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1. Why is it important for a client using a 4-point crutch gait to bear weight on
both legs?
Bearing weight on both legs provides stability and balance during
ambulation.
It reduces the risk of falling by shifting weight to one side.
It allows the client to rest their arms while walking.
It helps in strengthening the upper body muscles.
2. What is the first step an assistive personnel should take before transferring a
client from a bed to a wheelchair?
Locking the brakes on the bed and the wheelchair before moving
the client
Lowering the footplates of the wheelchair before the transfer
Placing the wheelchair perpendicular to the bed
Placing the wheelchair on the client's weaker side prior to the transfer
3. Why is the response 'Do you feel like you don't deserve to feel good about
yourself?' considered appropriate for a client with major depressive
disorder?
This response diverts the conversation away from the client's feelings.
This response suggests that the nurse understands the client's
situation without further exploration.
This response implies that the client should simply wait for
improvement.
, This response encourages the client to explore their feelings of self-
worth and addresses underlying issues related to their depression.
4. Which of the following must be confirmed by the nurse before administering
packed RBCs? (Select all that apply)
A) The client's ID number, C) The client's name, D) ABO compatibility,
E) Rh compatibility
C) The client's name, E) Rh compatibility
D) The client's ID number, B) The client's room number
B) The client's room number, D) ABO compatibility
5. Why is it important for a newly licensed nurse to have another nurse observe
the disposal of a controlled substance?
It allows the nurse to avoid responsibility for the medication.
It simplifies the documentation process for medication administration.
It ensures accountability and adherence to safety protocols in
medication disposal.
It is a requirement for all medication types, not just controlled
substances.
6. Describe the rationale behind using inspection as the first method of
abdominal assessment.
Inspection is primarily used to measure abdominal girth.
Inspection is used to listen for bowel sounds after palpating the
abdomen.
Inspection allows the nurse to visually assess the abdomen for any
abnormalities before proceeding with other methods.
, Inspection is the final step in the abdominal assessment process.
7. Why is it important for a nurse to assess a client's level of comfort during the
introductory phase of an admission interview?
It allows the nurse to skip unnecessary questions.
It helps in diagnosing the client's medical condition.
Assessing the client's comfort level ensures effective
communication and participation in the interview process.
It is a requirement for legal documentation.
8. What symptom indicates psychological distress in a patient undergoing
cancer treatment?
Nightmares about surgery
Support from family
Receiving gifts from friends
Counseling with spouse
9. What is the recommended action for a nurse when an electronic blood
pressure machine provides inconsistent readings?
Disconnect the machine and measure the blood pressure manually
every 15 min
Record only the highest reading from the machine
Adjust the machine settings to improve accuracy
Continue using the machine without any changes
10. A nurse is caring for a client undergoing chemotherapy who reports
persistent nausea and decreased appetite. Which strategy should the nurse
, implement to enhance the client's nutritional intake?
Suggest the client drink a large glass of water before meals.
Instruct the client to lie down after eating to aid digestion.
Advise the client to eat large meals to increase calorie intake.
Encourage small, frequent meals without liquids.
11. A nurse is caring for a client with acute kidney failure. The nurse understands
that the most accurate indicator of fluid loss or gain in an acutely ill client is
which of the following?
Weight
Blood pressure
Edema
Heart rate
12. A client who is unstable and requires frequent vital signs has an
ELECTRONIC BP MACHINE automatically measuring his bp EVERY 15 MIN.
However, the machine is reading the client's BP at MORE FREQUENT
INTERVALS AND THE READINGS ARE NOT SIMILAR. The nurse checks the
machine settings and observes the additional readings, but the PROBLEM
CONTINUES. Which of the following is the APPROPRIATE nursing action?
Turn on the machine every 15 min to obtain client's BP
Record only those BP readings needed for the 15-min intervals
Disconnect the machine and measure the bp manually every 15
minutes
Obtain both manual and automatic readings and compare them