A nurse is caring for a client who has a flaccid bladder following a spinal cord injury. Which of the following actions should the nurse take first? - ANSWER Initiate a bladder training schedule A ... nurse is caring for a client who is 48 hr post-operative following an abdominal aortic aneurysm resection. Which of the following findings is the most urgent? - ANSWER Absent dorsalis pedis pulse A nurse is caring for a child who has sickle cell disease and has been admitted in a vaso-occlusive crisis. Which of the following is the nurse's priority concern? - ANSWER Promoting oxygenation A nurse on a medical unit has received report on four clients. Which of the following clients should the nurse evaluate first? - ANSWER A client who has a fever of 38.4°C (101.2°F) with tenderness in the right lower quadrant A nurse is caring for a client who has a compound fracture of the tibia and fibula and is in skin traction. The client reports pain of a 6 on a scale of 0 to 10 under the traction bandage. Which of the following actions should the nurse take first? - ANSWER Check pedal pulse Following morning report, a nurse assigns completion of several tasks to an assistive personnel (AP). Which of the following tasks should the nurse have the AP perform first? - ANSWER Perform fingersticks for glucose levels on clients who have diabetes mellitus A nurses caring for a group of pediatric clients. Which of the following clients requires immediate intervention? - ANSWER A client who is prescribed digoxin (Lanoxin) and has had three episodes of vomiting A nurses caring for a client who has a radial head fracture. Which of the following should be the priority action by the nurse following application of the cast? - ANSWER Evaluate neurovascular status A nurse is caring for a client who has a fractured hip and a respiratory rate of 26/min. Which of the following actions should the nurse take first? - ANSWER Evaluate level of consciousness A nurse in a providers office is collecting data on a group of clients who are pregnant. Which of the following clients should be the nurses priority concern? - ANSWER A client who is 34 weeks of just station and reporting abdominal tenderness A school nurse is reinforcing teaching regarding bicycle safety to a group of school age children. Which of the following is the most important concept to include in the teaching? - ANSWER Used properly fitted bicycle helmet A nurses caring for a client who is experiencing panic level anxiety. Which of the following actions should the nurse take first? - ANSWER Engage the client in physical activity A nurse has been assigned to care for four clients on a medical-surgical floor. Which of the following clients should the nurse evaluate first? - ANSWER A client following knee replacement surgery complaining of pain and warmth in the calf A nurses caring for a client who is in preterm labor and is receiving magnesium sulfate. Which of the following client data is most important for the nurse to monitor? - ANSWER Maternal respirations A nurses caring for a client who is newly diagnosed with bipolar disorder and is currently experiencing an acute manic episode. Which of the following is a priority concern of the nurse? - ANSWER Preventing injury A public health nurse is triaging clients at the site of an explosion. The client with which of the following injuries should be the nurses priority concern? - ANSWER Incomplete amputation of the foot A nurse is caring for a client who was admitted to the unit three hours ago following a total hip arthroplasty. Which of the following findings should be the nurse's priority concern? - ANSWER Oxygen saturation of 90% on oxygen at 2 L per nasal cannula A nurse working the 7 PM to 7 AM shift on the pediatric unit has received report on four post operative clients. Which of the following requires immediate intervention? - ANSWER A preschooler who is post operative following a tonsillectomy and is experiencing frequent swallowing A nurse is caring for toddler who has laryngotracheobronchitis and is having difficulty breathing. Which of the following should be the first action of the nurse? - ANSWER Obtain an oxygen saturation level A nurse is collecting data on a client who has a diagnosis of myasthenia gravis. For which of the following complications is it most important for the nurse to monitor? - ANSWER Decreased respiratory effort [Show More]
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