Numerade

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ANSWERED

The nurse is caring for a client in the first stage of labor and observes that a segment of the umbilical cord is visible in the vaginal opening after rupture of the client’s amniotic membranes. Which of the following actions should the nurse take? 1. Instruct the client to lie on her left side. 2. Attempt to place the umbilical cord back into the uterus. 3. Assist the client into a knee-chest position. 4. Administer an intravenous tocolytic agent.

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Danielle Fairburn

Numerade educator

The nurse is caring for a client who has a prescription for an intravenous infusion of 0.45% sodium chloride (halfstrength saline). The nurse notes the client is receiving 5% dextrose in water. Which of the following actions should the nurse take first? 1. Change the intravenous fluid to the prescribed fluid. 2. Notify the primary health care provider. 3. Complete an incident report. 4. Assess the client.

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James Kiss

Numerade educator

The nurse is talking with a client who has a positive laboratory test result for human immunodeficiency virus (HIV) infection. Which of the following statements by the client would require follow-up? 1. “I try to eat a well-balanced diet.” 2. “I avoid crowds when I go outside the house.” 3. “I am taking a vitamin C tablet daily to help prevent infections.” 4. “I take echinacea every day to help improve my immune system.”

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James Kiss

Numerade educator

The nurse in the psychiatric unit is administering medications when a client with a borderline personality disorder approaches and asks to talk. The nurse suggests having a talk in 1 hour. The client shouts, “I’ll wait, but you will be sorry!” and then picks up a pitcher of water and throws it onto the floor. 1. Offer to listen to the client while continuing to administer the medications. 2. Suggest that the client take a p.r.n. prescribed medication for agitation. 3. Ask another nurse to finish administering the medications, and talk with the client. 4. Request assistance from several nearby staff members with controlling the client’s behavior. Which of the following actions should the nurse take?

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James Kiss

Numerade educator

The nurse has observed a staff member tell a client with bipolar disorder that there will be consequences for making negative comments about conditions in the facility. When the nurse meets privately with the staff member, which of the following statements would be most appropriate for the nurse to make to the staff member? 1. “Threatening a client can result in the immediate dismissal of a staff member.” 2. “Staff members who have difficulty with control issues often seek power over clients.” 3. “Clients have a right to provide feedback about services without fear of punishment.” 4. “Staff should set limits with clients in a nonjudgmental manner.”

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James Kiss

Numerade educator

The nurse in the inpatient psychiatric unit is leading a support group for clients. It would be a priority for the nurse to intervene if the client with 1. bipolar I disorder is experiencing a manic episode, is moving the legs, and is looking around the room restlessly 2. borderline personality disorder is saying that another group member is too disturbed to be attending the session 3. major depressive disorder is sitting quietly with the eyes downcast 4. schizophrenia is rocking in place and copying the gestures of another client in the group

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INSTANT ANSWER

The nurse is assessing a client with suspected mononucleosis. Which of the following findings would support a diagnosis of mononucleosis? 1. polyarthralgia 2. costovertebral pain 3. cervical lymphadenopathy 4. left lower quadrant (LLQ) tenderness

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James Kiss

Numerade educator

The nurse is planning a staff education program about infection control guidelines. Which of the following information about alcohol-based hand rub should the nurse include? 1. “Use before touching medical equipment that will come in direct contact with the client.” 2. “Avoid using when moving your hands from a contaminated body site to a clean body site during client care.” 3. “Avoid using before caring for clients who have severe neutropenia.” 4. “Use after contact with body excretions that do not cause your hands to be visibly soiled.”

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The nurse is preparing to admit a client who has pleuritic chest pain and is reporting a cough productive of yellow sputum for the past 1 week. The client has a pulse oximetry reading of 90% on room air. Which of the following infection control precautions should the nurse implement? 1. Use a stethoscope that is designated for use with the client only. 2. Wear sterile gloves when inserting a peripheral venous access device (VAD). 3. Assign the client to a private room with monitored negative air pressure. 4. Place a box of surgical masks inside the client’s room

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Jennifer Stoner

Numerade educator

The nurse is caring for the following clients. The nurse should recommend a referral to an occupational therapist for the client with 1. rheumatoid arthritis (RA) who has a 2-month-old infant 2. an intertrochanteric hip fracture who works as a surgeon 3. mononucleosis who is a college student 4. tendonitis who is a professional tennis player

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kyle s.