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1. The nurse is caring for four clients. The client with Respiratory rate of 25
which clinical manifestation requires immediate atten- breaths per minute after
tion from the nurse? resting for 3 minutes after
activity
2. The nurse places a client who had abdominal surgery "Lifting your chest above
in the semi-Fowler position. The client states, "I prefer your abdomen facilitates
to lie flat when in bed. I feel like I am almost sitting up." drainage in your wound
Which is an appropriate response by the nurse? drains."
3. The nurse is educating a client who has just been pre- Change positions slowly to
scribed a diuretic about how to safely perform activi- minimize orthostatic hy-
ties of daily living. Which statement should the nurse potension
include in the teaching
4. The nurse recognizes that which statements made by "I will not watch television
a patient indicate an understanding of behaviors that in bed."
will promote sleep? (Select all that apply.)
"I will not drink caffeine
later in the day."
"I will start to exercise reg-
ularly during the day."
5. Your patient is being discharged home and will be The patient injects the
required to self-administer injectable Heparin. You are needle 1 inch away from
observing the patient administer their scheduled dose the umbilicus
of Heparin to confirm that the patient knows how to do
it correctly. What action by the patient requires you to
re-educate them about how to administer Heparin?
6. A nurse caring for patients in a long-term care facil- The nurse collects about
ity is often required to collect urine specimens from 3 mL of urine from a pa-
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, D439 Foundations of Nursing OA Approval Q & A (Copy)
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patients for laboratory testing. Which techniques for tient's indwelling catheter
urine collection are performed correctly? Select all that to send for a urine cul-
apply. ture.
The nurse discards the first
urine of the day when per-
forming a 24-hour urine
specimen collection on a
patient.
7. The nurse is caring for a 60-year-old client with a di- Impaired skin integrity
agnosis of C-diff and is incontinent who requires fre-
quent linen changes. What should the nurse be most
concerned for
8. The nurse is making an occupied bed. Which nursing Ensuring that the client's
action is most important head is supported and is
in functional alignment
9. When giving a client a bed bath, a nurse washes the Stimulates Venous return
client's extremities from distal to proximal. Which of
the following rationales best supports this nursing ac-
tion?
10. The nurse is caring for a debilitated female client with Positioning a bedside
nocturia. Which nursing intervention is the priority commode near the bed
when planning to meet this client's needs
11. The nurse plans to teach a client with hemiparesis to Hold the cane in the strong
use a cane. Which should the nurse teach the client to hand when walking
do? Select all that apply.
12.
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