates further follow-up is
.
.
the pic is the right one..
.
7
.
.
measles outbreakis resolved.
.
Restrict unvaccinated children from attending school until
8
.
Unilateral facial drooping
Persistent coughing while drinking
Inappropriate or exaggerated mood swings
Abnormal responses for cranial nerves I and II
9
When planning care for a client with acute pancreatitis, which nursing intervention has the highest priority?
Administer antiemetic as needed.
Withhold food and fluid intake.
Initiate IV fluid replacement.
Evaluate intake and output ratio.
10
.
Consistently applies TED hose before getting dressed in the morning.
Completely stop cigarette/ cigar smoking.
Inspect the leg frequently for any irritation or skin breakdown
Frequently elevated legs thorough the day.
11
.
Assess the abdomen for bowel sounds.
Assess the client ability to use a numeric pain scale
Initiate the dosage lockout mechanism on the PCA pump
Instruct the client to use the medication before the pain becomes severe
12
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Obtain specimen for uranalysis
Evaluate postural blood pressure measurements
Assess bowel sounds in all quadrants
Encourage popsicles and fluids of choice
13
.
.
.
.
Recommend weigh bearing physical activity
14
.
.
Ensure that the knot can be quickly released.
.
.
15
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Massage the uterus to decrease atony
Review the hemoglobin to determined hemorrhage
Check for a destined bladder
Increase intravenous infusion
16
.
Heat loss
Hypoglycemia
Fluid balance
Bleeding tendencies
17
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Change the client's to NPO status
Decrease the client's iv rate to 50 ml per hour
discontinue the magnesium sulfate immediately
Continue with the plan of care for this client
18
.
Asses for paradoxical blood pressure
Notify healthcare provider to prepare for pericardiocentesis
Observe neck for jugular vein distention
Monitor oxygen saturation (Sp02) via continuous pulse oximetry
19
.
.
.
.
Her mother and sister have a history of breast cancer
20
To reduce staff nurse role ambiguity, which strategy should the nurse manager implemented?
accurate, andrecurrent.
.
Review the staff nurse job description to ensure that it is clear,
.
21
.
The client’s blood pressure and respiration rate
When the client’s stroke symptoms started
The client’s previous GCS score
If the client is oriented to time
22
The nurse inserts an indwelling urinary catheter as seen in the video what action should the nurse take next?
Leave the catheter in place and obtain a sterile catheter.
Remove the catheter and insert into urethral opening
Insert the catheter further and observe for discomfort.
Observe for urine flow and then inflate the balloon.
23
i think its a SATA/// all correct
Leakage of CSF from the incisional site
Abdominal distention
.
Poor feeding and vomiting
24
.
.
.
.
Epinephrine Injection, USP IV
25
SATA its all
Mashed, potatoes, pudding, milk.
Pasta, noodles, rice.
.
Egg, tofu, ground meat.
26
.
.
.
.
Raise the client’s legs and feet
27
.
Administer PRN antianxiety medication.
Review the client’s serum calcium level
Tell the UAP to use a different sphygmomanometer.
Ask the UAP to take the blood pressure in the other arm
28
.
Have the child lie with the ear up for one to two minute after installation
.
.
.
29
Which assess. is more important for the nurse to include in the daily plan of care for aclient with a burned extremity?
Presence of exudate
Distal pulse intensity
Range of Motion
Extremity sensation
30
.
....hemoconcentration of serum solutes
.
.
Insensible loss of body fluids contributes to the ...
31
it all but agian didnt think ita was a SATA
Provide supplemental oxygen
Auscultate bilateral lung fields
.
Reinforce occlusive CT dressing
32
.
Keep nitroglycerin in a light-colored plastic bottle and readily available.
Avoid all isometric exercises, but walk regularly.
Engage in physical exercise immediately after eating to help decrease chole
Walk briskly in cold weather to increase cardiac output
33
just the pic
.
.
.
.
34
.
.
Respiratory apnea of 30 seconds
.
.
35
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Sitting upright.
Straining on stool
Crying
Vomiting
36
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Increase hunger and thirst
Persistent fever
Headache
Joint stiffness
37
.
Gather emergency tracheostomy equipment
Prepare to administer atropine 0.4 mg IVP
Place cardiac monitor leads on the client’s chest.
Prepare to administer lidocaine at 100 mg IVP
38
.
.
.
They decrease the risk for joint trauma
.
39
.
.
.
