orient the client to person, place, and time during every contact limit visitors to one 15-minute visit per 8-hour shift explain all nursing care keep the lighting level consistent throughout the day
A client has recently lost her best friend to cancer. The client tells the nurse, “I’m very sad about the loss of my friend.” Which of the following responses by the nurse is the most appropriate?
“I lost my best friend two years ago, but I feel better now.” “It’s important for you to keep busy.” “Why do you feel this way?” “It’s normal to feel loss. Tell me about your friend.”
An 88-year-old client fractured a hip after a fall in her home. Because of her peripheral vascular disease and asthma, surgery is not an option. The client tells the nurse she does not know how she is going to get better. Which response by the nurse is best ?
“You’ll do just fine.” “You can’t live alone anymore.” “What are you most worried about?” “You should get a second opinion.”
A client asks what diabetes mellitus does to the body over time. Which condition should the nurse include in teaching as a common chronic complication of diabetes mellitus?
hyperglycemia diabetic ketoacidosis hyperglycemia retinopathy
The nurse is preparing to pull a thin, frail client up in the bed. No one responds to the nurse’s call for lifting assistance. Which is the best action by the nurse?
call again and apologize to the client for the wait stand behind the bed at the client’s head, and pull her up gently from her armpits since the client is small, pull her up in the bed by pulling on the draw sheet, alternating sides if the client is able to roll and bend her…
Four 6-month-old children arrive at the clinic for diphtheria-pertussis-tetanus immunization. Which child can safely receive the immunization at this time?
the child with a runny nose the child who experienced a seizure after the last immunization the child who experienced a life-threatening allergic reaction after the last immunization the child with a temperature of 102°F
The nurse is caring for a client on airborne precautions. Which of the following would the nurse expect to see in the client’s medical record?
measles influenza Lyme disease herpes simplex
A client is on contact and airborne precautions. In which order should the nurse don personal protective equipment (PPE) before entering the room?
perform hand hygiene, don the gown, don the mask, don eye protection, apply gloves don the gown, perform hand hygiene, don the mask, apply gloves, don eye protection don the mask, don eye protection, perform hand hygiene, don the gown, apply gloves don eye protection, don the mask, perform hand hygiene, apply gloves, don the…
The nurse is working with an unlicensed assistive personnel (UAP). In planning the morning’s care, which tasks can the nurse delegate to the UAP? Select all that apply.
feeding a client who has lost the use of his hands starting an IV in a confused client who pulled her IV out assisting a stable and alert client up to the bedside commode checking an apical pulse in a client prior to administering digoxin ambulating a client in the hall for the first time…
A client has signed the consent form for a right radical mastectomy. Shortly before the client is to be taken to surgery, she tells the nurse, “I’m not really sure that this is what I want to do. Everything was so sudden.” Which response by the nurse is most appropriate?
“You will be glad you did it once it’s over.” “What are your thoughts right now on this procedure?” “I will notify the surgeon and let her know you have concerns about having the surgery.” “The OR has been prepared for you, and the doctor will be mad if you mess up the surgery schedule.”