COMPREHENSIVE TEST PAPER FULL SOLUTION
SET
◉ A nurse is assessing a client who wears partial dentures and reports
mouth pain. Which of the following actions should the nurse take?
Answer: Advise the client to rinse their mouth and dentures after each
meal.
The nurse should advise the client to rinse their mouth and dentures after
each meal to remove food and particles and to promote healing of gums
and oral mucosa.
◉ A nurse is planning care for a client who has dysphagia and is at risk
for aspiration. Which of the following referrals should the nurse make?
Answer: Speech-language pathologist
The nurse should recommend a referral for a client who has dysphagia to
a speech-language pathologist. Clients who have dysphagia have
difficulty swallowing and are at risk for aspiration. The speech-language
pathologist can perform a swallow study to determine the extent of the
client's dysphagia and work with the client to develop new swallowing
techniques.
◉ A nurse is planning teaching for a client who has a new diagnosis of
type 2 diabetes mellitus. Which of the following actions should the nurse
take prior to performing the teaching? (select all that apply) Answer: -
Establish the client's learning needs
,- Determine the client's literacy level
- Evaluate the client's readiness for learning
- Identify the client's learning style
Establish the client's learning needs is correct. Prior to planning any
teaching session, the nurse should perform a comprehensive assessment
of the client's learning needs. This assessment incorporates information
from the client's history and physical assessment, current health
problems, understanding of and adherence to the prescribed treatment
plan, and support system. Determine the client's literacy level is correct.
Knowing the client's literacy level is an important factor in
communicating with the client and in delivering audiovisual
presentations and written materials. If the client cannot understand the
information the nurse presents, they will not learn. Evaluate the client's
readiness for learning is correct. The nurse should determine the client's
physical readiness (pain control), emotional readiness (acceptance of
diagnosis), and cognitive readiness (appropriate level of consciousness).
Identify the client's learning style is correct. The best way to learn varies
from client to client. Some people learn best by watching a
demonstration, while others thrive in a group setting, and others prefer to
read information on their own. In a group setting, the nurse should use a
variety of styles to accommodate most learners.
, ◉ A nurse is preparing to notify the provider about a change in a client's
status. Which of the following information should the nurse plan to
include in the "background" portion of the SBAR communication tool?
Answer: Previous treatments
The nurse should include previous treatments in the "background"
portion of the SBAR communication tool. Other information the nurse
should include in the "background" portion is the client's admission
history, diagnosis, pertinent medical history, and code status.
◉ A nurse is providing discharge teaching to a client who has a new
prescription for home oxygen therapy utilizing a compressed oxygen
system. Which of the following statements by the client indicates an
understanding of the teaching? Answer: "I will store oxygen tanks in an
upright position"
This statement by the client indicates an understanding of the teaching.
The nurse should instruct the client to store oxygen tanks in an upright
position in a holder to prevent damage to the tank and injury to the client
and the client's family.
◉ A nurse is caring for a client who has terminal cancer. The client
begins to cry and says, "I am afraid of dying." Which of the following
responses should the nurse make? Answer: "It must me a very difficult
time for you."