1. A charge nurse is teaching new staff members about factors that increase a client’s risk to
become violent. Which of the following risk factors should the nurse include as the best predictor
d. A history of being in prison
Risk factors also include: past history of aggression, poor impulse control, and violence.
Comorbidity that leads to acts of violence (psychotic delusions, command hallucinations, violent
angry reactions with cognitive disorders).
Individual Assessment for Violence
. 2. A nurse is caring for a client who has severe preeclampsia and is receiving magnesium
sulfate intravenously. The nurse discontinues the magnesium sulfate after the client displaces
toxicity. Which of the following actions should the nurse take?
b. Prepare an IV bolus of dextrose 5% in water
c. Administer methylergonovine IM
d. Administer calcium gluconate IV
Calcium gluconate is given for magnesium sulfate toxicity. Always have an injectable form of
calcium gluconate available when administering magnesium sulfate by IV.
3. A nurse is preparing to perform a sterile dressing change. Which of the following actions
should the nurse take when setting up the sterile field?
a. Place the cap from the solution sterile side upon clean surface
b. Open the outermost flap of the sterile kit toward the body→ flap AWAY from the body's
c. Place the sterile dressing within 1.25 cm (0.5in) of the edge of the sterile field → 2.5 cm
(1-inch) border around any sterile drape or wrap that is considered contaminated.
d. Set up the sterile field 5 cm (2 in) below waist level→ it says BELOW waist level; should
4. A nurse is providing teaching to an older adult client about methods to promote nighttime
sleep. Which of the following instructions should the nurse include?
a. Eat a light snack before bed time
b. Stay in bed at least 1 hr if unable to fall asleep
c. Take a 1 hr nap during the day
d. Perform exercises prior to bedtime
5. A home health nurse is preparing for an initial visit with an older adult client who lives
alone. Which of the following actions should the nurse take first?
a. Educate the client about current medical diagnosis
b. Refer the client to a meal delivery program
c. Identifyenvironmental hazards in the home
d. Arrange for client transportation to follow-up appointments
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