NR688 week 3 Exam with |! |! |! |! |!
precise detailed solutions |! |! |!
The nurse is preparing to receive an 18-month-old client from surgery who
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had repair of a congenital hip deformity. What type of traction does the nurse
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anticipate setting up for the client? - Correct answer ✔Bryant's Traction
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The nurse is caring for a client whose lab results show triglycerides of 380
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and cholesterol level of 240. Which foods would the nurse educate the client
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about including in his diet when he is discharged? Select all that apply.
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A. wheat toast with sugar-free jelly
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B. grilled salmon seasoned with herbs
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C. an egg-white omelet with vegetables
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D. natural honey from a local farmer's market
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E. plain grilled steak prepared with pepper only - Correct answer ✔b. grilled
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salmon seasoned with herbs |! |! |!
c. an egg-white omelet with vegetables
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The nurse is discharging a client who was prescribed prednisone. The nurse
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tells the client that one of the side effects may be impaired sleep. The client
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says, "I already have a hard time sleeping. What can I do to help with that?"
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Which recommendations should the nurse make? Select all that apply.
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,A. avoid alcohol late in the evening
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B. keep the bedroom dark and quiet
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C. maintain the same consistent sleep schedule
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D. eat a large, heavy meal at dinner to help promote sleep
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E. read or do another quiet, noncomputer activity before bed
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F. do a vigorous exercise routine after work to help him become tired -
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Correct answer ✔a. avoid alcohol late in the evening
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b. keep the bedroom dark and quiet
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c. maintain the same consistent sleep schedule
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e. read or do another quiet, noncomputer activity from bed
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The nurse is preparing to discharge a client who was treated for tuberculosis.
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Which guidelines for home management should the nurse include in his
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discharge teaching? Select all that apply. |! |! |! |! |!
A. The client may resume his normal activities.
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B. The family should maintain respiratory isolation at home.
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C. The medication regimen should be followed diligently as prescribed.
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D. The client may return to work when three sputum cultures are negative.
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E. The nurse should educate the client about the medication and possible
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side effects and their management. - Correct answer ✔b. the family should
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maintain respiratory isolation at home |! |! |! |!
c. the medication regimen should be followed diligently as prescribed
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d. the client may return to work when three sputum cultures are negative
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,The nurse is caring for a client who has a nasogastric tube for medication
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administration and tube feedings. How should the nurse care for the tube |! |! |! |! |! |! |! |! |! |! |! |!
during her shift? Select all that apply.
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|!
A. flush tube every 4 hours with hot water to maintain patency
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B. allow the feeding and tubing to hang until empty, up to 48 hours
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C. maintain the head of bed in a high-Fowler's position during feedings
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D. check residuals and replace them unless the amount is greater than 300
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mL
E. check under the adhesive tape on the nose daily to assess for skin
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breakdown |!
F. assess the bowel sounds before feeding, and feed at half the rate if bowel
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sounds are absent - Correct answer ✔c. maintain the head of bed in a high-
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Fowler's position during feedings |! |! |!
e. check under the adhesive tape on the nose daily to assess for skin
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breakdown
The nurse is teaching a group of nursing students about proper client
|! |! |! |! |! |! |! |! |! |! |! |!
positioning. Which statement by a student nurse indicates an understanding
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of proper positioning?
|! |! |!
A. A client receiving an enema should be placed on the right side in the Sims'
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position.
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B. A client with a below-the-knee amputation should be positioned with the
|! |! |! |! |! |! |! |! |! |! |! |!
affected limb elevated at a 45-degree angle. C. Clients with pulmonary edema
|! |! |! |! |! |! |! |! |! |! |! |!
should be positioned upright with the legs dangling over the side of the bed.
|! |! |! |! |! |! |! |! |! |! |! |! |! |!
, D. Clients with a craniotomy should be positioned with the head of bed at a
|! |! |! |! |! |! |! |! |! |! |! |! |! |! |!
20-degree angle with the head in a neutral, midline position. - Correct answer
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✔c. clients with pulmonary edema should be positioned upright with the
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legs dangling over the side of the bed
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The nurse is caring for a client with deep vein thrombosis (DVT). Which
|! |! |! |! |! |! |! |! |! |! |! |! |!
should be included in the plan of care?
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A. bed rest with the affected extremity elevated
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B. bed rest with the bed in reverse Trendelenburg
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C. walking slowly in the hall with assistance to prevent pneumonia D. sitting
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up in the chair for all meals and during visitation time - Correct answer ✔a.
