A nurse is instructing a client, who has an injury of the left lower extremity. about the
use of the cane. Which of the following instructions should the nurse include? (Select
all that apply)
A. Hold the cane on the right side
B. Keep two points of support on the floor
C. Place the cane 38cm (15 in) in fron of the feet before advanding
D. after adcaning the cane, move the weaker leg forward
E. Advamnce the stronger leg so that it aligns evenly with the cane
Give this one a try later!
A, B, D
,A client is at risk for sensory deprivation. Which of the following clinical signs
would the nurse observe? Select all that apply.
A 1. Sleeplessness
B 2. Decreased attention span
C 3. Irritability
D 4. Excessive sleeping
E 5. Crying, depression"
Give this one a try later!
2, 4, and 5
A nurse is preparing to performs endotracheal suctioning for a client. The nurse
should follow shich of the following guidelines? Select all that apply.
A. Applyu suction while withdraing the catheter
B. Perform suctioning on a routine basis every 2-3 hours
C. Maintain medical asepsis during suctioning
D. Use a new catheter for each suctioning attempt
E. Limit total suction time to 5 minutes
Give this one a try later!
A, D, E
A nurse is assessing a client who has an acute respiratory infection that puts her at risl
for hypoxemia. Which of the following findings are earluy indications thay shoudl alet
the nurse thay the client is developing hypoxemia? Select all that apply.
A. Restlessness
,B. Tachypenia
C. Bradycardia
D. Confusion
E. Pallor
Give this one a try later!
A, B, D, E
To prevent postoverative complications, the nurse assits the client with coughing
and deep-breathing exercises. This is best accomplished by implementing which of
the following?
A. 1. Coughing exercises 1 hour before meals and deep breathing 1 hour after meals
B. 2. Forceful coughing as many times as tolerated
C. 3. Huff coughing every 2 hours or as needed
D. 4. Diaphragmatic and pursed-lip breathing 5 to 10 times, four times a day"
Give this one a try later!
C Huff Coughing helps keep the airways open and secretions mobilized
A client with a new stoma who has not had a bowel movement since surgery last
week reports feeling nauseous. What is the appropriate nursing action?
a.Prepare to irrigate the colostomy.
b.After assessing the stoma and surrounding skin, notify the surgeon.
c.Assess bowel sounds and administer antiemetic.
d.Administer a bulk-forming laxative, and encourage increased fluids and exercise.
Give this one a try later!
, b.After assessing the stoma and surrounding skin, notify the surgeon.
a.Correct. The client has assessment findings consistent with complications
of surgery.
A nurse is preparing to administer a cleaning enema to an adult client in preparintion
for a diagnmostic procedure. Which of the following steps wshould the nurse take?
(select all that apply)
A. Warm the enema solution prior to installation
B. Posoton the client on the left side with right leg flexed forward.
C. Luibraicate the rectal tube or nozzle
D. Slowing inters the rectal tube about 5cm (2 inches)
E. Hang the enemna container 61 cm (24 inces) above the client's anus
Give this one a try later!
A,B, C
The client is ambulating for the first time after surgery. The client tells the nurse, “I
feel faint.” Which is the best action by the nurse?
A 1. Find another nurse for help.
B 2. Return the client to her room as quickly as possible.
C 3. Tell the client to take rapid, shallow breaths.
D 4. Assist the client to a nearby chair."
Give this one a try later!
D
use of the cane. Which of the following instructions should the nurse include? (Select
all that apply)
A. Hold the cane on the right side
B. Keep two points of support on the floor
C. Place the cane 38cm (15 in) in fron of the feet before advanding
D. after adcaning the cane, move the weaker leg forward
E. Advamnce the stronger leg so that it aligns evenly with the cane
Give this one a try later!
A, B, D
,A client is at risk for sensory deprivation. Which of the following clinical signs
would the nurse observe? Select all that apply.
A 1. Sleeplessness
B 2. Decreased attention span
C 3. Irritability
D 4. Excessive sleeping
E 5. Crying, depression"
Give this one a try later!
2, 4, and 5
A nurse is preparing to performs endotracheal suctioning for a client. The nurse
should follow shich of the following guidelines? Select all that apply.
A. Applyu suction while withdraing the catheter
B. Perform suctioning on a routine basis every 2-3 hours
C. Maintain medical asepsis during suctioning
D. Use a new catheter for each suctioning attempt
E. Limit total suction time to 5 minutes
Give this one a try later!
A, D, E
A nurse is assessing a client who has an acute respiratory infection that puts her at risl
for hypoxemia. Which of the following findings are earluy indications thay shoudl alet
the nurse thay the client is developing hypoxemia? Select all that apply.
A. Restlessness
,B. Tachypenia
C. Bradycardia
D. Confusion
E. Pallor
Give this one a try later!
A, B, D, E
To prevent postoverative complications, the nurse assits the client with coughing
and deep-breathing exercises. This is best accomplished by implementing which of
the following?
A. 1. Coughing exercises 1 hour before meals and deep breathing 1 hour after meals
B. 2. Forceful coughing as many times as tolerated
C. 3. Huff coughing every 2 hours or as needed
D. 4. Diaphragmatic and pursed-lip breathing 5 to 10 times, four times a day"
Give this one a try later!
C Huff Coughing helps keep the airways open and secretions mobilized
A client with a new stoma who has not had a bowel movement since surgery last
week reports feeling nauseous. What is the appropriate nursing action?
a.Prepare to irrigate the colostomy.
b.After assessing the stoma and surrounding skin, notify the surgeon.
c.Assess bowel sounds and administer antiemetic.
d.Administer a bulk-forming laxative, and encourage increased fluids and exercise.
Give this one a try later!
, b.After assessing the stoma and surrounding skin, notify the surgeon.
a.Correct. The client has assessment findings consistent with complications
of surgery.
A nurse is preparing to administer a cleaning enema to an adult client in preparintion
for a diagnmostic procedure. Which of the following steps wshould the nurse take?
(select all that apply)
A. Warm the enema solution prior to installation
B. Posoton the client on the left side with right leg flexed forward.
C. Luibraicate the rectal tube or nozzle
D. Slowing inters the rectal tube about 5cm (2 inches)
E. Hang the enemna container 61 cm (24 inces) above the client's anus
Give this one a try later!
A,B, C
The client is ambulating for the first time after surgery. The client tells the nurse, “I
feel faint.” Which is the best action by the nurse?
A 1. Find another nurse for help.
B 2. Return the client to her room as quickly as possible.
C 3. Tell the client to take rapid, shallow breaths.
D 4. Assist the client to a nearby chair."
Give this one a try later!
D
