Questions and Answers | Professor Verified Answers | Graded A
1.A nurse at a long-term care facility is caring for a client who requires oral suctioning.
Which of the following supplies should the nurse plan to use for this task?
A. Regular suction catheter
B. Yankauer catheter
C. Endotracheal suction catheter
D. Inline suction catheter
Correct Answer: B
Rationale: A Yankauer catheter is a clean suction catheter used when performing oral and
oropharyngeal suctioning to remove secretions from the client's mouth to facilitate
breathing or obtain a sample for diagnostic evaluation.
2.
A nurse in a long-term care facility is serving on the ethics committee, which is addressing
a client care dilemma. Which of the following strategies will facilitate resolving the
dilemma? (Select all that apply.)
[1] Determine the facts related to the dilemma.
[2] Identify possible solutions.
[3] Consider the client's wishes.
[4] Allow the family's financial situation to dictate the outcome.
[5] Apply personal religious beliefs to the case.
A. [1], [2], and [3] only
B. [2], [4], and [5] only
C. [1], [3], and [5] only
D. All of the options
Correct Answer: A
Rationale: Ethical dilemmas are best resolved through systematic processes that include
gathering all factual information, generating multiple potential solutions, and placing a high
,priority on the autonomy and expressed wishes of the client. Financial backgrounds and
personal biases of the committee members should not dictate the care plan.
3.
A nurse is talking with a client whose son died in a motor-vehicle crash 2 weeks ago. The
client states, "I really thought I'd be back to my usual routines by now, but I can't think of
anything else except that my son is gone." Which of the following responses should the
nurse make?
A. "You should try to focus on the good times you shared rather than his death."
B. "Grieving for your son is hard work. It will take as much time as you need to come to
terms with your loss."
C. "It has only been two weeks, most people take months to feel bad like this."
D. "Let's talk about scheduling you for a psychiatric evaluation to help you move on."
Correct Answer: B
Rationale: This therapeutic response validates the client’s feelings and normalizes the
grieving process. Grieving is an individualized, non-linear experience that requires time,
and two weeks is an exceptionally short period following a traumatic loss.
4.
A nurse is reinforcing teaching with a client about cancer prevention. The nurse should
include that frequent consumption of which of the following foods increases the risk for
developing cancer?
A. Poultry
B. Tuna fish
C. Lamb
D. Whole grains
Correct Answer: C
Rationale: Frequent consumption of red meats (such as lamb, beef, and pork) and
processed meats is linked to an increased risk of developing certain types of cancer,
particularly colorectal cancer. Conversely, including poultry, fish like tuna, and whole
grains reduces or does not increase this risk.
5.
,A nurse notices an assistive personnel (AP) taking a nap in the break room during mealtime.
The nurse also notes that the AP is drowsy while performing routine tasks. Which of the
following actions should the nurse take?
A. Confrornt the AP aggressively in front of other sta; members.
B. Report the observation about the AP to the unit nurse manager.
C. Ignore the behavior since the AP was on their scheduled meal break.
D. Assign the AP's high-risk tasks to another unsuspecting coworker.
Correct Answer: B
Rationale: Client safety is the paramount concern. If an sta; member is drowsy while
performing routine tasks, they pose a safety hazard. The nurse must report these
observations to the unit manager to handle the situation through the proper administrative
and corrective channels.
6.
A nurse on a pediatric unit is collecting data from four newly admitted clients. Which of the
following clients should the nurse identify as being at risk for urinary retention?
A. A school-age child who has allergic rhinitis and is taking diphenhydramine.
B. A toddler who has acute gastroenteritis and mild dehydration.
C. An infant who has a history of gastroesophageal reflux.
D. A preschooler who is recovering from a mild asthma exacerbation.
Correct Answer: A
Rationale: Diphenhydramine is an antihistamine with significant anticholinergic side
e;ects. Anticholinergic actions decrease bladder detrusor muscle tone and increase
urinary sphincter resistance, directly predisposing the child to urinary retention.
7.
A nurse is caring for a client following a bronchoscopy. Which of the following actions
should the nurse take first?
A. Provide oral hygiene measures to the client.
B. Administer prescribed prophylactic antibiotics.
C. Check for the presence of a gag reflex.
, D. Instruct the client on deep-breathing exercises.
Correct Answer: C
Rationale: The topical anesthetic used to numb the throat during a bronchoscopy
suppresses the client's swallow and gag reflexes. To prevent aspiration, the nurse's priority
action before allowing any oral intake is to verify that the gag reflex has fully returned.
8.
A nurse is assisting with the admission of a client who has a latex allergy. The nurse should
identify that which of the following supplies has the potential to contain latex?
A. Sterile gauze pads
B. Indwelling urinary catheter
C. Plastic measuring cups
D. Stainless steel surgical instruments
Correct Answer: B
Rationale: Many standard indwelling urinary catheters, rubber stoppers, and older medical
gloves are constructed using natural rubber latex. The nurse must ensure that a latex-free
alternative (such as a silicone catheter) is used for this client.
9.
A nurse is performing postmortem care for a client prior to the arrival of the client's family
for viewing of the body. Which of the following actions should the nurse take?
A. Place the client's body in a prone position.
B. Keep the room brightly illuminated for the family.
C. Gently close the client's eyelids.
D. Leave all tubes and IV lines fully intact and visible.
Correct Answer: C
Rationale: Postmortem care involves preparing the client's body to look as peaceful and
natural as possible. Gently closing the eyelids gives a natural appearance of sleep, which
helps reduce emotional distress for the family during viewing.
10.