Answers | Graded A+
1. A nurse is preparing to measure a client's blood glucose level but notices the
client has cold hands. What should the nurse do to ensure an accurate
reading?
Use a different site for the blood sample.
Warm the client's hands to promote blood flow before puncturing
the finger.
Test the blood glucose level without any preparation.
Puncture the finger immediately to avoid delay.
2. Describe the importance of ensuring that the weights in Buck's traction are
hanging freely.
It helps in monitoring the patient's vital signs more effectively.
It allows for easier access to the pin insertion sites.
It ensures that the weight is appropriate for the patient's size.
It prevents unnecessary pressure on the fracture site and maintains
proper alignment.
3. A nurse is preparing to assess a 2-year-old toddler. Which of the following
behaviors should the nurse expect during the examination?
The child questions how her development compares to other children
at the same age
The child asks specific questions about body functions
The child is interested in how the examination equipment works
The child prefers to sit on the parent's lap during the examination
,4. The client with vancomycin-intermediate-resistant staphylococcus aureus
VISA is admitted to the nursing unit. What type of precautions should the
nurse institute?
neutropenic precautions
droplet precautions
standard precaution
contact precautions
5. What type of isolation precautions is required for a client with pulmonary
tuberculosis?
Protective
Droplet
Contact
Airborne
6. Why is it important for a client undergoing radiation therapy to avoid
exposing the neck to cold temperatures?
Cold exposure has no effect on the treatment process.
Cold temperatures can enhance the effectiveness of radiation therapy.
Cold temperatures help reduce swelling in the area.
Cold exposure can exacerbate skin sensitivity and irritation caused
by radiation.
7. Why is it critical for the nurse to prioritize the client with schizophrenia
experiencing command hallucinations over the others?
, The client with schizophrenia and command hallucinations may be
at risk of harm due to the nature of the hallucinations.
The client with depressive disorder needs social interaction.
The client with ADHD requires immediate medication adjustment.
The client with bipolar disorder is more unstable than the others.
8. A client taking digoxin reports feeling unusually fatigued and weak. What
should the nurse do next?
Suggest the client take a break from their medication.
Encourage the client to increase their fluid intake.
Instruct the client to eat more potassium-rich foods.
Assess the client's pulse and check for signs of digoxin toxicity.
9. In a scenario where a terminally ill patient exhibits decreased energy levels,
what should the nurse's priority action be?
Encourage the patient to engage in physical activities.
Focus solely on pain management.
Assess the patient's emotional state and provide support.
Immediately refer the patient for psychological evaluation.
10. If a nurse finds that the weights in Buck's traction are resting on the floor,
what immediate action should the nurse take?
Check the client's circulation every hour.
Increase the weight to 12 kg (26 lb) for better traction.
Adjust the weights to ensure they are hanging freely.
Notify the physician immediately.
, 11. If a client who had a right total hip arthroplasty begins to cross their legs
despite being advised against it, what potential complication should the
nurse monitor for?
Deep vein thrombosis
Hip dislocation
Delayed wound healing
Infection at the surgical site
12. What is one key instruction a nurse should provide to a family of a client with
dependent personality disorder?
Encourage the client to be assertive
Limit the client's social interactions
Maintain a verbal no-harm contract with the client
Assume responsibility for making the client's decisions
13. Why is the statement 'I would rather be alone than with my friends'
considered a priority for the nurse to address?
It suggests the client is managing stress well and does not need
support.
It reflects a common issue among adolescents that is not concerning.
It shows normal adolescent behavior and does not need immediate
attention.
It may indicate feelings of loneliness or depression that require
further assessment.
14. When dealing with a patient's confidential health information, a nurse must: