21. The nurse is observing an unlicensed assistive personnel (UAP) caring for a client who has hepatitis B. Which action, performed by the UP is not correct?   

5. A client has edema in the lower extremities and needs to be repositioned. The nurse should place this client in which of the following positions?

1. A bed-bound, elderly client has a pressure ulcer that looks like a shallow crater and involves the epidermis and dermis. The pressure ulcer is in which stage?

15. A nurse is assessing a client and notes that the client’s lower extremities are cold to touch, hairless, pale in appearance, the capillary refill is greater than 3 seconds, and the dorsalis pedis pulse is absent.  These assessment findings are consistent with what circulatory complication?

6. Which client would be at the greatest risk for a pressure wound?

13. A nurse has received a health care provider’s prescription to transfer a client to the chair. This is the client’s first time out of bed during this hospitalization. How should the nurse proceed?

4. A nurse is caring for a client with documented orthostatic hypotension. Which nursing intervention would be most beneficial to this patient to reduce the risk of falls?

A nurse is calculating the intake of a client during the past 9 hr. The client’s intake includes: D5 1/2NS IV at 125 mL/hr cefazolin 2 gm IVPB in 50 mL of 0.9% sodium chloride two units of packed RBCs of 300 mL and 265 mL two IVPBs of 250 mL of 0.9% sodium chloride 1 cup of ice chips How many mL of intake should the nurse record?

A  According to Peplau, a nurse who provides an abandoned child with parental guidance and praise following small accomplishments is serving which therapeutic role?

Anna’s dog Jax ran away from her while they were on a hiking trail.  He ran into the street and was hit by a car.  Anna cannot remember any of these circumstances of his death.  This is an example of what defense mechanism?