ANSWERS
A nurse is collecting data from a client who has an elevated temperature with no sweating.
Which of the following findings is an indication of hypernatremia?
Thirst
A nurse is caring for a client who reports difficulty sleeping due to the noise on the nursing unit.
Which of the following actions should the nurse take to reduce environmental noise?
Close the door to the client's room.
A nurse is reinforcing teaching about health promotion with a client. Which of the following
actions should the nurse take first to promote effective learning?
Identify areas of concern.
A home health nurse is assisting with the plan of care for a client. Which of the following should
the nurse include during the orientation phase of the helping relationship?
Clarify the role of this individual nurse.
A nurse is preparing to assist with the admission of a client who has pneumonia. Which of the
following observations about the client's room requires immediate attention?
The wheel locks on the bed are malfunctioning.
, A nurse is reinforcing teaching about health promotion with an older adult client. Which of the
following instructions to the client is an example of secondary prevention?
Participate in screenings for tuberculosis.
A licensed practical nurse (LPN) is receiving change-of-shift report for a client who had a stroke.
For which of the following tasks should the nurse request assistance from a registered nurse
(RN)?
Staging a pressure ulcer
A nurse is reinforcing teaching about home safety with a client who is at risk for falls. Which of
the following client statements indicates an understanding of the teaching?
"I will secure all of my electrical cords to the baseboard."
A home health nurse is reinforcing teaching about infection control with a client who has
hepatitis A. The nurse should identify that which of the following client statements indicates an
understanding of the teaching?
"I will wash my hands with soap and water for 15 seconds after having a bowel movement."
A nurse at a rehabilitation facility is assisting with the admission of a client who has left-sided
hemiplegia following a stroke. Which of the following actions should the nurse take first?
Determine the client's mental status.