,A nurse is caring for a client who has D
visual loss. Which os the following Orient the client to the room to reduce the risk of
actions should the nurse implement? falls
A. Remove all objects from the
client's bedside table
B. Instruct the client to open items in
the food tray
C. Walk a step behind the client
when assisting with ambulation
D. Count steps to the bathroom with
the client
A nurse is discussing activity B
modification with a client who had a Prevent adduction of the hip and possible
right total hip arthroplasty. Which of dislocation
the following statements should the
nurse include in the information?
A. Plan to sit in a straight-backed
chair when out of bed
B. Place a pillow between your legs
when lying in bed
C. You can cross your legs at the
ankles when sitting
D. You should bend at the waist
when tying your shoes
,A nurse is teaching a newly licensed A
nurse about preventing a catheter- Kinks can cause blockage of urinary flow and result
associated urinary tract infection for in a UTI
a client who has an indwelling
urinary catheter. Which of the
following instructions should the
nurse include?
A. Ensure the urinary catheter tubing
is not kinked
B. Rest the catheter bag on the floor
when the client is sitting in a chair
C. Clean the perineal area with an
antiseptic solution
D. Empty the collection bag for the
client every 12 hr
A nurse is planning wound A
management for a client who has a Check wound for tunneling
stage 3 pressure injury. Which of the
following interventions should the
nurse include in the plan?
A. Measure the depth of the wound
with a cotton-tipped applicator
B. Measure the wound using a
reusable tape measure
C. Cover the wound bed with dry
gauze dressings
D. Cleanse the wound with soap and
water
, A nurse is planning care for four D
clients following chase-of-shift The client is unstable and a rigid abdomen is a
report. Which of the following clients manifestation of a perforated peptic ulcer and
is the nurse's priority? could lead to septicemia and shock.
A. A client who had a stroke and has
expressive aphasia
B. A client who has a hemoglobin of
11g/dL and requires 1 unit of blood
C. A client who has asthma and a
peak expiratory flow rate in the
green zone
D. A client who has peptic ulcer
disease and a rigid abdomen
A nurse is planning care for four C
clients following chase-of-shift Hiccuping is a manifestation of a dislocation of the
report. Which of the following clients pacemaker lead and could lead to bradycardia and
should the nurse see first? decreased CO
A. A client who is receiving
propranolol and has a HR of 55/min
B. A client who is receiving warfarin
and has an INR of 2.5
C. A client who has a pacemaker and
has persistent hiccuping
D. A client who has cholecystitis and
reports rebound tenderness
visual loss. Which os the following Orient the client to the room to reduce the risk of
actions should the nurse implement? falls
A. Remove all objects from the
client's bedside table
B. Instruct the client to open items in
the food tray
C. Walk a step behind the client
when assisting with ambulation
D. Count steps to the bathroom with
the client
A nurse is discussing activity B
modification with a client who had a Prevent adduction of the hip and possible
right total hip arthroplasty. Which of dislocation
the following statements should the
nurse include in the information?
A. Plan to sit in a straight-backed
chair when out of bed
B. Place a pillow between your legs
when lying in bed
C. You can cross your legs at the
ankles when sitting
D. You should bend at the waist
when tying your shoes
,A nurse is teaching a newly licensed A
nurse about preventing a catheter- Kinks can cause blockage of urinary flow and result
associated urinary tract infection for in a UTI
a client who has an indwelling
urinary catheter. Which of the
following instructions should the
nurse include?
A. Ensure the urinary catheter tubing
is not kinked
B. Rest the catheter bag on the floor
when the client is sitting in a chair
C. Clean the perineal area with an
antiseptic solution
D. Empty the collection bag for the
client every 12 hr
A nurse is planning wound A
management for a client who has a Check wound for tunneling
stage 3 pressure injury. Which of the
following interventions should the
nurse include in the plan?
A. Measure the depth of the wound
with a cotton-tipped applicator
B. Measure the wound using a
reusable tape measure
C. Cover the wound bed with dry
gauze dressings
D. Cleanse the wound with soap and
water
, A nurse is planning care for four D
clients following chase-of-shift The client is unstable and a rigid abdomen is a
report. Which of the following clients manifestation of a perforated peptic ulcer and
is the nurse's priority? could lead to septicemia and shock.
A. A client who had a stroke and has
expressive aphasia
B. A client who has a hemoglobin of
11g/dL and requires 1 unit of blood
C. A client who has asthma and a
peak expiratory flow rate in the
green zone
D. A client who has peptic ulcer
disease and a rigid abdomen
A nurse is planning care for four C
clients following chase-of-shift Hiccuping is a manifestation of a dislocation of the
report. Which of the following clients pacemaker lead and could lead to bradycardia and
should the nurse see first? decreased CO
A. A client who is receiving
propranolol and has a HR of 55/min
B. A client who is receiving warfarin
and has an INR of 2.5
C. A client who has a pacemaker and
has persistent hiccuping
D. A client who has cholecystitis and
reports rebound tenderness
