kaplan CAT 2 KAPLAN 2

1. The nurse assess a client who is in the 24th week of gestation. Which finding is a priority for the nurse to follow-up? 1. Fetal heart rate of 130 to 140 beats/min. 2. Fundal level at 3 fingers below the umbilicus. 3. Fetal movements felt faintly on lower part of abdomen. 4. Client reports backache and leg cramps when sleeping. 2. The nurse administers carisoprodol to the incorrect client. Which strategy should the nurse use to reduce the risk of malpractice litigation? (Select all that apply.) 1. Ask the charge nurse to reassign the client to a different nurse. 2. Notify the health care provider of the medication error immediately. 3. Report the incident to the manager for appropriate follow-up with the client. 4. Print a copy of the incident report to keep in the nurse’s personal records. 5. Explain to the client that the nurse has a heavier assignment than normal. 3. The nurse provides care for a client who is receiving sitagliptin for type 2 diabetes mellitus. Which assessment finding causes the nurse to suspect the client is experiencing an adverse reaction to the medication? 1. Weight gain. 2. Anemia. 3. Abdominal pain. 4. Edema. 4. The nurse orients a new nurse who inquired about electrical cardioversion. Which statement about cardioversion by the nurse is accurate? (Select all that apply.) 1. “Cardioversion is used to treat ventricular fibrillation.” 2. “Pulseless electrical activity (PEA) responds to cardioversion.” 3. “Cardioversion treats atrial fibrillation and atrial flutter.” 4. “An intravenous sedative is required in elective cardioversion.” 5. “Check for life-threatening dysrhythmia during cardioversion.” 5. A wound located on the foot of a client with type 2 diabetes mellitus (DM) is healing. The nurse teaches the client about the prevention of future foot wounds. Which client statement indicates the teaching is effective? (Select all that apply.) 1. “I should not cross my legs.” 2. “I should wear shoes only when I go outside.” 3. “I should apply lotion between my toes after a shower.” 4. “I should inspect the inside of my shoes before I put them on.” 5. “I should use a mirror to examine the bottom of my feet every day.” 6. The nurse prepares discharge instructions for a client who speaks very little English and is recovering from an emergency appendectomy. Which nursing action best helps this client understand wound care instructions? 1. Asking if the client understands the instruction. 2. Demonstrating the procedure and having the client return the demonstration. 3. Asking an interpreter to replay the instructions to the client. 4. Writing out the instructions and having a family member read them to the client.