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bed rest with the affected extremity elevated
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The nurse is assessing a six-month-old infant at the clinic. When the nurse
|! |! |! |! |! |! |! |! |! |! |! |! |!
strokes from the heel of the foot upward toward the ball, the infant exhibits
|! |! |! |! |! |! |! |! |! |! |! |! |! |!
no movement. Which action is the priority for the nurse?
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A. take the infant's vital signs
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B. order a neurology consult
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C. examine the infant's nose and ears
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D. ask how much formula the infant consumes daily - Correct answer ✔b.
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order a neurology consult |! |! |!
The nurse is caring for a client with COPD who complains of poor quality of
|! |! |! |! |! |! |! |! |! |! |! |! |! |! |!
sleep. Which question should the nurse ask next?
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precise detailed solutions |! |! |!
The nurse is preparing to receive an 18-month-old client from surgery who
|! |! |! |! |! |! |! |! |! |! |! |!
had repair of a congenital hip deformity. What type of traction does the nurse
|! |! |! |! |! |! |! |! |! |! |! |! |!
anticipate setting up for the client? - Correct answer ✔Bryant's Traction
|! |! |! |! |! |! |! |! |! |! |!
The nurse is caring for a client whose lab results show triglycerides of 380
|! |! |! |! |! |! |! |! |! |! |! |! |! |!
and cholesterol level of 240. Which foods would the nurse educate the client
|! |! |! |! |! |! |! |! |! |! |! |! |!
about including in his diet when he is discharged? Select all that apply.
|! |! |! |! |! |! |! |! |! |! |! |! |!
A. wheat toast with sugar-free jelly
|! |! |! |! |! |!
B. grilled salmon seasoned with herbs
|! |! |! |! |! |!
C. an egg-white omelet with vegetables
|! |! |! |! |! |!
D. natural honey from a local farmer's market
|! |! |! |! |! |! |! |!
E. plain grilled steak prepared with pepper only - Correct answer ✔b. grilled
|! |! |! |! |! |! |! |! |! |! |! |! |!
salmon seasoned with herbs |! |! |!
c. an egg-white omelet with vegetables
|! |! |! |! |!
The nurse is discharging a client who was prescribed prednisone. The nurse
|! |! |! |! |! |! |! |! |! |! |! |!
tells the client that one of the side effects may be impaired sleep. The client
|! |! |! |! |! |! |! |! |! |! |! |! |! |! |!
says, "I already have a hard time sleeping. What can I do to help with that?"
|! |! |! |! |! |! |! |! |! |! |! |! |! |! |! |!
Which recommendations should the nurse make? Select all that apply.
|! |! |! |! |! |! |! |! |!
,A. avoid alcohol late in the evening
|! |! |! |! |! |! |!
B. keep the bedroom dark and quiet
|! |! |! |! |! |! |!
C. maintain the same consistent sleep schedule
|! |! |! |! |! |! |!
D. eat a large, heavy meal at dinner to help promote sleep
|! |! |! |! |! |! |! |! |! |! |!
E. read or do another quiet, noncomputer activity before bed
|! |! |! |! |! |! |! |! |! |!
F. do a vigorous exercise routine after work to help him become tired -
|! |! |! |! |! |! |! |! |! |! |! |! |! |!
Correct answer ✔a. avoid alcohol late in the evening
|! |! |! |! |! |! |! |! |!
b. keep the bedroom dark and quiet
|! |! |! |! |! |!
c. maintain the same consistent sleep schedule
|! |! |! |! |! |!
e. read or do another quiet, noncomputer activity from bed
|! |! |! |! |! |! |! |! |!
The nurse is preparing to discharge a client who was treated for tuberculosis.
|! |! |! |! |! |! |! |! |! |! |! |! |!
Which guidelines for home management should the nurse include in his
|! |! |! |! |! |! |! |! |! |! |!
discharge teaching? Select all that apply. |! |! |! |! |!
A. The client may resume his normal activities.
|! |! |! |! |! |! |! |!
B. The family should maintain respiratory isolation at home.
|! |! |! |! |! |! |! |! |!
C. The medication regimen should be followed diligently as prescribed.
|! |! |! |! |! |! |! |! |! |!
D. The client may return to work when three sputum cultures are negative.
|! |! |! |! |! |! |! |! |! |! |! |! |!
E. The nurse should educate the client about the medication and possible
|! |! |! |! |! |! |! |! |! |! |! |!
side effects and their management. - Correct answer ✔b. the family should
|! |! |! |! |! |! |! |! |! |! |! |!
maintain respiratory isolation at home |! |! |! |!
c. the medication regimen should be followed diligently as prescribed
|! |! |! |! |! |! |! |! |!
d. the client may return to work when three sputum cultures are negative
|! |! |! |! |! |! |! |! |! |! |! |!
