Updated 2026) Complete Questions & Answers
(Solved) 100% Correct
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A nurse is caring for a client who reports feeling a pop after
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coughing without properly splinting an abdominal incision. On
assessment, the nurse notes that the client's wound has
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eviscerated. Which of the following actions should the nurse
take? (Select all that apply.)
A. Carefully reinsert the intestine through the opening in the
wound.
B. Place the client in a supine position with the hips and knees
flexed.
C. Leave the room to call the surgeon.
,D. Cover the wound and intestine with a ster
B, D, E
A nurse on a medical-surgical unit is caring for a client. Which
of the following actions should the nurse prioritize when using
the nursing process?
A. Identify goals for client care.
B. Obtain client information.
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C. Document nursing care needs.
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D. Evaluate the effectiveness of care.
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B
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A nurse is preparing to administer a tap water enema to a
client. Which of the following actions should the nurse take?
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C
A. Raise the enema bag if the client experiences cramping.
B. Lubricate 2.54 cm (1 in) of the tip of the rectal tube prior to
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insertion.
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C. Place the client in a left Sims' position.
D. Don sterile
C
A client who reports shortness of breath requests the nurse's
help in changing positions. After repositioning the client, which
of the following actions should the nurse take next?
A. Encourage the client to take deep breaths.
,B. Observe the rate, depth, and character of the client's
respirations
C. Prepare to administer oxygen
D. Give the client a back rub to promote relaxation
B
A nurse is preparing to insert an indwelling catheter. Which of
the following instructions should the nurse give the client to
ease the passage of the catheter through the urinary meatus?
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A. "Bear down."
B. "Perform Kegel exercises."
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C. "Hold your breath."
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D. "Raise your head off of the pillow."
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A
C
A nurse is preparing to administer a feeding via a gastronomy
tube to a client who had a stroke. Which of the following
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actions should the nurse take prior to initiating the feeding?
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A. Warm the feeding in a microwave oven
B. Elevate the head of the client's bed
C. Flush the tube with 0.9% sodium chloride for irrigation
D. Verify that the client's gastric pH is above 4.
B
, A nurse is admitting a client who has measles. Which of the
following types of transmission precautions should the nurse
initiate?
A. Airborne
B. Droplet
C. Contact
D. Protective Equipment
D
A
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A nurse is caring for a client who reports not sleeping at night,
which interferes with her ability to function during the day.
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Which of the following interventions should the nurse suggest
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to the nurse to this client?
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A. Avoid beverages that contain caffeine
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B. Take a sleep medication regularly at bedtime
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C. Watch television for 30 minutes in bed to relax prior to
falling asleep
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D. Advise the client to take several naps during the day
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A nurse enters a client's room and finds the client sitting on the
floor and leaning against the side of the bed. The client states
she slipped while getting out of bed. Which of the following
actions should the nurse take first?