RN Domain 4: Reduction of Risk Potential (Quiz 1)

Following a fall from a ladder, a patient is admitted to the ICU with a diagnosis of traumatic brain injury (TBI). The nurse observes that he is increasingly restless and has developed weakness in his right arm. He is also complaining of nausea. What is the nurse's BEST immediate action?

For a stroke patient, what is the best position for insertion of a nasogastric (NG) tube?

Before administering an intermittent enteral feeding by nasogastric tube (NGT), what is the nurse's FIRST action?

While doing admit for a male client, the nurse asks about possible allergies. The client denies any drug allergies but states he is allergic to bananas and avocados. The nurse knows these allergies put the client at risk for an allergy to

A client with a diagnosis of congestive heart failure (CHF) is taking digoxin (Lanoxin) 0.25 mg po qd and furosemide (Lasix) 20 mg po bid. Which is the MOST important laboratory test result for the nurse to monitor?

The healthcare provider is assessing a patient recovering from a total knee replacement. Which of these assessment findings indicates the patient is at risk of developing a complication from the surgery?

The nurse is giving discharge instructions to a male client who had a total hip arthroplasty. Which statement by the client indicates a lack of understanding?

The nurse is teaching a client with emphysema how to do pursed-lip breathing. The nurse knows it will help the client because

Seven months after birth, an infant is diagnosed with a persistent patent foramen ovale (PFO). The parents ask the nurse what this means. The nurse explains that before the infant was born, the purpose of the foramen ovale was to bypass

A nurse educates a client who is scheduled for a lipid panel. Which of the client's statements would indicate a lack of understanding?

For a client receiving chemotherapy, which laboratory value is MOST important for the nurse to monitor?

The earliest identifying sign for a developing pressure sore is a localized

Which of these would be most important to include in discharge teaching for a patient with a platelet count of 40,000/mcL (40 x 10^9/L)?

A daughter takes her 85-year-old father to the clinic because he is confused and weak. She tells the nurse that his appetite is poor. The nurse also observes that his blood pressure is lower than normal. The provider orders blood work for the client. Which lab result should the nurse immediately report?

The nurse is caring for a fresh postoperative cholecystectomy client with a T-tube in place. As the nurse records the output from the T-tube, what is the typical drainage for the first 24 hours?

On reviewing the culture results of a newly admitted patient, the nurse notes that the patient has methicillin-resistant Staphylococcus aureus (MRSA). Which transmission-based precautions should be instituted for this patient?

The nurse is preparing a client for a liver biopsy. Which instruction regarding the procedure is correct?

The nurse is performing an assessment of a client who had major abdominal surgery 5 days ago. The client reports feeling a "pop where my surgery was" when the client coughed. On inspection, the nurse notes that the wound edges have separated at the incision line. What should the nurse do FIRST?

While providing post-operative care for a 7-year-old who has had a tonsillectomy and adenoidectomy, which is the appropriate nursing action?

A patient with a fractured hip has been placed in Buck's traction. Which of the following statements about this treatment is true?

When a client is on warfarin therapy, which laboratory value should the nurse monitor?

In the proper sequence for removing personal protective equipment (PPE), which item is removed last?

On Thursday, January 1, following a motor vehicle crash, EMS transports a male named Robert to the Emergency Department. The nurse asks the client to state his name, where he is, and the date. Robert answers, "Robert, hospital, December." What verbal response score on the Glasgow Coma Scale does the nurse assign?

The results of an adult patient's blood pressure screening on three occasions were: 120/80 mmHg, 130/76 mmHg, and 118/86 mmHg. How will the healthcare provider interpret this information?

A client's arterial blood gas (ABG) values are pH 7.48, PO2 98 mmHg, PCO2 28 mmHg, HCO3 24 mEq/L. These results are consistent with which of the following clients' conditions?