,The nurse is caring for a client who has a nasogastric tube for medication
|! |! |! |! |! |! |! |! |! |! |! |! |! |!
administration and tube feedings. How should the nurse care for the tube |! |! |! |! |! |! |! |! |! |! |! |!
during her shift? Select all that apply.
|! |! |! |! |! |!
|!
A. flush tube every 4 hours with hot water to maintain patency
|! |! |! |! |! |! |! |! |! |! |!
B. allow the feeding and tubing to hang until empty, up to 48 hours
|! |! |! |! |! |! |! |! |! |! |! |! |! |!
C. maintain the head of bed in a high-Fowler's position during feedings
|! |! |! |! |! |! |! |! |! |! |! |!
D. check residuals and replace them unless the amount is greater than 300
|! |! |! |! |! |! |! |! |! |! |! |! |!
mL
E. check under the adhesive tape on the nose daily to assess for skin
|! |! |! |! |! |! |! |! |! |! |! |! |! |!
breakdown |!
F. assess the bowel sounds before feeding, and feed at half the rate if bowel
|! |! |! |! |! |! |! |! |! |! |! |! |! |! |!
sounds are absent - Correct answer ✔c. maintain the head of bed in a high-
|! |! |! |! |! |! |! |! |! |! |! |! |! |!
Fowler's position during feedings |! |! |!
e. check under the adhesive tape on the nose daily to assess for skin
|! |! |! |! |! |! |! |! |! |! |! |! |! |!
breakdown
The nurse is teaching a group of nursing students about proper client
|! |! |! |! |! |! |! |! |! |! |! |!
positioning. Which statement by a student nurse indicates an understanding
|! |! |! |! |! |! |! |! |! |!
of proper positioning?
|! |! |!
A. A client receiving an enema should be placed on the right side in the Sims'
|! |! |! |! |! |! |! |! |! |! |! |! |! |! |!
position.
|! |!
B. A client with a below-the-knee amputation should be positioned with the
|! |! |! |! |! |! |! |! |! |! |! |!
affected limb elevated at a 45-degree angle. C. Clients with pulmonary edema
|! |! |! |! |! |! |! |! |! |! |! |!
should be positioned upright with the legs dangling over the side of the bed.
|! |! |! |! |! |! |! |! |! |! |! |! |! |!
, D. Clients with a craniotomy should be positioned with the head of bed at a
|! |! |! |! |! |! |! |! |! |! |! |! |! |! |!
20-degree angle with the head in a neutral, midline position. - Correct answer
|! |! |! |! |! |! |! |! |! |! |! |!
✔c. clients with pulmonary edema should be positioned upright with the
|! |! |! |! |! |! |! |! |! |! |! |!
legs dangling over the side of the bed
|! |! |! |! |! |! |!
The nurse is caring for a client with deep vein thrombosis (DVT). Which
|! |! |! |! |! |! |! |! |! |! |! |! |!
should be included in the plan of care?
|! |! |! |! |! |! |! |!
A. bed rest with the affected extremity elevated
|! |! |! |! |! |! |! |!
B. bed rest with the bed in reverse Trendelenburg
|! |! |! |! |! |! |! |! |!
C. walking slowly in the hall with assistance to prevent pneumonia D. sitting
|! |! |! |! |! |! |! |! |! |! |! |! |!
up in the chair for all meals and during visitation time - Correct answer ✔a.
|! |! |! |! |! |! |! |! |! |! |! |! |! |! |!
bed rest with the affected extremity elevated
|! |! |! |! |! |!
The nurse is assessing a six-month-old infant at the clinic. When the nurse
|! |! |! |! |! |! |! |! |! |! |! |! |!
strokes from the heel of the foot upward toward the ball, the infant exhibits
|! |! |! |! |! |! |! |! |! |! |! |! |! |!
no movement. Which action is the priority for the nurse?
|! |! |! |! |! |! |! |! |! |!
A. take the infant's vital signs
|! |! |! |! |! |!
B. order a neurology consult
|! |! |! |!
C. examine the infant's nose and ears
|! |! |! |! |! |! |!
D. ask how much formula the infant consumes daily - Correct answer ✔b.
|! |! |! |! |! |! |! |! |! |! |! |! |!
order a neurology consult |! |! |!
The nurse is caring for a client with COPD who complains of poor quality of
|! |! |! |! |! |! |! |! |! |! |! |! |! |! |!
sleep. Which question should the nurse ask next?
|! |! |! |! |! |! |!
