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A nurse in the intensive care unit is training a graduate nurse how to manage a client with a traumatic brain injury. Based on the client’s orders, when the client’s intracranial pressure (ICP) begins to rise above normal parameters, the nurse should perform a neurologic examination and notify the primary healthcare provider of the assessment findings. Which of the following devices would the nurse instruct the graduate nurse to monitor to determine the client’s ICP?
A nurse receives orders to perform a Romberg test on a client admitted to the neuro unit. Which of the following indicates a positive result?
The nurse is preparing to perform a 12-lead ECG for a client with complaints of heart palpitations and shortness of breath. Which of the following locations is the most appropriate placement for the V2 lead?
A nurse draws an INR on a client taking warfarin (Coumadin®). The result of the INR is 1.2. Which of the following nurse reactions is most appropriate?
The nurse is observing an elderly client with diabetes perform their self-care routine. Due to the risk for skin breakdown, which of the following actions by the client should be corrected by the nurse?
A client admitted to a healthcare facility for observation related to severe anxiety and panic attacks begins hyperventilating. The client, unable to calm down, continues the irregular and quick breathing pattern. The client is at highest risk for which of the following?
A nurse is preparing to take vital signs on a client requiring intermittent dialysis. The client has an AV fistula in the right arm. Which of the following actions is the most appropriate?
A client presents to the emergency department with profound muscle weakness, disorientation, and shortened QT interval on ECG. Which of the following electrolyte imbalances does the nurse suspect?
A 65-year-old post-op esophagectomy client with esophageal cancer has a PEG tube placement. Which of the following nursing diagnoses is the priority for the client?
A nurse is preparing to insert a nasogastric tube in a client requiring enteral nutrition. In which of the following positions should the nurse place the client?
A client with a foley catheter has orders to have the catheter removed. Which of the following actions by the nurse demonstrates appropriate removal of the foley?
A postpartum nurse checks a mother 24 hours post birth. The mother tells the nurse that she has run out of pads because she has struggled with bleeding. When asked, the mother states she has saturated two pads every hour. Which of the following is the priority nursing action?
Which of the following is the best way to assess the appropriate placement of a nasogastric tube?
A client treated for a deep vein thrombosis asks the nurse what measures he can take at home to help reduce his risk of getting another blood clot. Which of the following recommendations is the most appropriate for the nurse to give?
The nurse is assessing a client post arthroscopy with a right groin access site. Which of the following assessment findings should the nurse report to the primary healthcare provider?
The nurse caring for a client post abdominal closure following acute abdominal compartment syndrome discusses factors that may delay wound healing for the client. Which of the following factors is least compromising for the client’s healing?
The nurse is caring for an elderly client with acute confusion and a urinary tract infection. After drawing several labs, the nurse receives the results. Which of the following laboratory results should the nurse report immediately to the primary healthcare provider?
A client with epilepsy begins to have a grand mal seizure in their bed. Which action by the nurse should be performed first?
The nurse is assessing a client with right-sided heart failure. The nurse anticipates assessing for edema in which location?
A client post-op abdominal tumor resection is at elevated risk for blood clotting. Which of the following nursing interventions would be most appropriate to help prevent a deep vein thrombosis (DVT)?