,A nurse is teaching a newly licensed Ensure the urinary catheter tubing is not kinked.
nurse about preventing a catheter-
associated urinary tract infection for Rationale: The nurse should instruct the newly
a client who has an indwelling licensed nurse to make certain the catheter tubing
urinary catheter. Which of the is free of kinks, which could cause a blockage of
following instructions should the urinary flow and result in a urinary tract infection.
nurse include?
A nurse is planning wound Measure the depth of the wound with a cotton-
management for a client who has a tipped applicator.
stage 3 pressure injury. Which of the
following interventions should the Rationale: The nurse should plan to reapply new
nurse include in the plan? dressings after checking the depth of the wound
for tunneling using a cotton-tipped applicator.
A nurse is planning care for four A client who has peptic ulcer disease and a rigid
clients following change of shift abdomen.
report. Which of the following clients
is the nurses priority? Rationale: When using the stable vs. unstable
approach to client care, the nurse should assess
this client first. A client who has peptic ulcer
disease and a rigid abdomen is unstable. A rigid
abdomen is a manifestation of a perforated peptic
ulcer and could lead to septicemia and shock.
A nurse is planning care for four A client who has a pacemaker and has a persistent
clients following change of shift hiccupping.
report. Which of the following clients
is the nurse to see first? Rationale: When using the urgent vs. nonurgent
approach to client care, the nurse determines that
the priority client to see is the client who has a
pacemaker and has persistent hiccupping.
Hiccupping is a manifestation of a dislocation of
the pacemaker lead and could lead to bradycardia
and decreased cardiac output.
, A nurse is reviewing the lab data of a Platelet count 100,000/mm3
client who is taking the herbal
supplement feverfew to reduce the Rationale: Feverfew can lead to platelet
frequency of migraine headaches. dysfunction by suppressing platelet aggregation. A
The nurse should identify that which client who has a decreased platelet count should
of the following indicates a potential not take feverfew because this can increase the risk
contraindication to taking this herbal of bleeding. Clients should monitor for bleeding
supplement? and impaired coagulation while taking feverfew.
A nurse is providing dietary teaching I will use homemade vinegar and oil dressings on
to a client who has heart failure. The my salads.
nurse should identify which of the
following client statements an Rationale: A client who has heart failure should
understanding of the teaching? make foods at home to maintain a low-sodium diet.
The client should use homemade vinegar and oil
dressings in place of bottled salad dressing to
reduce sodium intake.
Diet: low sodium or no added salt
A nurse is caring for a client who is Shiny area on the clients ankles and feet.
post operative ad has a history of
heart failure. The client reports slight Rationale: Edema, fluid leaking into interstitial
dyspnea when ambulating. Which of spaces, is an expected finding for a client who has
the following findings should the a history of heart failure and is experiencing slight
nurse expect when performing a skin dyspnea with exertion. Edematous skin appears
assessment? taut and shiny, and can also look swollen and
blanched.
A hospice nurse is planning end of Position the client on their side to improve
life care for a client. Which of the breathing.
following interventions should the
nurse include in the plan? Rationale: The nurse should include to position the
client laterally to improve breathing and promote
comfort.
nurse about preventing a catheter-
associated urinary tract infection for Rationale: The nurse should instruct the newly
a client who has an indwelling licensed nurse to make certain the catheter tubing
urinary catheter. Which of the is free of kinks, which could cause a blockage of
following instructions should the urinary flow and result in a urinary tract infection.
nurse include?
A nurse is planning wound Measure the depth of the wound with a cotton-
management for a client who has a tipped applicator.
stage 3 pressure injury. Which of the
following interventions should the Rationale: The nurse should plan to reapply new
nurse include in the plan? dressings after checking the depth of the wound
for tunneling using a cotton-tipped applicator.
A nurse is planning care for four A client who has peptic ulcer disease and a rigid
clients following change of shift abdomen.
report. Which of the following clients
is the nurses priority? Rationale: When using the stable vs. unstable
approach to client care, the nurse should assess
this client first. A client who has peptic ulcer
disease and a rigid abdomen is unstable. A rigid
abdomen is a manifestation of a perforated peptic
ulcer and could lead to septicemia and shock.
A nurse is planning care for four A client who has a pacemaker and has a persistent
clients following change of shift hiccupping.
report. Which of the following clients
is the nurse to see first? Rationale: When using the urgent vs. nonurgent
approach to client care, the nurse determines that
the priority client to see is the client who has a
pacemaker and has persistent hiccupping.
Hiccupping is a manifestation of a dislocation of
the pacemaker lead and could lead to bradycardia
and decreased cardiac output.
, A nurse is reviewing the lab data of a Platelet count 100,000/mm3
client who is taking the herbal
supplement feverfew to reduce the Rationale: Feverfew can lead to platelet
frequency of migraine headaches. dysfunction by suppressing platelet aggregation. A
The nurse should identify that which client who has a decreased platelet count should
of the following indicates a potential not take feverfew because this can increase the risk
contraindication to taking this herbal of bleeding. Clients should monitor for bleeding
supplement? and impaired coagulation while taking feverfew.
A nurse is providing dietary teaching I will use homemade vinegar and oil dressings on
to a client who has heart failure. The my salads.
nurse should identify which of the
following client statements an Rationale: A client who has heart failure should
understanding of the teaching? make foods at home to maintain a low-sodium diet.
The client should use homemade vinegar and oil
dressings in place of bottled salad dressing to
reduce sodium intake.
Diet: low sodium or no added salt
A nurse is caring for a client who is Shiny area on the clients ankles and feet.
post operative ad has a history of
heart failure. The client reports slight Rationale: Edema, fluid leaking into interstitial
dyspnea when ambulating. Which of spaces, is an expected finding for a client who has
the following findings should the a history of heart failure and is experiencing slight
nurse expect when performing a skin dyspnea with exertion. Edematous skin appears
assessment? taut and shiny, and can also look swollen and
blanched.
A hospice nurse is planning end of Position the client on their side to improve
life care for a client. Which of the breathing.
following interventions should the
nurse include in the plan? Rationale: The nurse should include to position the
client laterally to improve breathing and promote
comfort.
