Question

1. A nurse is providing teaching to a client who has a new medication prescription. Which of the following manifestations of a mild allergic reaction should the nurse include?
   1. Urticaria
   2. Ptosis
   3. Nausea
   4. Hematuria
2. A provider prescribes cold application for a client who report ankle joint stiffness. Which of the following assessment findings should the nurse identify as a contraindication to the application of cold?
   1. Capillary refill 4 seconds
   2. 7.5 cm (3 in) diameter bruise on the ankle
   3. Warts on the affected ankle
   4. 2+ pitting edema
3. A nurse is admitting a client who is malnourished. The client states, “My wedding ring is loose and I’m worried I will lose it if it falls off. “Which of the following is an appropriate response by the nurse? (pg. 38)
   1. “I can pin it to your hospital gown so you won’t lose it.”
   2. “I will place it in your drawer so it won’t get lost.”
   3. “I will hold onto it until a family member can take it home.”
   4. “I can put it in a locked storage unit for you.”

4. A nurse is caring for a client who has a prescription for a stool specimen to be sent to the laboratory to be tested for ova and parasites. Which of the following instructions regarding specimen collection should the nurse provide to the assistive personnel?

   1. Collect at least 2 inches of formed stool
   2. Wear sterile gloves while obtaining the specimen.
   3. Use a culturette for specimen collection.
   4. Record the date and time the stool was collected.
5. A nurse is caring for a client who has restraints to each extremity. Which of the following assessments should the nurse perform first?
   1. Peripheral pulses
   2. Comfort level
   3. Elimination needs
   4. Skin integrity

Answer 1

1 urticaria. Hives (urticaria) are red, itchy welts that result from a skin reaction. The welts vary in size and appear and fade repeatedly as the reaction runs its course.

2.capillary refill time 4 seconds.

as cold application further compromises the circulation. Norma crt is 2 seconds or less.

3.d. Put in locked storage in an envelope with written full details of patient and the ring description.

4.details should be written on specimen container like name date and time of collection5.

5. Peripheral pulses should be checked first