Newest Version Questions with Answers
A nurse is providing teaching to a client who is on protective isolation precautions.
Which client statement indicates an understanding of the teaching? - ANSWER-I will
wear a face mask when leaving my hospital room
A nurse is preparing a heparin infusion for a client who was hospitalized with deep-vein
thrombosis. The order reads: 25,000 units of heparin in 250 mL of 0.9% sodium chloride
to infuse at 800 units/hr. At what rate should the nurse set the infusion pump? (Round
the answer to the nearest whole number. Use a leading zero if it applies. Do not use a
trailing zero - ANSWER-"8 mL/hr"(800/25,000)x250 mL STEP 1: What is the unit of
measurement the nurse should calculate? mL/hr STEP 2: What is the dose the nurse
should administer? Dose to administer = Desired 800 units/hr STEP 3: What is the dose
available? Dose available = Have 25,000 units STEP 4: Should the nurse convert the
units of measurement? No STEP 5: What is the quantity of the dose available? 250 mL
STEP 6: Set up an equation and solve for X. Desired x Quantity/Have = X mL800 units
x 250 mL/25,000 units = X mLX = 8 mL / hr
A nurse is performing a Romberg test during the physical assessment of a client. Which
of the following techniques should the nurse use? - ANSWER-Have the client stand with
their arms at their sides and their feet together.
A nurse is administering an otic medication to an older adult client. Which of the
following actions should the nurse take to ensure that the medication reaches the inner
ear? - ANSWER-Press gently on the tragus of the client's ear.
A nurse is caring for a client who has decreased mobility. Which action should the nurse
take to decrease the clients risk of developing plantar flexion contractures? - ANSWER-
Apply an ankle-foot orthotic device to the clients feet
A nurse is preparing to administer an injection of an opioid medication to a client. The
nurse draws out 1mL of the medication from a 2mL vial. Which action should the nurse
take? - ANSWER-Ask another nurse to observe the medication wastage
A nurse is planning strategies to manage time effectively for client care. Which of the
following strategies should the nurse implement? - ANSWER-Use the planning step of
the nursing process to prioritize client care delivery. Setting up a list of goals and tasks
to perform for clients can help the nurse set care priorities and plan tasks accordingly.
The priority to-do list is an efficient tool for optimal time management.
A nurse is giving change-of-shift report about a client they admitted earlier that day who
has pneumonia. Which of the following pieces of information is the priority for the nurse
to provide? - ANSWER-Breath sounds When using the airway, breathing, circulation
, approach to client care, the nurse should determine that the priority information to
provide is the current status of the client's breath sounds.
A nurse is caring for a client who has herpes zoster and asks the nurse about the use of
complementary and alternative therapies for pain control. the nurse should inform the
client that his condition is a contraindication for which? - ANSWER-acupuncture-
contradiction with someone with any skin disease, to prevent and open portal on the
skins surface, which could increase furth infection
A nurse is educating a client who has a terminal illness about declining resuscitation in
a living will. The client asks, "What would happen if I arrived at the emergency
department and I had difficulty breathing?" Which of the following responses should the
nurse make? - ANSWER-"We would give you oxygen through a tube in your nose"
A nurse is calculating a client's fluid intake over the past 8 hr. Which of the following
items should the nurse plan to document on the client's intake and output record as 120
mL of fluid? A. 2 cups of soup B. 1 quart of water C. 8 oz of ice chips D. 6 oz of tea -
ANSWER-8 oz ice chips
A nurse is caring for a client who is expressing anger about his diagnosis of colorectal
cancer. Which of the following actions should the nurse take? - ANSWER-Reassure the
client that this is an expected response to grief
A nurse is planning to insert a peripheral IV catheter for an older adult client. Which of
the following actions should the nurse plan to take? - ANSWER-Place the client's arm in
a dependent position
A nurse is reviewing a evidence based practice principles about administration of
oxygen therapy with a newly licensed nurse . Which of the following actions should the
nurse include ? - ANSWER-Regulate oxygen via nasal canal at a flow rate of no more
then 6L/ min
A nurse is caring for a client who had a spinal cord injury and has paraplegia. Select all
that apply that require intervention by the nurse: - ANSWER-Passive range-of-motion
exercises to lower extremities performed once each day is correct. The nurse should
perform passive range-of-motion exercises to the client's lower extremities two to three
times each day to reduce the risk for contractures-Plantar flexion contractures noted
bilaterally is correct. The nurse should place a footboard at the end of the client's bed or
apply foot boots to the client's feet to protect the client's heels and decrease the
contractures.-Left heel with 1.3 cm x 1.3 cm (0.5 in x 0.5 in) area of nonblanchable
erythema, skin intact is correct. The client has a stage 1 pressure injury on the heel.
The nurse should apply foot boots to the client's feet to protect the client's heels and
promote healing.
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