Brain damage with CP is not progressive but does have a variable course
.
40
Based on principles of asepsis, the nurse should consider which circumstance to be sterile?
One inch- border around the edge of the sterile field set up in the oper...
An open sterile Foley catheter kit set up on a table at the nurse waist lev
A wrapped unopened, sterile 4x4 gauze placed on a damp table top.
Sterile syringe is placed on sterile area as the nurse riches over the s...
41
.
Weigh every morning
Perform range of motion exercises
Eat a high protein diet
Limit fluid intake to 1,500 ml daily
42
.
Bilateral scleral edema
Muffled heart sounds
Jaundice skin tone
Pitting peripheral edema
43
.
.
.
Lethargy
.
44
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Remove sequential compression devices.
.
.
.
45
.
Complete the head to toes assessment to identify other sign of HIV
Obtain a blood sample to determine is the client is HIV positive
Send family to the waiting area while the client’s history is taking
Ask family member to wear gloves when touching the patient
46
.
Obtain specimen for culture and sensitivity analysis
Asses for fatty yellow streaks in the client’s stool.
Observe stool for a day-colored appearance.
Send stool sample to the lab for a guaiac test
47
.
.
.
Three days postoperative colon resection receiving ...
.....transfusion of packedRBCs.
48
.
.
Teach tracheal suctioning techniques
.
.
49
...
Advise him to seek several opinions before making decision
Encourage him to share memories about his life with his wife and family
Provide an opportunity for him to clarify his values related to the decisio
Offer to contact the hospital chaplain or social worker to offer support.
50
.
Move to welcome and accommodate a new person
Tell the new person to move belongings because of limited space
Ask the new person to move belonging to accommodate others
Bring in additional chairs so that all staff members can be seated
51
Which client should the nurse assess frequently because of the risk for overflow incontinence? A client
Who is confused and frequently forgets to go to the bathroom
.
.
.
52
.
Report the results to the healthcare provider.
Increase ventilator rate.
Administer a dose of sodium carbonate.
Decrease the flow rate of oxygen.
53
all are correct but i didnt think this was a SATA
Coordinate carbohydrate controlled meals at consistent times and intervals
Fingerstick glucose assessment q6h with meals
Teach subcutaneous injection technique, site rotation and insulinmanagement
Review with the client proper foot care and prevention of injury
54
.
.
.
.
Enable clients to become active participating in controlling the diseasepro
55
.
Eat meals at the same time daily.
Limit the intake of high calorie foods.
Maintain a low protein diet.
Restrict daily fluid intake.
56
.
Hourly urinary output
Cardiac rhythm and heart rate.
Daily intake of foods rich in potassium.
Thirst ad skin turgor.
57
.
Remove the heating pads and place a soft blanket over the....
.
.
...client’s leg and feet.
58
.
.
.
12.5
.
59
2 clients ring their call bells simultaneously requesting pain medication. What actionshould the nurse implement first?
.
.
.
Evaluate both client’s pain using a standardized pain scale
60
/
...effective in reducing phantom limbpain
.
.
Research indicates that mirror therapy is ...
61
.
.
.
.
Ask the wife to stop and assess the client’s swallowing reflex
62
.
Prepare the skin for procedure.
Check telemetry monitoring
Identify client's pulse points
Identify client's pulse points
63
..
Disturbed sleep pattern
Imbalance nutrition
Hygiene-self-care deficit
Self-neglect
64
.
Blurred visual field
Profuse diarrhea
Gradual weakness
Sudden dysphagia
65
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Establish trust with community leaders and respect cultural and familyvalue
.
.
.
66
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Insert saline lock for IV diuretic therapy.
Assess compliance with routine prescriptions.
Arrange transport for admission to the hospital.
Instruct the client to monitor daily caloric intake.
67
SATA its both
.
Provide a PRN dose of acetaminophen for headache
.
Administer a daily dose of lisinopril as scheduled.
68
.
Encourage the client to participate in group activities
Schedule a daily conference with the social worker
Encourage the client’s family to visit more often
Engage the client in a non-threatening conversation.
69
A client receives a new prescription for simvastatin(Zocor) 5 mg PO daily at bedtime. What action should the nurse take?
.
.
.
Administer the medication as prescribed with a glass of water
70
.
Tell the staff to keep all clients and visitors in the client
.
rooms with the doorsclosed
.
71
.
Irrigate the indwelling urinary catheter.
