B260 D&D CLINICAL JUDGEMENT FINAL REVIEW
airborne - Answers - A nurse is admitting a client who has tuberculosis and a productive
cough. which of the following types of isolation precautions should the nurse initiate for
the client?
a. contact
b. droplet
c. protective
d. airborne
denial - Answers - a nurse in a dialysis center is caring for a client who has a new
diagnosis of end-stage kidney disease. when he arrives for his first dialysis treatment,
he tells the nurse, I decided to come today, but I am not sure if I will need to come back
again this week. I am feeling much better since my discharge from the hospital and I
think my kidneys are working again. the nurse should identify that this client is
demonstrating which of the following Kubler-ross stages of grieving?
a. bargaining
b. denial
c. depression
d. anger
i just can't believe that this dialysis is going to ruin my whole life - Answers - a nurse is
caring for a client who has a new diagnosis of chronic kidney disease. which of the
following statements should the nurse identify as an indication of anticipatory grieving?
a. i know that i will get a kidney transplant. I am a good candidate.
b. i can now eat whatever I want. the dialysis will remove it from my system
c. i just can't believe that this dialysis is going to ruin my whole life
d. I know that kidney disease runs in my family, but I can prevent it.
performs active range of motion exercises of all extremities - Answers - a nurse is
assessing a client who has required strict bed rest for 1 week. which of the following
findings should the nurse identify as an indication that the client is ready to ambulate?
a. needs assistance raising her legs to put on socks
b. demonstrates mild dyspnea when eating breakfast
c. performs active range of motion exercises of all extremities
d. develops fatigue when assisting with morning hygiene care
inject the medication at 90 degree angle. - Answers - a nurse is planning to administer
an IM injection into a client's deltoid muscle. which of the following actions should the
nurse take?
a. inject the medication at 90 degree angle.
b. inject a volume of less than 2 ml
c. inject the medication 12.7 com (5in) below the client's acromion process
d. use a 21-guage needle for the injection
, the client's self-report of pain severity - Answers - a nurse is caring for a client who is
postoperative. the nurse should base her pain management interventions primarily on
which of the following methods of determining the intensity of the client's pain?
a. vital sign measurement
b. the client's self-report of pain severity
c. visual observations for nonverbal signs of pain
d. the nature and invasiveness of the surgical procedure
rub all surfaces of your hands with an alcohol rub for 20 to 30 seconds - Answers - a
nurse is teaching a new group of assistive personnel about the importance of hand
hygiene. which of the following statements should the nurse include?
an older adult client who is confused and has urinary frequency - Answers - a nurse on
the medical surgical unit is conducting a fall risk assessment for four clients. the nurse
should identify that which of the following clients is the greatest risk for a fall
the shoulders droop
the facial muscles relax
the pulse is within the
expected range - Answers - a nurse provides a back massage as a palliative care
measure to a client who is unconscious, grimacing, and restless. which of the following
findings should the nurse identify as indicating a therapeutic response.
Provide skin care with a moisture barrier is correct.
Administer artificial tears PRN is correct
Perform mouth care every hour is correct
Administer oxygen 2 L/min via nasal cannula is correct. - Answers - a hospice nurse is
reviewing the prescriptions for a client who is receiving palliative care. which of the
following prescriptions should the nurse expect?
aspirate the client's stomach contents - Answers - a nurse is planning care for a client
who is receiving enteral feedings through an NG tube. which of the following actions
should the nurse plan to take first?
A client who has had a cerebrovascular accident is correct.
A client who is 4 hr postoperative following a leg amputation with general anesthesia
A client who has had radiation therapy for head and neck cancer is correct. - Answers -
a nurse is caring for a group of clients. which of the following clients should the nurse
identify as having an increased risk for aspiration while eating?
airborne - Answers - A nurse is admitting a client who has tuberculosis and a productive
cough. which of the following types of isolation precautions should the nurse initiate for
the client?
a. contact
b. droplet
c. protective
d. airborne
denial - Answers - a nurse in a dialysis center is caring for a client who has a new
diagnosis of end-stage kidney disease. when he arrives for his first dialysis treatment,
he tells the nurse, I decided to come today, but I am not sure if I will need to come back
again this week. I am feeling much better since my discharge from the hospital and I
think my kidneys are working again. the nurse should identify that this client is
demonstrating which of the following Kubler-ross stages of grieving?
a. bargaining
b. denial
c. depression
d. anger
i just can't believe that this dialysis is going to ruin my whole life - Answers - a nurse is
caring for a client who has a new diagnosis of chronic kidney disease. which of the
following statements should the nurse identify as an indication of anticipatory grieving?
a. i know that i will get a kidney transplant. I am a good candidate.
b. i can now eat whatever I want. the dialysis will remove it from my system
c. i just can't believe that this dialysis is going to ruin my whole life
d. I know that kidney disease runs in my family, but I can prevent it.
performs active range of motion exercises of all extremities - Answers - a nurse is
assessing a client who has required strict bed rest for 1 week. which of the following
findings should the nurse identify as an indication that the client is ready to ambulate?
a. needs assistance raising her legs to put on socks
b. demonstrates mild dyspnea when eating breakfast
c. performs active range of motion exercises of all extremities
d. develops fatigue when assisting with morning hygiene care
inject the medication at 90 degree angle. - Answers - a nurse is planning to administer
an IM injection into a client's deltoid muscle. which of the following actions should the
nurse take?
a. inject the medication at 90 degree angle.
b. inject a volume of less than 2 ml
c. inject the medication 12.7 com (5in) below the client's acromion process
d. use a 21-guage needle for the injection
, the client's self-report of pain severity - Answers - a nurse is caring for a client who is
postoperative. the nurse should base her pain management interventions primarily on
which of the following methods of determining the intensity of the client's pain?
a. vital sign measurement
b. the client's self-report of pain severity
c. visual observations for nonverbal signs of pain
d. the nature and invasiveness of the surgical procedure
rub all surfaces of your hands with an alcohol rub for 20 to 30 seconds - Answers - a
nurse is teaching a new group of assistive personnel about the importance of hand
hygiene. which of the following statements should the nurse include?
an older adult client who is confused and has urinary frequency - Answers - a nurse on
the medical surgical unit is conducting a fall risk assessment for four clients. the nurse
should identify that which of the following clients is the greatest risk for a fall
the shoulders droop
the facial muscles relax
the pulse is within the
expected range - Answers - a nurse provides a back massage as a palliative care
measure to a client who is unconscious, grimacing, and restless. which of the following
findings should the nurse identify as indicating a therapeutic response.
Provide skin care with a moisture barrier is correct.
Administer artificial tears PRN is correct
Perform mouth care every hour is correct
Administer oxygen 2 L/min via nasal cannula is correct. - Answers - a hospice nurse is
reviewing the prescriptions for a client who is receiving palliative care. which of the
following prescriptions should the nurse expect?
aspirate the client's stomach contents - Answers - a nurse is planning care for a client
who is receiving enteral feedings through an NG tube. which of the following actions
should the nurse plan to take first?
A client who has had a cerebrovascular accident is correct.
A client who is 4 hr postoperative following a leg amputation with general anesthesia
A client who has had radiation therapy for head and neck cancer is correct. - Answers -
a nurse is caring for a group of clients. which of the following clients should the nurse
identify as having an increased risk for aspiration while eating?
