A nurse is assessing a client who is postoperative following an open reduction and internal fixation (ORIF) of the femur. Which of the following assessments should be the nurse’s priority?
Answer Choices:
Braden scale
Morse Fall Risk scale
Neurovascular assessment
Pain assessment
Answer: Neurovascular assessment.
A nurse is planning to withdraw medication from an ampule to prepare for an injection. Which of the following actions should the nurse plan to take?
Answer Choices:
Expel air into the ampule to aspirate air bubbles.
Withdraw the medication from the ampule using a needleless system.
Place a paper towel around the ampule’s neck to break off the top with both hands.
Dispose of the top of the ampule in a sharps container.
Answer: Dispose of the top of the ampule in a sharps container.
A nurse working in the emergency department is caring for a client who has a burn injury. After securing the client’s airway, which of the following interventions should the nurse take first?
Answer Choices:
Cleanse the client’s wounds.
Administer analgesic medication.
Increase the room temperature.
Start an IV with a large-bore needle.
Answer: Start an IV with a large-bore needle.
A nurse is caring for a client who is 16 hr postoperative and is experiencing abdominal gas pains. Which of the following actions should the nurse take?
Answer Choices:
Provide the client with low-fiber food.
Encourage the client to use an incentive spirometer.
Assist the client with ambulation.
Administer pain medication to the client.
Answer: Assist the client with ambulation.
A nurse in the emergency department is managing the care of a client who has an electrical shock injury. Which of the following actions should the nurse take first?
Answer Choices:
Titrate IV fluids to maintain urine output at 75 mL/hr.
Change dressings over the entrance and exit wounds.
Administer an opioid pain medication.
Obtain an ECG.
Answer: Obtain an ECG.
A nurse is preparing to administer fresh frozen plasma to a client. Which of the following actions should the nurse take?
Answer Choices:
Hold the transfusion if the client is actively bleeding.
Transfuse the plasma over 4 hr.
Administer the transfusion through a 25-gauge saline lock.
Administer the plasma immediately after thawing.
Answer: Administer the plasma immediately after thawing.
A nurse is caring for a client who has a herniated disc and is scheduled for a peripheral nerve block. The client tells the nurse, “I am afraid to have this procedure.” Which of the following responses should the nurse make?
Answer Choices:
“After this procedure, you will feel much better.”
“Tell me why you are scared to have this procedure.”
“Let’s discuss your concerns about this procedure.”
“Are you afraid of needles that will be used during the procedure?”
Answer: “Let’s discuss your concerns about this procedure.”
The nurse is assigned a post-op hip replacement patient with uncontrolled pain. Provider orders: Morphine IV q3h, Ketorolac IV BID. Complete the statement.
Answer Choices:
IV line is (patent/connected/infected/intact)
because (infiltration/extravasation/phlebitis/obstruction) may interfere with (excretion/metabolism/dosing/absorption)
Answer: IV line is patent because infiltration may interfere with absorption
A nurse is admitting a client who has arthritic pain and reports taking ibuprofen several times daily for 3 years. Which of the following tests should the nurse monitor?
Answer Choices:
Urine for white blood cells
Fasting blood glucose
Serum calcium
Stool for occult blood
Answer: Stool for occult blood.
A nurse is administering packed RBCs to a client. The client reports chills, lower back pain, and nausea 10 min after the infusion begins. Which of the following actions should the nurse take first?
Answer Choices:
Stop the infusion.
Administer oxygen to the client.
Check the client’s vital signs.
Collect a urine sample.
Answer: Stop the infusion.
A nurse is caring for a client who is 3 hr postoperative following a total knee arthroplasty. Which of the following actions should the nurse take to prevent venous thromboembolism?
Answer Choices:
Massage the client’s legs every 4 hr while they are awake.
Keep the client’s knees in a flexed position while they are in bed.
Encourage the client to perform circumduction of the feet.
Limit the client’s fluid intake to 2,000 mL daily.
Answer: Encourage the client to perform circumduction of the feet.
A nurse is reviewing the health history of a client who is scheduled for exploratory surgery. Which of the following food allergies indicates a risk for an allergic reaction to latex?
Answer Choices:
Peanuts
Shellfish
Strawberries
Eggs
Answer: Strawberries.