Obtain capillary blood glucose measurement.
Prepare the client for external pacing.
Titrate the dopamine infusion to raise the BP.
72
.
Use a quick dart-like motion to inject into the dorsogluteal site.
Select a 22 gauge 1 1⁄2 inch (3.8 cm) needle for the intramuscular injectio
Divide the medication into two injection with volumes under 1ml
Administer into the deltoid muscle while the parent holds the infant secure
73
.
Assess functional ability of the primary support system.
Evaluate the client’s mood, cognition and orientation.
Determine the client’s level of emotional functioning’
Review the client’s pattern of adaptive coping skill
74
...
.
.
Encourage screening for a peptic ulcer
.
75
.
Notify the healthcare provider and obtain a tracheostomy tray
.
.
.
76
.
.
.
Baked pork chop, applesauce, corn on the cob, 2% milk, and key-lime pie
.
77
.
Aspirin, low dose
Furosemide (lasix)
Enalapril (vasote)
Allopurinol (Zyloprim)
78
..
Increase in blood pressure
Goiter no longer palpable
Decrease in pulse rate
Decrease in serum T4 levels
79
.
Apply soft bilateral wrist restraints.
Redress the abdominal incision
Replace the IV site with a smaller gauge.
Leave the lights on in the room at night.
80
.
Provide high- calorie, high-protein diet
Begin parenteral antibiotic therapy
Bivalve the cast for distal compromise
Administer antiemetic agents
81
.
Advise the client to maintain a voiding diary for one week
Instruct in effective technique to cleanse the glans penis
Obtain a urine specimen for culture and sensitivity
Palpate the client's suprapubic area for distention
82
.
.
.
.
The hemoglobin A1C was 6.5g/100 ml last week
83
.
Low sodium
High protein
High carbohydrate.
Low fat
84
In early septic shock states, what is the primary cause of hypotension?
Peripheral vasoconstriction
A vagal response
Peripheral vasodilation
Cardiac failure
85
.
Ask a chemotherapy-certified nurse to administer the Zofran
Awaken the client to assess the need for administration of the Zofran.
Administer the Zofran after flushing the saline lock with saline
Hold the scheduled dose of Zofran until the client awakens
86
.
Chew food slowly and thoroughly before attempting to swallow
Plan volume-controlled evenly-space meal thorough the day
Sip fluid slowly with each meal and between meals
Eliminate or reduce intake fatty and gas forming food
87
.
36%
9%
18%
45%
88
..
Increase activity and exercise gradually, as tolerated.
Avoid crowds for first two months after surgery.
Limit intake fatty foods for one month after surgery.
Notify the healthcare provider if edema occurs.
89
.
Chronic liver failure with a hemoglobin of 10.1 and slight bilirubin elevat
.
.
.
90
.
Observe for swelling around the stump.
Note amount color of wound drainage.
Asses skin elasticity of the stump.
Evaluate closet proximal pulse.
91
.
Supplemental feedings with formula
Maternal diet high in protein
Breastfeeding every 2 or 3 hours.
Maternal intake of increased oral fluid
92
.
Neglects personal hygiene and has no appetite
Begin to show signs of improvement in affect
Lacks interest in the activity of the family and friends
Express feelings of sadness and loneliness
93
.
Do not read without direct lighting for 6 weeks.
Avoid straining at stool, bending, or lifting heavy objects.
Irrigate conjunctiva with ophthalmic saline prior to installing antibiotic
Limit exposure to sunlight during the first 2 weeks when the cornea is heal
94
.
Perform CPT after meals to increase appetite and improve food intake.
Stop using CPT during the daytime until the child has regained an appetite.
Perform CPT only in the morning, but increase frequency when appetiteimpro
CPT should be performed more frequently, but at least an hour before meals.
95
.
.
.
.
Auscultate bowel sounds in all four quadrants
96
.
Observe for changes in level of consciousness.
Determine client’s level current blood alcohol level.
Provide grief counseling for client and his family.
Involve the client’s family in healthcare decisions.
97
.
Administer the analgesic as requested
.
.
.
98
.
Explain to the client that her position is not safe.
Place a wedge under the client’s right hip.
Encourage the client to turn on her left side.
Place a pillow under the client’s head and knees.
99
.
.
.
.
8
100
Which problem reported by a client taking lovastatin requires the most immediate fallow up by the nurse?
Altered taste
Abdominal cramps
Muscle pain
Diarrhea and flatulence

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