QUESTIONS WITH VERIFIED CORRECT SOLUTIONS
GUARANTEED PASS | ASSURED A+
The nurse is developing a plan of care for a client who was injured in a motor vehicle accident
yesterday. The client is to be sedated for more than 2 weeks while breathing with the assistance
of a mechanical ventilator. Which of the following would be an appropriate nursing diagnosis for
them at this time?
a.) Risk for infection related to subcutaneous injuries
b.) Risk for impaired skin integrity related to immobility
c.) Impaired tissue integrity related to ventilator dependency
d.) Impaired skin integrity related to ventilator dependency - Answer>>> b.) Risk for impaired
skin integrity related to immobility
The hospital nurse educator is preparing an orientation class for those newly hired on the surgical
suite. Which information will the educator include in the orientation curriculum regarding hand
and fingernail care? Select all that apply.
a.) Healthcare staff must routinely inspect their hands for breaks in the skin.
b.) Artificial nails are permitted if properly secured to the nail bed.
c.) Wristwatches may be worn as long as they are all metal.
d.) Healthcare staff are to avoid wearing nail polish.
e.) Fingernail length should be kept to half inch or less. - Answer>>> a.) Healthcare staff must
routinely inspect their hands for breaks in the skin.
d.) Healthcare staff are to avoid wearing nail polish.
When providing postmortem care, the nurse places dentures in the mouth and closes the eyes and
mouth of the patient within 2 to 4 hours after death. Why is the timing of the action so
important?
,a.) To prevent blood from settling in the head, neck, and shoulders
b.) To perform these actions more easily before rigor mortis develops
c.) To set the mouth in a natural position for viewing by the family
d.) To avoid discoloration caused by blood settling in the facial area - Answer>>> b.) To
perform these actions more easily before rigor mortis develops
The nurse instructs a woman about providing a clean-catch urine specimen. Which statement
indicates the patient correctly understands the procedure?
a.) "I will be sure to urinate into the 'hat' you placed on the toilet seat."
b.) "I will wipe my genital area from front to back before I collect the specimen midstream."
c.) "I will need to lie still while you put in a urinary catheter to obtain the specimen."
d.) "I will collect my urine each time I urinate for the next 24 hours." - Answer>>> b.) "I will
wipe my genital area from front to back before I collect the specimen midstream."
A nurse teaches a class for the community discussing routine screening tests for different types
of cancer. What level of health prevention would the nurse classify this activity?
a.) Primary
b.) Secondary
c.) Tertiary
d.) Maintenance - Answer>>> b.) secondary
A patient is prescribed morphine sulfate 4 mg intravenously for postoperative pain. Which action
should the nurse take before administering the medication?
a.) Monitor the patient's respiratory status.
b.) Auscultate the patient's heart sounds.
c.) Check blood pressure with the patient in the supine and sitting positions.
, d.) Assess the patient for elevated temperature. - Answer>>> a.) Monitor the patient's respiratory
status.
A preschool-aged child is scheduled for a tonsillectomy. Which strategy might help lessen the
child's anxiety before surgery?
a.) Give the child a coloring book about the surgery.
b.) Offer the child a detailed rationale for the surgery.
c.) Allow the child to use online sources of information to learn about the surgery.
d.) Provide one-to-one instruction about the care the child will need after surgery. - Answer>>>
a.) Give the child a coloring book about the surgery.
While working with an unlicensed assistive personnel (UAP) in a local nursing home, which of
the following fall risk and prevention measures may be delegated to the UAP by the nurse?
Select all that apply.
a.) Remove clutter and spills in patient rooms.
b.) Place nonskid slippers on patients.
c.) Lock beds and wheelchairs.
d.) Assess each patient for fall risk.
e.) Monitor for injuries if the patient falls. - Answer>>> a.) Remove clutter and spills in patient
rooms.
b.) Place nonskid slippers on patients.
c.) Lock beds and wheelchairs.
The nurse is preparing to teach a client about walking with crutches. Which action would the
nurse take first?
a.) Mutually develop learning goals for walking with crutches.
b.) Demonstrate how to use the crutches.
c.) Determine what the client already knows about crutches.