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Question 1 of 5

An elderly man is admitted to an inpatient psychiatric unit with an initial diagnosis of psychotic depression. The INITIAL nursing priority is to

Correct Answer: C

Rationale: initial nursing priority for all psychiatric patients is to ensure their safety and the safety of all members of the milieu

Question 2 of 5

A client is scheduled to have a parathyroidectomy. The nurse would be MOST concerned if the client was observed eating quantities of food from which of the following food groups?

Correct Answer: A

Rationale: low-calcium diet is recommended preoperatively

Question 3 of 5

A client has a bovine graft inserted into the left arm for hemodialysis. During the immediate postoperative period, which of the following actions, if performed by the nurse, is BEST?

Correct Answer: B

Rationale: BP should always be taken on the opposite arm from the graft

Question 4 of 5

The nurse assesses a prolonged deceleration of the fetal heart rate while the client is receiving oxytocin IV to stimulate labor. The priority nursing intervention would be to

Correct Answer: A

Rationale: will decrease contractions and thus possibly remove uterine pressure to the fetus, which is possibly cause of deceleration

Question 5 of 5

The nurse has just received report from the previous shift. Which of the following clients should the nurse see FIRST?

Correct Answer: C

Rationale: indicates hypoglycemia; symptoms include tachycardia, cold and clammy skin, weakness and pallor; check blood sugar, offer milk

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