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The nurse is caring for an adult client who suffered second
degree burns over 25% of their body in a house fire. Which
observation best indicates that fluid resuscitation has been
effective? 1Elastic, nontenting skin turgor 2Moist oral mucus
membranes
3Urine output of 35 mL per hour
4No reports of thirst - ANSWER-3
The goal is to maintain an hourly urine output of 0.5 mL/hour
(about 30 mL/hour) for the average adult.
Which of the following actions by the nurse indicates a need
for additional education on the prevention of health care-
associated infections (HAIs)? 1The nurse uses their own
stethoscope to assess the lung sounds of a client placed on
contact precautions for Methicillin-resistant Staphylococcus
aureus (MRSA) infection.
2The nurse calls the health care provider (HCP) to request the
removal of the indwelling urinary catheter for a two days
postoperative client.
,3The nurse cleanses hands with soap and water for 60 seconds
after caring for a client with Clostridium difficile (C. difficile)
infection.
4The nurse wears a gown and gloves when providing perineal
care to a client with Vancomycin-resistant Enterococci (VRE)
infection. - ANSWER-1
A client has been diagnosed with dysphagia due to a stroke.
What nursing
intervention should the nurse implement for
this client?
1Instruct the client to tilt their head back while
swallowing.
2Position the client in an upright position while
they are eating.
3Assist the client to drink
through a straw.
4Instruct the client to use sips of water to help wash down
food. - ANSWER-2
A client is transferred from the postanesthesia care unit (PACU)
to the medicalsurgical unit after an appendectomy. Which
action should the nurse on the medical-surgical unit perform
first?
1Ask the client about pain.
2Orient the client to the unit.
3Review the postoperative orders.
4Take the client's vital signs. - ANSWER-4
,The nurse is evaluating the effectiveness of a bowel training
program for a client with chronic constipation. Which
statements made by the client should the LPN/VN report to the
RN for additional teaching? - ANSWER-Bowel training
programs are designed to return defecation to normal. Fluid
intake should be 2.5 to 3 liters per day. The client should
increase fiber in their diet, and intake hot drinks just prior to
their normal bowel elimination time to facilitate normal bowel
function. A suppository treatment should be administered
about half an hour before the client's normal bowel elimination
time—inserting it just prior to bedtime will disturb the client's
sleep pattern. The client should be provided with privacy for
about 30 to 40 minutes and should sit on a commode or bedpan
whenever they have the urge to defecate.
An obese client tells the nurse, "I just started a diet and I am
eating no more than 800 calories a day." What information
should the nurse reinforce with the client?
1Very low-calorie diets often have severe and irreversible side
effects.
2Very low-calorie diets are adequate if balanced with fruits and
vegetables. 3Very low-calorie diets are intended for short-term
use only.
4Very low-calorie diets are appropriate for long-term weight
management. -
ANSWER-3
A 2-year-old child is brought to the pediatrician's office by the
parents, who report that the child has been having diarrhea for
, two days. What nutritional information should the nurse
provide to the parents?
1Keep the child fasting, give them nothing to eat, and return the
next day.
2Give the child only clear liquids and gelatin for 24 hours.
3Continue a regular diet and add electrolyte replacement
drinks.
4Give the child bananas, apples, rice and toast as tolerated. -
ANSWER-3
The nurse is providing care to an older adult client diagnosed
with bilateral pneumonia. Which intervention should the nurse
implement to best promote the client's comfort?
1Encourage visits from family and friends.
2Keep conversations short.
3Increase the client's oral fluid intake.
4Monitor vital signs frequently. - ANSWER-2
An 82-year-old male client is admitted with benign prostatic
hyperplasia (BPH).
Which finding by the nurse will require immediate action?
1Severe abdominal pain
2A bladder ultrasound value of 900 mL
3A heart rate of 110 bpm
4A blood pressure of 180/105 - ANSWER-2
The nurse is reviewing the laboratory results for a client
diagnosed with dehydration. Which result is most important to
communicate to the health care provider?