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A nurse is caring for a client who is 2 days postoperative following a
total knee arthroplasty. Which of the following findings indicates that
the nurse should modify the client's plan of care? - CORRECT
ANSWER Reports pain as a 5 on a scale of 0 to 10
A report of pain as 5 on a scale of 0 to 10 indicates the client is
experiencing moderate pain. The nurse should contact the provider to
obtain a prescription for pain management interventions and should
update the client's plan of care.
A nurse is caring for a client who has a new tracheostomy. The nurse
should ensure that which of the following pieces of equipment is
present in the client's room? - CORRECT ANSWER An
obturator
The nurse should ensure that a client who has a tracheostomy has an
obturator at their bedside. If the tracheostomy is dislodged, an
obturator is used to reinsert the outer cannula of the tracheostomy.
The nurse should also ensure that a spare tracheostomy of the client's
size, as well as a tracheostomy of one size smaller, supplemental
humidified air or oxygen, and suction equipment are at the client's
bedside to ensure safe client care.
A nurse is assessing a client who has multiple sclerosis. Which of the
following assessments is the nurse's priority? - CORRECT
ANSWER Ability to swallow
,The greatest risk to the client is aspiration due to dysphagia. Therefore,
the nurse's priority assessment is the client's ability to swallow.
A nurse is teaching a client who is scheduled for an intravenous
pyelogram. The nurse should identify that which of the following client
statements indicates an understanding of the procedure? -
CORRECT ANSWER "Contrast dye will be used for this test."
The nurse should ensure the client understands that a contrast dye is
injected through a vein to visualize the passage of urine from the renal
pelvis to the bladder. This study is used to diagnose hematuria or
obstruction of the urinary tract and can identify the presence of renal
calculi or tumors.
A nurse manager is teaching about the rights of delegation to assistive
personnel (AP) and practical nurses (PN). Which of the following
examples should the nurse manager include in the teaching? -
CORRECT ANSWER Delegating a PN to insert an indwelling
urinary catheter
The insertion of an indwelling urinary catheter is a nursing
responsibility. The RN must be the one to assess the client's need for
catheterization and can then delegate the responsibility of insertion to
a PN. Due to the knowledge of anatomy and sterile technique, this task
does not fall within the range of function for an AP.
A nurse is planning to discharge a client who had a stroke 1 week ago to
home. The nurse should collaborate with which of the following
members of the interprofessional team to assist the client with the
preparation of nutritious meals? - CORRECT ANSWER
Registered dietitian
,The nurse should collaborate with the registered dietitian for assistance
with the preparation of nutritious meals. The registered dietitian has
the specific dietary knowledge to assist both the client and those who
may be assisting the client.
A nurse is caring for an older adult client who is postoperative following
abdominal surgery. Which of the following age-related changes can
result in delayed wound healing? - CORRECT ANSWER
Decreased sebum production
The nurse should identify that older adult clients experience a decrease
in sebum production, which causes the skin to become dry and can
cause an increase in cracking. This can result in delayed wound healing.
A nurse is assessing a client who has enlarged lymph nodes. In which of
the following locations should the nurse palpate to locate the
postauricular nodes? - CORRECT ANSWER Over the mastoid
The nurse should palpate over the mastoid or behind the ear to assess
the postauricular nodes. The detection of an enlarged or tender lymph
node can indicate the presence of an infection or a malignancy and
should be reported to the provider.
A nurse is teaching a client who has COPD about how to use an
incentive spirometer. Which of the following instructions should the
nurse include? - CORRECT ANSWER "Cough after the
incentive spirometer procedure."
The nurse should encourage the client to cough following the incentive
spirometer procedure. After breathing deeply, secretions can become
loose and coughing can help to remove them.
, A nurse is creating a plan of care for a client who is at risk for falls.
Which of the following interventions should the nurse include in the
plan? - CORRECT ANSWER Have the client demonstrate the
use of the call light.
The nurse should teach the client how to use the call light to receive
assistance when there is a need to get out of bed or a chair. The nurse
should keep the call light within the client's reach at all times and have
the client demonstrate the ability to use it properly.
A nurse is assisting a client to ambulate to the bathroom when the
client begins to fall. Which of the following actions should the nurse
take? - CORRECT ANSWER Place one foot in front of the other
while spreading the feet apart.
The nurse should place one foot in front of the other while spreading
the feet farther apart to widen their own base of support. Then the
nurse should lower the client to the floor as smoothly as possible. This
will assist with supporting the client's weight and help to prevent injury
to the nurse.
A nurse enters a client's room and finds the client on the floor
experiencing a seizure. Which of the following actions should the nurse
take? - CORRECT ANSWER Position the client on their side.
The nurse should position the client on their side. This assists the
client's airway to remain open and can prevent aspiration if the client
has emesis or secretions in their mouth.
A nurse is preparing to administer medications to a client. Which of the
following information should the nurse use to verify the client's
identity? - CORRECT ANSWER Home telephone number