Complete Questions and Correct Detailed Answers With Rationales.
Practice questions for this set (Original)
, A charge nurse smells smoke, enters the visitor restroom, and sees flames in the trash
can. What is the sequence of actions that the nurse should take? (Move the steps into
4
the box on the right, placing them in the selected order of performance. Use all the
steps.)
Don't know?
Terms in this set (63)
A nurse is caring for a client Decrease the rate of the feeding
who is receiving continuous
NG tube feedings. The nurse
- Rationality: The nurse should expect to hear bowel sounds
listens to the client's bowel
sounds. Which of the every 5 to 35 seconds. This audio clip indicates
following actions should the hypermotility because there are greater than 40 bowel
nurse take? (Click on the
sounds/min. Hypermotility leads to diarrhea and is an
audio button to listen to the
clip.) indication of intolerance to the enteral feeding. Therefore,
the nurse should slow the rate of the feeding to promote
the client's tolerance of the feeding.
The nurse should maintain a client who is receiving
continuous NG tube feedings in a position with the head of
the bed elevated 30° to 45° to prevent aspiration of the
formula.
,A nurse is preparing to Nonrebreather mask
administer oxygen to a client
who has heart failure and is
Rationality:
having severe difficulty
breathing. Which of the A nonrebreather mask provides the highest
following oxygen delivery percentage of oxygen concentration without
equipment should the nurse
intubation and mechanical ventilation.
select to provide the highest
concentration of oxygen to
the client? A Venturi mask can be adjusted to provide a consistent
lower oxygen concentration.
A simple face mask can be adjusted for short-term delivery of
low to medium oxygen concentration.
A nasal cannula provides a low oxygen concentration.
, A charge nurse smells smoke, Evacuate clients from the area is the first step.
enters the visitor restroom,
and sees flames in the trash
Rationality: The first action the nurse should take when using the
can. What is the sequence of
actions that the nurse should RACE protocol is to "rescue" or evacuate the clients from the area
take? (Move the steps into to prevent harm.
the box on the right, placing
them in the selected order of
performance. Use all the Pull the lever on the fire alarm box is the second step.
steps.)
Rationality: For the next step, "alarm," the nurse should
activate the facility fire alarm and call to report the fire to
the facility emergency extension.
Close the fire doors on the unit is the third step.
Rationality: Close the fire doors on the unit is the third
step. For the third step, "confine," the nurse should close
the unit fire doors to prevent the fire from spreading.
Use a fire extinguisher to put out the fire is the fourth step.
Rationality: For the final step, "extinguish," the nurse should
use a fire extinguisher to put out the fire by aiming the nozzle
at the base of the fire and using a sweeping motion.
"Tell me what the afterlife means to you."
A nurse is caring for a client Rationale: This statement respects the client's spiritual
who has metastatic cancer needs by using open-ended therapeutic communication to
and practices Catholicism. assist the client to talk about their concerns.
The client asks the nurse to
discuss the afterlife with
them. Which of the following
statements by the nurse
assists in meeting the client's
spiritual needs?