QUESTIONS AND VERIFIED CORRECT
ANSWERS GRADE A+ 100 % PASS
< BRAND NEW VERSION !! >
The nurse is planning care for a client who has expressive aphasia after a left-sided stroke. Which of the
following statements by the client's spouse would indicate a correct understanding of the client's
communication abilities and interaction needs? Select all that apply.
1. "My spouse's response of 'fine' when asked how the day has been may or may not be what my spouse
meant
to communicate."
2. "I can anticipate what my spouse wants to say, so I complete my spouse's sentences to make
communication quicker."
3. "I will purchase a picture board to help my spouse express common needs, thoughts, and feelings that
are difficult to communicate."
4. "My spouse's angry response when we have a conversation makes me hesitant to try further
communication."
5. "I have arranged for my spouse to meet with a speech therapist twice each week to improve
communication skills."
1,3,5
The nurse is caring for a client who is in Buck traction. Which of the following would require immediate
intervention?
1. A pillow is placed under the knee.
2. The foot is 2 in (5 cm) away from the foot plate.
3. The weights attached to the pulley are 6 in (15 cm) from the floor.
4. A pillow is placed under the lower leg with the heel off the bed.
2. The foot is 2 in (5 cm) away from the foot plate.
Should be touching the foot plate
,The nurse has taught the adult child caregiver of a client with moderate Alzheimer's disease (AD) about
home care. Which of the following statements by the adult child would indicate a correct understanding
of the teaching?
1. "I will only allow my parent to smoke while my parent is outdoors."
2. "I will place a picture on the bathroom door to indicate which room in our home is the bathroom."
3. "I will encourage family members to visit in large groups to keep my parent interested in the
conversation."
4. "I will encourage my parent to take walks in the park when the weather permits to get the exercise
needed."
2. "I will place a picture on the bathroom door to indicate which room in our home is the bathroom."
4. dangerous, they can get lost
The nurse is teaching a client newly diagnosed with diverticulosis. Which of the following information
should the nurse include?
1. "Limit your daily fluid intake to 2 L to avoid bloating."
2. "You may be prescribed a bulk-forming laxative."
3. "Limit your intake of dairy products such as milk and yogurt."
4. "You should avoid consuming cooked vegetables."
2. "You may be prescribed a bulk-forming laxative."
No need to restrict fluids and no need to restrict diet. Diet does not cause diverticulitis exacerbations!
The nurse is preparing to administer lorazepam 2 mg, IV, now to a client who is scheduled for surgery in
30 minutes. The nurse is unfamiliar with the dosage for the medication.
Which of the following actions should the nurse take next?
1. Check the medication dosage in a medication reference source.
,2. Ask another nurse whether the prescribed dose is a safe dose.
3. Clarify that the dose is correct with the primary health care provider.
4. Contact the pharmacist to verify the safe dosage range for the medication.
1. Check the medication dosage in a medication reference source.
The nurse is caring for a client who is receiving a high dose of a phenothiazine. When evaluating the
client for a life-threatening syndrome related to the medication, it would be a priority for the nurse to
report
1. dry mouth
2. orthostatic hypotension
3. fever
4. photophobia
3. fever
Rationale: Phenothazine side effects include ABCDEFG -- Anticholinergic (dry mouth), blurry vision,
constipation, drowsiness, EPS, Photosensitivity, and agranulocytosis. Fever would be a complication of
agranulocytosis and requires the nurse to report.
The nurse is caring for a client who is receiving a blood transfusion and states, "I feel chilled and am
having back pain." Which of the following actions should the nurse take? Select all that apply.
1. Stop the transfusion.
2. Check the client's vital signs.
3. Notify the client's primary health care provider.
4. Return the blood and infusion tubing to the blood bank.
5. Infuse 5% dextrose in water through the intravenous catheter.
6. Administer a dose of an antiemetic prescribed p.r.n. to the client.
1, 2, 3, 4
Back pain and chills are symptoms of Hemolytic transfusion reaction (wrong blood type). Must stop
infusion, check vital signs, and notify the provider
, 5. NS to keep the line open, not dextrose in water
The nurse is preparing a staff education program about total parenteral nutrition (TPN). Which of the
following information should the nurse include? Select all that apply.
1. "The TPN intravenous tubing should be changed once a week."
2. "TPN can be administered through a peripherally inserted central catheter (PICC)."
3. "Clients receiving TPN should be weighed daily."
4. "An infusion pump is used to deliver TPN."
5. "Serum glucose levels should be monitored in clients receiving TPN."
2, 3, 4, 5
1. TPN tubing is changed daily (every 24hr)!
The nurse has taught a client with bipolar I disorder who is experiencing a manic episode and is receiving
lithium. Which of the following statements by the client would indicate a correct understanding of the
teaching?
1. "I will increase my oral fluid intake to 2 to 3 L daily while taking the medication."
2. "I will experience an improvement in my condition 5 weeks after starting the medication."
3. "I should decrease my intake of dietary sodium after starting the medication."
4. "I should limit time spent in a sauna to 1 hour weekly while taking the medication."
1. "I will increase my oral fluid intake to 2 to 3 L daily while taking the medication."
Getting dehydrated can increase risk for lithium toxicity.
Rationale:
2. about 1-3 weeks to work
3. Do NOT go on a low sodium diet bc it can decrease lithium elimination and cause lithium toxicity
4. Sweating too much can cause you to lose too much sodium.