1. A nurse is caring for a client who has bipolar disorder and is experiencing acute mania. The nurse obtained a verbal prescription for restraints. Which of the following should the actions the nurse take?
A. Request a renewal of the prescription every 8 hr.
B. Check the client’s peripheral pulse rate every 30 min
C. Obtain a prescription for restraint within 4 hr.
D. Document the client’s condition every 15 minutes
2. A nursing planning care for a school-age child who is 4 hr postoperative following perforated appendicitis. Which of the following actions should the nurse include in the plan of care?
a. Offer small amounts of clear liquids 6 hr following surgery (assess for gag reflex first)
b. Give cromolyn nebulizer solution every 6 hr (for asthma)
c. Apply a warm compress to the operative site every 4 hr
d. Administer analgesics on a scheduled basis for the first 24 hr
3. A nurse is receiving change-of-shift report for a group of clients. Which of the following clients should the nurse plan to assess first?
a. A client who has sinus arrhythmia and is receiving cardiac monitoring b. A client who has diabetes mellitus and a hemoglobin A1C of 6.8%
c. A client who has epidural analgesia and weakness in the lower extremities
d. A client who has a hip fracture and a new onset of tachypnea
4. A nurse is preparing to apply a transdermal nicotine patch for a client. Which of the following actions should the nurse tak e?
a. Shave hairy areas of skin prior to application (apply to hairless, clean & dry areas to promote absorption; avoid oily or broken skin)
b. Wear gloves to apply the patch to the client’s skin
c. Apply the patch within 1 hr of removing it from the protective pouch (apply immediately)
d. Remove the previous patch and place it in a tissue (fold patch in half with sticky sides pressed together)
5. A nursing planning care for a school-age child who is 4 hr postoperative following perforated appendicitis. Which of the following actions should the nurse include in the plan of care?
e. Offer small amounts of clear liquids 6 hr following surgery (assess for gag reflex first)
f. Give cromolyn nebulizer solution every 6 hr (for asthma)
g. Apply a warm compress to the operative site every 4 hr
h. Administer analgesics on a scheduled basis for the first 24 hr
6. A nurse is receiving change-of-shift report for a group of clients. Which of the following clients should the nurse plan to assess first?
e. A client who has sinus arrhythmia and is receiving cardiac monitoring f. A client who has diabetes mellitus and a hemoglobin A1C of 6.8%
g. A client who has epidural analgesia and weakness in the lower extremities
h. A client who has a hip fracture and a new onset of tachypnea
7. A nurse is preparing to apply a transdermal nicotine patch for a client. Which of the following actions should the nurse tak e?
e. Shave hairy areas of skin prior to application (apply to hairless, clean & dry areas to promote absorption; avoid oily or broken skin)
f. Wear gloves to apply the patch to the client’s skin
g. Apply the patch within 1 hr of removing it from the protective pouch (apply immediately)
h. Remove the previous patch and place it in a tissue (fold patch in half with sticky sides pressed together)
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