Select All That Apply

The nurse cares for children at a daycare. On a hot summer day, four children return from recess with various complaints. Which of the following children should the nurse see FIRST?

• A child diagnosed with leukemia was stung by a bee and is complaining of feeling hot and itchy all over.

• A child diagnosed with hemophilia says she has a headache and has slurred speech.

• A child with asthma is complaining of dizziness and a sore throat.

• A child diagnosed with type one diabetes is sweaty, pale, and complains of shakiness.

A client with a casted left leg rings his call bell. Which of the following statements, if made by the client, requires an immediate intervention?

• My leg itches.”

• “Can you give me a ruler so I can scratch my leg inside my cast?”

• “My leg feels funny.”

• “The edge of the cast is hurting my skin.”

The nurse performs discharge teaching for a client with a left leg cast who will be using crutches to ambulate. Which of the following statements, if made by the client to the nurse, would require further teaching?

• “When going up stairs, I will first lift my bad leg and then my good one.”

• “I will put all of my body weight on the handholds and keep it off my armpits.”

• “I will remember not scratch inside the cast.”

• ”When going down the stairs, I will follow my bad leg with my good leg.”

What is the priority nursing care for a client after ECT (electroconvulsive therapy)?

• Reorient to time and place

• Put the side rails up

• Explain that memory loss is expected.

• Notify the family

After receiving morning report, which client should the nurse see first?

• Client with pancreatitis complaining of jaw pain, 5 on a scale of 10.

• Client dependent on insulin who complains of feeling shaky, and hungry.

• Client who is confused and has activated the bed alarm used to prevent falls

• Client with “red-colored”drainage in foley bag following TURP surgery

The nurse is assessing a client with a serum calcium level of 3.5 mg/dl. Which of the following clinical manifestations are consistent with this finding? (Select all that apply)

• Bradycardia

• Muscle twitching of the face

• Constipation

• Increased deep tendon reflexes

• Diarrhea

The nurse is administering tetracycline to a client. Which of the following statements indicates a need for further education? (Select all that apply)

• I will take this medication with milk.

• I will avoid sunlight while taking this medication.

• When I fell better I can stop the medication

• I’ll take this in the morning with my multivitamins.

• This medication is not safe to take during pregnancy.

A client comes to the ER with a sprained ankle. After receiving ibuprofen for pain, the nurse provides instructions about the medication. Which of the following statements made by the client indicates the need for further education? (Select all that apply)

• I can drink alcohol while taking this medication

• I will report to my physician if I have dark tarry stools.

• This medication is safe to take with kidney disease

• My risk of having a stroke is increased while taking this medication

• I should take ibuprofen with milk or food.

The nurse is teaching a client with Type 1 diabetes the manifestations of diabetic ketoacidosis (DKA). Which of the following should be included? (Select all that apply)

• Cool, clammy skin

• Kussmaul’s respirations

• Polyuria

• Diaphoresis

• Potassium imbalance

The nurse is teaching the client how to use a metered dose inhaler (MDI) to administer a Corticosteroid drug. Which of the following client actions indicates that he is using the MDI correctly? Select all that apply.

• The inhaler is held upright.

• Head is tilted down while inhaling the medication

• Client waits 5 minutes between puffs.

• Mouth is rinsed with water following administration

• Client lies supine for 15 minutes following administration.