Concordia University Texas

NUR 3535

1)A nurse is caring for a client who reports pain. When documenting the quality of the clients pain on an initial pain assessment, the nurse should record which of the following client statements?

2. A client who is nonambulatory notifies the nurse that his trash can is on fire. After the nurse confirms the presence of the fire, which of the following actions should the nurse take next?

3. A nurse is completing an admission assessment for a client who reports vomiting and diarrhea for the past 3 days. Which of the following findings should the nurse expect?

4. A nurse has accepted a verbal prescription “for three tenth of a milligram of levothyroxine IV stat” for a client who has myxedema coma. How should the nurse transcribe the dosage of this medication in the client’s medical record?

5. A nurse is preparing a heparin infusion for a client who was admitted to the facility with deep-vein thrombosis. The prescription reads: 25,000 units of heparin in 0.9% sodium chloride 250 mL to infuse at 800 units/hr. At what rate should the nurse set the infusion pump.

6. A nurse is caring for a client who has a prescription for wound irrigation. Which of the following actions should the nurse take?

7. A nurse is caring for a client who is receiving fluid through a peripheral IV catheter. Which of the following findings at the IV site should the nurse identify as indicating infiltration?

8. A nurse is teaching a client whose left leg is in a cast about using crutches. Which of the following statements should the nurse identify as an indication that the client understands the teaching?

9. A nurse is caring for a client who has an NG tube and is receiving intermittent feedings through an open system. Which of the following actions should the nurse take first?

10. A nurse is reviewing a client’s medication prescription that reads, “digoxin 0.25 by mouth every day.” Which of the following components of the prescription should the nurse verify with the provider?

11. A nurse is caring for a client who has recently started using a behind-the-ear hearing aid. Which of the following statements should the nurse identify as an indication that the client understands the use of this assistive device?

12. A nurse enters a client’s room and finds her on the floor. The client’s roommate reports that the client was trying to get out of bed and fell over the side rail onto the floor. Which of the following statements should the nurse document about this incident?

13. A nurse on a medical unit is preparing to discharge a client to home. Which of the following actions should the nurse take as part of the medication reconciliation process?

14. A nurse is caring for a client who requires an informed consent for a surgical procedure. Which of the following actions is the nurse’s responsibility?