B QUESTIONS AND ANSWERS WITH B B B
RATIONALE 2024. B B
A nurse is planning care for an older adult client who is at risk for
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developing pressure ulcers which of the following intervention
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should the nurse used to help maintain the integrity of the
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clients?
B
a. use a transfer device to lift the client up in bed
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b. apply cornstarch to keep sensitive skin areas dry
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c. massage the skin over the clients bony prominences
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d. elevate the head of the bed no more than 45 degrees -
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ANSWER-a. use a transfer device to lift the client up in bed
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A nurse is planning care for a client who has a decreased level of
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consciousness the client is receiving continuous enteral feedings
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via a gastrostomy tube due to inability to swallow which of the
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following is the priority action by the nurse?
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a. observe the clients respiratory status
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b. elevate the head of the bed 30-45 degrees
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c. monitor intake and output every 8 hours
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d. check residual volume every 4-6 hrs - ANSWER-b. elevate the
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head of the bed 30-45 degrees
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,A nurse is providing teaching to a client who has constipation
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which of the following information should the nurse include
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a. increase intake of low fiber foods '
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b. avoid drinking hot liquids
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c. increase fluid intake to 1500 mL a day
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d. include probiotic foods in the daily diet
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e. increase daily exercise - ANSWER-c. increase fluid intake to
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1500 mL, d. include probiotic foods, e. increase daily exercise
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A nurse is caring for a client who has peripheral vascular disease
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and reports difficulty sleeping because of cold feet which of the
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following nursing action should the nurse take to promote the
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clients comfort
B B
a. obtain a pair of slipper-socks
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b. rub the clients feet briskly for several minutes
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c. increase the clients oral fluid intake
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d. place a moist heating pad under the clients feet - ANSWER-a.
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obtain a pair of slipper-socks
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A nurse is measuring a client for knee-high antiembolic stockings
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to help venous stasis which of the following action should the
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nurse take
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,a. measure from the heel to the gluteal fold
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b. measure the length of the feet
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c. measure from the heel to the popiteal space
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d. measure the ankle circumfrance - ANSWER-c. measure from
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the heel to the popiteal space
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A nurse is assisting an older client who sometimes loses her
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balance while walking which of the following devices to the nurse
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use when helping the client ambulate
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a. gait belt
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b. jacket harness
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c. four-wheel walker
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d. cane - ANSWER-a. gait belt
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A nurse is caring for a client who has a prescription for a stool
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test for guaiac. the nurse understands the purpose of the test is
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to checl the stool for which of the following substances?
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a. steatorrhea
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b. blood
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c. bacteria
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d. parasites - ANSWER-b. blood
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, A nurse is performing a cardiac assessment on a client in Alsco
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Tate's in S3 sound. The nurse should recognize that this sound
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represent which of the following heart conditions?
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a. atrial gallop
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b. ventricular gallop
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c. closure of the mitral valve
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d. closure of the pulmonic valve - ANSWER-b. ventricular gallop
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A nurse is assessing a client radio pulse in the terminals that the
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pulse is irregular. Which of the following action should the nurse
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take?
B
a. assess the apical pulse for a full minute
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b. assess the apical pulse with a doppler
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c. assess the pedal pulses for a full minute
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d. assess the pedal pulses with a doppler device - ANSWER-a.
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assess the apical pulse for a full minute
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A nurse is teaching a group of males about testicular self-
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examination. Which info should nurse include?
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a. perform self examination twice a year
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b. pinch testicles to feel for abnormalities
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c. examine the testicles after bath or shower
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