Accuracy & Up-to-Date Answers
During an evaluation, the nurse must gather information about the client to...
A. Identify whether the client outcomes have been met.
B. Organize resources to proceed with implementing interventions
C. Establish client-centered outcomes that are measurable and realistic.
D. determine the priority of care and appropriate interventions. - correct answer A
a nurse is caring for a client who fell at a nursing home. the client is oriented to person,
place, and time and can follow directions. which of the following actions should the
nurse take to decrease the risk of another fall (select all that apply)
A. place belt restraint on the client when he is sitting on the bedside commode
B. keep bed in lowest position with all side rails up
C. make sure clients call light is within reach
D. proved nonskid footwear
E. complete fall-risk assessment - correct answer C
D
E
a nurse manager is reviewing with nurses on the unit the care of a client who has had a
seizure. which of the following statements by a nurse requires further instruction?
A. I will place the client on his side
B. I will go to the nurses station for assistance
C. I will administer his meds
D. i will prepare to insert an airway - correct answer B
,a nurse observes smoke coming from under the door of the staffs lounge. which of the
following actions is the nurses priority?
A. extinguish the fire
B. activate the alarm
C. move the clients who are nearby
D. close all open doors on the unit - correct answer C
a nurse is caring for a client who has a history of falls. which of the following actions is
the nurses priority?
A. complete fall-risk assessment
B. educate client and family about fall risks
C. eliminate safety hazards from clients environment
D. make sure the client uses assistive devices - correct answer A
a charge nurse is assigning rooms for the clients to be admitted to the unit. to prevent
falls, which of the following clients should be assigned to rooms closest to the nursing
station?
A. a middle adult who is postop following a laparoscopic cholecystectomy
B. a middle adult who requires telemetry for a possible myocardial infarction
C. young adult who is postop following an open reduction internal fixation of the ankle
D. an older adult who is postop following a below-the-knee amputation - correct
answer D
a nurse is caring for a client who has been sitting in a chair for 1 hr. which of the
following complications is the greatest risk to the client?
, A. decreased subQ fat
B. muscle atrophy
C. pressure ulcer
D. fecal impaction - correct answer C
a nurse is caring for a client who is postop. which of the following interventions should
the nurse take to reduce the risk of thrombus development (select all that apply)
A. instruct client not to perform Valsalva maneuver
B. apply elastic stockings
C. review laboratory values for total protein level
D. place pillows under clients knees and lower extremities
E. assist client to change position often - correct answer B
E
a nurse is planning care for a client who is on bed rest. which of the following
interventions should the nurse plan to implement?
A. encourage client to perform antiembolic exercises q2
B. instruct client to cough and deep breathe q4
C. restrict clients fluid intake
D. reposition q4 - correct answer A
a nurse is evaluating teaching on a client who has a new rx for a sequential
compression device. which of the following client statements should indicate the client
understands?
A. this device will keep me from getting sores on my skin
B. this thing will keep the blood pumping through my leg
C. with this thing my leg muscles wont get weak