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RN Comprehensive Online Practice 2019 A/ Questions & Answers /With Rationales

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A nurse is planning care for a client who is receiving heparin to treat a deep-vein thrombosis of the left lower leg. Which interventions should the nurse include in the plan of care? maintain the... client on bed rest restrict the client to 1 L of fluid per day place cool compresses on the edematous area elevate the affected leg (ANS- elevate the affected leg the nurse should elevate the client's affected extremity to reduce edema and decrease the risk of chronic venous insufficiency A nurse is teaching a group of guardians about child safety measures. Which of the following statements by a guardian indicates an understanding of the teaching? I will make sure my 4 year old child wears a helmet when using a skateboard I should have my child avoid sun exposure between 10 am and 2 pm I can give my 2 year old child a whole hotdog on a bun When my infant is in the carrier, I will place it on a raised, flat surface whenever possible (ANS- I should have my child avoid sun exposure between 10 am and 2 pm To prevent sunburns, guardians should apply sunscreen, dress their child in protective clothing, and avoid sun exposure between 1000 and 1400 A home health nurse is providing teaching about infection prevention to a client who has cancer and receiving chemotherapy. Which of the following statements by the client indicates an understanding of the teaching? I will leave my drinking water out of my refrigerator for at least 1 hour so it will be room temperature I will clean my toothbrush in my dishwasher once each month I will take my temperature once each week and let my doctor know if it is high I will walk short distances throughout the day (ANS- I will walk for short distances throughout the day The client should ambulate for short distances as tolerated throughout the day. This will help reduce pulmonary stasis and prevent the development of respiratory infections A nurse is providing dietary teaching to the parents of a 6-month old infant. Which of the following instructions should the nurse include? Provide the infant with 1 cup of cereal Give the infant 240 mL (8 oz) of juice per day Introduce new foods one at a time over 5 to 7 days Give whole milk first, then small amounts of solid food (ANS- Introduce new foods one at a time over 5 to 7 days The parents should introduce new foods one at a time over 5 to 7 days to identify potential food allergies A charge nurse is planning care for a client who has mechanical restraints in place. Which of the following interventions should the nurse include in the plan? Remove the client's restraints while sleeping Document the client's status every 60 min Check for a new prescription every 6 hours Provide a staff member to stay with the client continuously (ANS- Provide a staff member to stay with the client continuously A staff member must remain continuously with a client who is in restraints or view the client via audiovisual equipment if necessary due to the risk of injury A community health nurse is assisting with the development of a disaster management plan. The nurse should include which of the following nursing responsibilities in the disaster response stage of the plan? Performing a rapid needs assessment Organizing an immunization campaign Identifying the specific roles of disaster workers Conducting home visits to identify health hazards (ANS- Performing a rapid needs assessment Disaster management includes prevention, preparedness, response, and recovery stages. The nurse should perform a rapid needs assessment during the response phase of the disaster cycle. A rapid needs assessment allows the nurse to identify the severity of the incident, the health needs of the community, and the priority actions needed during the response stage A nurse manager is assisting with the orientation of a newly licensed nurse. Which of the following actions by the nurse requires the nurse manager to intervene? Informs the provider about a client's suicide plan Notifies the health department of a client's diagnosis of chlamydia Reports suspected child maltreatment to social services Tells the hospital chaplain a client's diagnosis (ANS- Tells the hospital chaplain a client's diagnosis Discussing a client's diagnosis with the hospital chaplain is a breach of client confidentiality and a violation of HIPPA A nurse is caring for a client who is in labor at 39 weeks of gestation. During the second stage of labor, the nurse observes early decelerations on the monitor tracing. Which of the following actions should the nurse take? Continue observing the fetal heart rate Assist the client to a knee-chest position Prepare the client for continuous internal monitoring Prepare for an emergency cesarean birth (ANS- Continue observing the fetal heart rate Early decelerations indicate the progression of labor and are an expected finding. The nurse should continue to monitor the fetus by observing the fetal heart rate and tracing [Show More]

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