a nurse is evaluating a client's use of a cane. which of the following actions should the nurse identify as an indication of
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correct use? - answersthe client holds the cane on the stronger side of her body
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a nurse receives report about a client who has 0.9% sodium chloride infusing IV at 125 mL/hr. when the nurse performs t
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initial assessment, he notes that the client has received only 80 mL over the last 2 hr. which of the following actions shou
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the nurse take first? - answerscheck the IV tubing for obstruction
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a nurse is caring for a client who requires an NG tube for stomach decompression. which of the following actions should
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the nurse take when inserting the NG tube? - answershave the client take sips of water to promote insertion of the NG tu
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into the esophagus
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a nurse is reviewing a client's fluid and electrolyte status. which of the following findings should the nurse report to the
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provider? - answerspotassium 5.4 mEq/L
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a nurse is providing discharge instructions to a client who will be using a walker. which of the following client statements
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indicates an understanding of the teaching? - answers"I will hire someone to trim the tree that hangs low over the stairs o
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my front porch"
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a nurse is planning care for a client who has had a stroke, resulting in aphasia and dysphagia. which of the following task
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should the nurse assign to an assistive personnel (AP)? select all that apply: - answers- assist the client with a partial be
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bath
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- measure the client's BP after the nurse administers and antihypertensive medication
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- use a communication board to ask what the client wants for lunch
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a nurse is caring for a client who is expressing anger about his diagnosis of colorectal cancer. which of the following
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actions should the nurse take? - answersreassure the client that this is an expected response to grief
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a nurse is preparing to apply a dressing for a client who has a stage 2 pressure injury. which of the following types of
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dressing should the nurse use? - answershydrocolloid
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a nurse is administering an otic medication to an older adult client. which of the following actions should the nurse take to
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ensure that the medication reaches the inner ear? - answerspress gently on the tragus of the client's ear
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a nurse is using an open irrigation technique to irrigate a client's indwelling urinary catheter. which of the following action
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should the nurse take? - answerssubtract the amount of irritant used from the client's urine output
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a nurse is initiating a protective environment for a client who has had an allogeneic stem cell transplant. which of the
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following precautions should the nurse plan for this client? - answersmake sure the client wears a mask when outside he
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room if there is construction in the area
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a nurse is auscultating the anterior chest of a client who was newly admitted to a medical-surgical unit. listen to the audio
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clip of what the nurse auscultates through the stethoscope and identify the type of breath sounds. (listen) -
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answersnormal breath sounds
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,a nurse is planning strategies to manage time effectively for client care. which of the following strategies should the nurs
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implement? - answersuse the planning step of the nursing process to prioritize client care delivery
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a nurse is caring for a client who is postoperative following a knee arthroplasty and requires the use of thigh-length
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sequential compression sleeves. which of the following actions should the nurse take? - answersmake sure two fingers
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can fit under the sleeves
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a nurse is caring for a client who has a respiratory infection. which of the following techniques should the nurse use when
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performing nasotracheal suctioning for the client? - answersapply intermittent suction when withdrawing the catheter
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a nurse is assessing a client who reports increased pain following physical therapy. which of the following questions
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should the nurse ask when assessing the quality of the client's pain? - answers"is your pain sharp or dull?"
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a nurse is providing discharge teaching to a client about self-administering heparin. which of the following instructions
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should the nurse include in the teaching? - answersadminister the medication into the abdomen
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a nurse in a long-term care facility is caring for a client who dies during the nurse's shift. identify the sequence in which th
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nurse should perform the following steps - answers1. obtain the pronouncement of death from the provider
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2. remove tubes and indwelling lines
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3. wash the client's body
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4. ask the client's family members if they would like to view the body
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5. place a name tag on the body
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a nurse is teaching a client and his family how to care for the client's tracheostomy at home. which of the following
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instructions should the nurse include in the teaching? - answersuse tracheostomy covers when outdoors
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a nurse is caring for a client who has a terminal illness and is approaching death. the client is short of breath and has nois
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respirations from secretions in their airway. which of the following actions should the nurse take? - answersturn the clien
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every 2 hr
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a nurse is caring for a child who has a prescription for a blood transfusion. the child's parents have refused the treatment
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due to their religious beliefs. which of the following actions should the nurse take? - answersexamine personal values
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about the issue
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a nurse is preparing to administer enoxaparin subcutaneously to a client. which of the following actions should the nurse
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take? - answersadminister the medication with the needle at a 45 degree angle
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a nurse is admitting a client who is having an exacerbation of heart failure. in planning this client's care, when should the
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nurse initiate discharge planning? - answersduring the admission process
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a nurse is assessing a client who has required bed rest for the past month. which of the following findings should the nurs
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identify as an indication that the client has developed thrombophlebitis? - answerscalf swelling
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a nurse is caring for a client who has dementia. which of the following interventions should the nurse take to minimize the
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risk for injury to the client? - answersuse a bed exit alarm system
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a nurse is assessing an older adult client's risk for falls. which of the following assessments should the nurse use to ident
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the client's safety needs? (select all that apply) - answers- pupil clarity
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- visual fields
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- visual acuity
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