A nurse is collecting data from a client who has an elevated temperature with no sweating.
Which of the following findings is an indication of hypernatremia?
Thirst
Muscle twitching
Headache
Abdominal cramps - ANSWER Answer: Thirst.
Rationale: Thirst, combined with an elevated temperature and a lack of sweating, can be an
indication of hypernatremia.
A nurse is caring for a client who reports difficulty sleeping due to the noise on the nursing
unit. Which of the following actions should the nurse take to reduce environmental noise?
Close the door to the client's room.
Turn off the alarms and beeps on monitoring equipment.
Conduct change-of-shift report outside the client's door.
Keep the television on low in the client's room. - ANSWER Answer: Close the door
to the client's room.
Rationale: The nurse should close the door to the client's room whenever possible to reduce
environmental noise.
1
,A nurse is reinforcing teaching about health promotion with a client. Which of the following
actions should the nurse take first to promote effective learning?
Identify areas of concern.
Prioritize learning objectives.
Demonstrate psychomotor skills.
Observe nonverbal communication. - ANSWER Answer: Identify areas of concern.
Rationale: The first action the nurse should take when using the nursing process is to collect
data from the client. Identifying and understanding the client's concerns prior to reinforcing
teaching promotes effective learning.
A home health nurse is assisting with the plan of care for a client. Which of the following
should the nurse include during the orientation phase of the helping relationship?
Review current client data.
Assist to meet client goals.
Review shared memories of interactions with client.
Clarify the role of this individual nurse. - ANSWER Answer: Clarify the role of this
individual nurse.
Rationale: The nurse should plan to establish a warm, caring relationship while clarifying the
role of each participant, which occurs during the orientation phase of the relationship.
A nurse is preparing to assist with the admission of a client who has pneumonia. Which of
the following observations about the client's room requires immediate attention?
The wall BP gauge is missing.
2
, The room has no IV infusion pump.
The examination light above the bed does not work.
The wheel locks on the bed are malfunctioning. - ANSWER Answer: The wheel
locks on the bed are malfunctioning.
Rationale: The greatest risk to this client is injury from a fall when getting into or out of a bed
that is unstable due to malfunctioning locks. Therefore, the priority is to report and replace
the bed before admitting the client to the room.
A nurse is reinforcing teaching about health promotion with an older adult client. Which of
the following instructions to the client is an example of secondary prevention?
Participate in screenings for tuberculosis.
Follow dietary recommendations to reduce the risk for osteoporosis.
Limit alcohol intake to one drink per day.
Perform yoga exercises three times per week. - ANSWER Answer: Participate in
screenings for tuberculosis.
Rationale: The nurse should encourage the client to participate in screenings for
tuberculosis, a secondary prevention measure. Secondary prevention measures focus on
diagnosis and early intervention.
A licensed practical nurse (LPN) is receiving change-of-shift report for a client who had a
stroke. For which of the following tasks should the nurse request assistance from a
registered nurse (RN)?
Administering a cleansing enema
Staging a pressure ulcer
Inserting an indwelling urinary catheter
3
Which of the following findings is an indication of hypernatremia?
Thirst
Muscle twitching
Headache
Abdominal cramps - ANSWER Answer: Thirst.
Rationale: Thirst, combined with an elevated temperature and a lack of sweating, can be an
indication of hypernatremia.
A nurse is caring for a client who reports difficulty sleeping due to the noise on the nursing
unit. Which of the following actions should the nurse take to reduce environmental noise?
Close the door to the client's room.
Turn off the alarms and beeps on monitoring equipment.
Conduct change-of-shift report outside the client's door.
Keep the television on low in the client's room. - ANSWER Answer: Close the door
to the client's room.
Rationale: The nurse should close the door to the client's room whenever possible to reduce
environmental noise.
1
,A nurse is reinforcing teaching about health promotion with a client. Which of the following
actions should the nurse take first to promote effective learning?
Identify areas of concern.
Prioritize learning objectives.
Demonstrate psychomotor skills.
Observe nonverbal communication. - ANSWER Answer: Identify areas of concern.
Rationale: The first action the nurse should take when using the nursing process is to collect
data from the client. Identifying and understanding the client's concerns prior to reinforcing
teaching promotes effective learning.
A home health nurse is assisting with the plan of care for a client. Which of the following
should the nurse include during the orientation phase of the helping relationship?
Review current client data.
Assist to meet client goals.
Review shared memories of interactions with client.
Clarify the role of this individual nurse. - ANSWER Answer: Clarify the role of this
individual nurse.
Rationale: The nurse should plan to establish a warm, caring relationship while clarifying the
role of each participant, which occurs during the orientation phase of the relationship.
A nurse is preparing to assist with the admission of a client who has pneumonia. Which of
the following observations about the client's room requires immediate attention?
The wall BP gauge is missing.
2
, The room has no IV infusion pump.
The examination light above the bed does not work.
The wheel locks on the bed are malfunctioning. - ANSWER Answer: The wheel
locks on the bed are malfunctioning.
Rationale: The greatest risk to this client is injury from a fall when getting into or out of a bed
that is unstable due to malfunctioning locks. Therefore, the priority is to report and replace
the bed before admitting the client to the room.
A nurse is reinforcing teaching about health promotion with an older adult client. Which of
the following instructions to the client is an example of secondary prevention?
Participate in screenings for tuberculosis.
Follow dietary recommendations to reduce the risk for osteoporosis.
Limit alcohol intake to one drink per day.
Perform yoga exercises three times per week. - ANSWER Answer: Participate in
screenings for tuberculosis.
Rationale: The nurse should encourage the client to participate in screenings for
tuberculosis, a secondary prevention measure. Secondary prevention measures focus on
diagnosis and early intervention.
A licensed practical nurse (LPN) is receiving change-of-shift report for a client who had a
stroke. For which of the following tasks should the nurse request assistance from a
registered nurse (RN)?
Administering a cleansing enema
Staging a pressure ulcer
Inserting an indwelling urinary catheter
3
