use Wite-Out® to cover the error, and proceed after it dries throw away the nurse’s note and start over with a fresh note mark through the error in red ink and place her initials afterward mark a single line through the error in black ink and place her initials afterward
The nurse in an ambulatory care clinic is admitting a 27-year-old client with severe systemic lupus erythematosus (SLE). In assessing the client’s health history, the nurse knows to question which of the following statements?
“I avoid being outside on sunny days.” “The medications I take make me bloated.” “My work schedule is down to four hours a day.” “I get an eye exam annually.”
A client admitted for treatment of a deep venous thrombosis of the calf complains of dyspnea and chest pain. What is the best response by the nurse?
administer oxygen at 2L/min as ordered prn place client in a semi-Fowler’s position prepare client for diagnostic tests obtain vital signs
The nurse is preparing a 73-year-old client for cataract surgery on the left eye. Which statement by the client indicates a need for further teaching?
“I will wear glasses when going outside.” “I will avoid bending below the waist.” “I will stop taking Coumadin after surgery.” “I will still be able to work out on weight training.”
The nurse is caring for a client with dementia who has pulled out three peripheral IVs. Which intervention by the nurse is the best way to manage this client?
place the client in restraints or mitts tell the family that they need to stay with the client replace the IV and wrap it in gauze to hide it from view tell the client that if she pulls another IV out, she will have to have a PICC line placed
The nurse is providing post-op education to a client who had a splenectomy. Which statement by the client indicates that the nurse’s teaching was successful?
“I can resume yoga classes in two weeks.” “I need to eat a diet low in fiber to rest my digestive tract.” “I will need to be careful when I go to the NFL game next month.” “I need to talk to my doctor about getting influenza, pneumococcal, and meningococcal vaccines.”
The nurse is caring for a client who fractured her leg in a motor vehicle accident. A cast is applied. The nurse will assess which of the following? Select all that apply.
pulses capillary refill skin temperature squeeze the cast every hour to check for firmness assess for pain, numbness, tingling, or inability to move the toes
The nurse is providing client education on self-administration of insulin. Which action by the client indicates the need for further education?
The client gently rubs the insertion site after removing the needle. The client verifies the type of insulin and checks the expiration date. The client cleans and grasps the skin, inserting the needle at a 90-degree angle. The client cleans the rubber stopper on the bottle with an alcohol swab before drawing a dose.
The nurse is reviewing labs on a client receiving IV heparin and notes an INR of 4.6. Which order by the health care provider does the nurse anticipate?
an order for vitamin K IM an order for protamine sulfate an order to redraw labs in 6 hours an order to increase the infusion rate