The nurse encounters resistance when inserting the tubing into a client's rectum for a tap
water enema. What action should the nurse implement?
Ask the client to relax and run a small amount of fluid into the rectum.
3 MULTIPLE CHOICE OPTIONS
The nurse is discussing dietary preferences with a client who adheres to a vegan diet. Which
dietary supplement should the nurse encourage the client to include in the dietary plan?
Vitamin B12.
3 MULTIPLE CHOICE OPTIONS
Brainpower
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An older client who is able to stand but not to ambulate receives a prescription to be
mobilized into a chair as tolerated during each day.What is the best action for the nurse to
implement when assisting the client from the bed to the chair?
Place a transfer belt around the client, assist to stand, and pivot to a chair that is placed at a
right angle to the bed.
3 MULTIPLE CHOICE OPTIONS
A male client with an infected wound tells the nurse that he follows a macrobiotic diet. Which
type of foods should the nurse recommend that the client select from the hospital menu?
Combination of plant proteins to provide essential amino acids.
3 MULTIPLE CHOICE OPTIONS
,A 4-year-old boy who is scheduled for a tonsillectomy and adenoidectomy asks the nurse,
"Will it hurt to have my tonsils and adenoids taken out?" Which response is best for the
nurse to provide?
"It may hurt but we'll give you medicine to help you feel better."
3 MULTIPLE CHOICE OPTIONS
When the nurse enters a client's room to do an initial assessment, the client shouts, "Get out
of my room! I'm tired of being bothered!" How should the nurse respond?
"What is concerning you this morning?"
3 MULTIPLE CHOICE OPTIONS
Which statement correctly identifies a written learning objective for a client with peripheral
vascular disease?
Upon discharge, the client will list three ways to protect the feet from injury.
3 MULTIPLE CHOICE OPTIONS
The nurse is providing passive range of motion (ROM) exercises to the hip and knee for a
client who is unconscious.
After supporting the client's knee with one hand, what action should the nurse take next?
Cradle the client's heel.
3 MULTIPLE CHOICE OPTIONS
While preparing to insert a rectal suppository in a male adult client, the nurse observes that
the client is holding his breath while bearing down. What action should the nurse implement?
Instruct the client to take slow deep breaths and stop bearing down.
3 MULTIPLE CHOICE OPTIONS
What action should the nurse implement when adding sterile liquids to a sterile field?
Consider the sterile field contaminated if it becomes wet during the procedure.
3 MULTIPLE CHOICE OPTIONS
When assessing a client with a nursing diagnosis of fluid volume deficit, the nurse notes that
the client's skin over the sternum "tents" when gently pinched. Which action should the nurse
implement?
, Continue the planned nursing interventions to restore the client's fluid volume.
3 MULTIPLE CHOICE OPTIONS
A client is admitted to the hospital with intractable pain. What instruction should the nurse
provide the unlicensed assistive personnel (UAP) who is preparing to assist this client with a
bed bath?
Take measures to promote as much comfort as possible.
3 MULTIPLE CHOICE OPTIONS
The nurse is preparing to irrigate a client's indwelling urinary catheter using an open
technique. What action should the nurse take after applying gloves?
Draw up the irrigating solution into the syringe.
3 MULTIPLE CHOICE OPTIONS
The nurse is administering an intermittent infusion of an antibiotic to a client whose
intravenous (IV) access is an antecubital saline lock. After the nurse opens the roller clamp
on the IV tubing, the alarm on the infusion pump indicates an obstruction. What action
should the nurse take first?
Reposition the client's arm.
3 MULTIPLE CHOICE OPTIONS
What intervention should the nurse include in the plan of care for a client who is being
treated with an Unna’s paste boot for leg ulcers due to chronic venous insufficiency?
Check capillary refill of toes on lower extremity with Unna's paste boot.
3 MULTIPLE CHOICE OPTIONS
A client is admitted with a stage four pressure ulcer that has a black, hardened surface and a
light-pink wound bed with a malodorous green drainage. Which dressing is best for the nurse
to use first?
Wet to moist dressing.
3 MULTIPLE CHOICE OPTIONS
A female client informs the nurse that she uses herbal therapies to supplement her diet and
manage common ailments. What information should the nurse offer the client about general
use of herbal supplements?