NCLEX.ME Nurse – Page 91

The nurse is caring for an elderly client following a total knee replacement. The client is disoriented to time and place, and has pulled out multiple IVs. The health care provider writes an order for soft wrist restraints. Which of the following are appropriate nursing actions for this client? Select all that apply.

Posted on March 5, 2022 by NCLEX.ME Nurse

secure restraints with a double knot offer toileting and nutrition every 2 hours ask for a new restraint order every 48 hours check restraints for proper placem...

NCLEX-RN Practice Test

An RN is working with an LPN to care for a group of clients. Which client would the RN most likely assign to the LPN?

Posted on March 5, 2022 by NCLEX.ME Nurse

a client receiving blood following back surgery a client who has just returned from having a left heart catheterization a client with an arterial line who is on...

NCLEX-RN Practice Test

The nurse is working in the ED when a client in labor comes in and says that she does not have health insurance, but wants to know if a doctor will see her. The nurse understands that the client’s right to emergency services, regardless of ability to pay, is provided by which piece of legislation?

Posted on March 5, 2022 by NCLEX.ME Nurse

HIPAA the Continuity of Care Act the Patient’s Bill of Rights the Code of Ethics for Nurses

NCLEX-RN Practice Test

The nurse is talking with a client who has been diagnosed with thyroid cancer. The client is asking about different treatment options. Which response by the nurse is most appropriate?

Posted on March 5, 2022 by NCLEX.ME Nurse

“There are several local support groups you can join after you have completed chemo.” “Don’t worry about it. Your doctor will explain the best course of treatme...

NCLEX-RN Practice Test

The nurse is caring for a group of clients in an alcohol rehabilitation facility. A local news station is doing a story on addiction, and a representative comes to the facility, asking to interview a client. A client agrees to appear in the story, and the crew films an interview in the dayroom, showing a glimpse of other clients. Which violation has the nurse committed?

Posted on March 5, 2022 by NCLEX.ME Nurse

allowing clients in a substance abuse facility to be interviewed by the media violating the HIPAA need to know rule releasing information about a minor without ...

Physiological Adaptation

The nurse is reviewing morning labs for a client. Which lab value requires immediate intervention by the nurse?

Posted on March 4, 2022 by NCLEX.ME Nurse

calcium 9.8 mg/dL sodium 137 mEq/L chloride 104 mEq/L potassium 3.1 mEq/L

Physiological Adaptation

The nurse is performing the Glasgow coma scale on a client. The assessment is as follows: eye opening, to pain; motor response, localizes pain; verbal response, inappropriate words. The nurse interprets which score is correct for this client?

Posted on March 4, 2022 by NCLEX.ME Nurse

9 10 11 12

Physiological Adaptation

The nurse is caring for a client with a Braden score of 13. How does the nurse interpret this client’s risk of skin breakdown?

Posted on March 4, 2022 by NCLEX.ME Nurse

high risk mild risk severe risk moderate risk

Physiological Adaptation

The nurse is caring for a client with a sacral wound. The wound is full thickness, measures 4 cm × 6 cm with irregular borders, and is covered by a layer of black collagen. Which is this wound stage?

Posted on March 4, 2022 by NCLEX.ME Nurse

Stage I Stage II Stage III unstageable

Physiological Adaptation

The nurse is caring for a client with cardiogenic shock. The nurse expects which signs present with this client? Select all that apply.

Posted on March 4, 2022 by NCLEX.ME Nurse

hypertension; slow, labored breathing decreased urine output; warm, pink skin increased urine output; cool, clammy skin hypotension; weak pulse; cool, clammy sk...