QUESTIONS AND CORRECT ANSWERS (VERIFIED
ANSWERS) |AGRADE
When turning an immobile bedridden client without assistance, which action by the nurse best
ensures client safety?
A. Securely grasp the client's arm and leg.
B. Put bed rails up on the side of bed opposite from the nurse.
C. Correctly position and use a turn sheet.
D. Lower the head of the client's bed slowly.
B
Rationale: Because the nurse can only stand on one side of the bed, bed rails should be up on the
opposite side to ensure that the client does not fall out of bed. Option A can cause client injury to the
skin or joint. Options C and D are useful techniques while turning a client but have less priority in terms
of safety than use of the bed rails.
A health care provider has prescribed isoniazid (Laniazid) for a client. Which instruction should the
nurse give the client about this medication?
1
Prolonged use can cause dark concentrated urine.
2
The medication is best absorbed when taken on an empty stomach.
3
Take the medication with aluminum hydroxide to minimize GI upset.
4
Drinking alcohol daily can cause drug-induced hepatitis
4
Daily alcohol intake can cause drug induced hepatitis. Prolonged use does not cause dark concentrated
urine. The client should take isoniazid with meals to decrease GI upset. Clients should avoid taking
aluminum antacids at the same time as this medication because it impairs absorption.
To minimize the side effects of the vincristine (Oncovin) that a client is receiving, what does the nurse
expect the dietary plan to include?
1
,Low in fat
2
High in iron
3
High in fluids
4
Low in residue
3
A common side effect of vincristine is a paralytic ileus that results in constipation. Preventative
measures include high-fiber foods and fluids that exceed minimum requirements. These will keep the
stool bulky and soft, thereby promoting evacuation. Low in fat, high in iron, and low in residue dietary
plans will not provide the roughage and fluids needed to minimize the constipation associated with
vincristine.
A postoperative client says to the nurse, "My neighbor, I mean the person in the next room, sings all
night and keeps me awake." The neighboring client has dementia and is awaiting transfer to a nursing
home. How can the nurse best handle this situation?
1
Tell the neighboring client to stop singing.
2
Close the doors to both clients' rooms at night.
3
Give the complaining client the prescribed as needed sedative.
4
Move the neighboring client to a room at the end of the hall
4
Moving the client who is singing away from the other clients diminishes the disturbance. A client with
dementia will not remember instructions. It is unsafe to close the doors of clients' rooms because they
need to be monitored. The use of a sedative should not be the initial intervention
The nurse is providing postoperative care to a client who had a submucosal resection (SMR) for a
deviated septum. The nurse should monitor for what complication associated with this type of
surgery?
Incorrect1
Occipital headache
2
Periorbital crepitus
3
Expectoration of blood
4
Changes in vocalization
3
After an SMR, hemorrhage from the area should be suspected if the client is swallowing frequently or
expelling blood with saliva. A headache in the back of the head is not a complication of a submucosal
,resection. Crepitus is caused by leakage of air into tissue spaces; it is not an expected complication of
SMR. The nerves and structures involved with speech are not within the operative area. However, the
sound of the voice is altered temporarily by the presence of nasal packing and edema.
A nurse is reviewing a plan of care for a client who was admitted with dehydration as a result of
prolonged watery diarrhea. Which prescription should the nurse question?
1
Oral psyllium (Metamucil)
2
Oral potassium supplement
3
Parenteral half normal saline
4
Parenteral albumin (Albuminar)
4
Albumin is hypertonic and will draw additional fluid from the tissues into the intravascular space. Oral
psyllium will absorb the watery diarrhea, giving more bulk to the stool. An oral potassium supplement is
appropriate because diarrhea causes potassium loss. Parenteral half normal saline is a hypotonic
solution, which can correct dehydration.
A nurse is preparing to administer an ophthalmic medication to a client. What techniques should the
nurse use for this procedure? Select all that apply.
1
Clean the eyelid and eyelashes.
2
Place the dropper against the eyelid.
3
Apply clean gloves before beginning of procedure.
4
Instill the solution directly onto cornea.
5
Press on the nasolacrimal duct after instilling the solution.
1,3,5
Cleaning of the eyelids and eyelashes helps to prevent contamination of the other eye and lacrimal duct.
Application of gloves helps to prevent direct contact of the nurse with the client's body fluids. Applying
pressure to the nasolacrimal duct prevents the medication from running out of the eye. The dropper
should not touch the eyelids or eyelashes in order to prevent contamination of the medication in the
dropper. The medication should not be instilled directly onto the cornea because cornea has many pain
fibers and is therefore very sensitive. The medication is to be instilled into the lower conjunctival sac.
The nurse recognizes that which are important components of a neurovascular assessment? Select all
that apply.
1
Orientation
2
, Capillary refill
3
Pupillary response
4
Respiratory rate
5
Pulse and skin temperature
6
Movement and sensation
2,5,6,
A neurovascular assessment involves evaluation of nerve and blood supply to an extremity involved in
an injury. The area involved may include an orthopedic and/or soft tissue injury. A correct neurovascular
assessment should include evaluation of capillary refill, pulses, warmth and paresthesias, and movement
and sensation. Orientation, pupillary response, and respiratory rate are components of a neurological
assessment.
A client reaches the point of acceptance during the stages of dying. What response should the nurse
expect the client to exhibit?
1
Apathy
2
Euphoria
3
Detachment
4
Emotionalism
3
When an individual reaches the point of being intellectually and psychologically able to accept death,
anxiety is reduced and the individual becomes detached from the environment. Although detached, the
client is not apathetic but still may be concerned and use time constructively. Although resigned to
death, the individual is not euphoric. In the stage of acceptance, the client is no longer angry or
depressed.
A dying client is coping with feelings regarding impending death. The nurse bases care on the theory
of death and dying by Kübler-Ross. During which stage of grieving should the nurse primarily use
nonverbal interventions?
1
Anger
2
Denial
3
Bargaining
4
Acceptance