PN Fundamentals Online Practice 2020 B

A nurse is documenting client care in a client's electronic health record. Which of the following entries should the nurse include in the documentation? a) "Became short of breath when ambulating." 2) A nurse is caring for a client who has dysphagia following a stroke. Which of the following interventions should the nurse use when feeding the client? a) Instruct the client to tilt their head forward while eating. 3) A nurse is reinforcing teaching about advance directives with a client who has end-stage renal disease. Which of the following client statements indicates an understanding of the teaching? a) "I know that I can change my advance directives if I need to in the future (pt can change their advance directives at their discretion)." 4) A nurse is contributing to the plan of care for four clients. For which of the following clients should the nurse initiate airborne precautions? a) A client who has measles- virus is transmitted by direct contact with infectious droplets or by airborne spread when an infected person breathes, coughs, or sneezes (can remain infectious in the air for up to 2 hrs after an infected person leaves an area). b) Measles- infectious viral disease causing fever & a red rash on the skin, typically during childhood. 5) A nurse is caring for a client who has chronic kidney disease. The nurse should identify that which of the following findings is the priority to report to the provider? a) The client's output was 60 mL for the past 3 hr- using the urgent vs. nonurgent approach to client care, the nurse should determine that the priority finding to report to the provider is a urinary output of 60 mL over 3 hr. This finding represents oliguria and can indicate a decrease in kidney perfusion or function. 6) A nurse is caring for a client who is scheduled for surgery the following day. During the night, the client is unable to sleep and is restless. Which of the following statements should the nurse make? a) "It must be difficult facing this type of surgery."- Stating that it must be difficult to be in this position is an open-ended and nonjudgmental statement that allows the client to talk about their fears. 7) A nurse is reinforcing teaching with a client who has hypertension and a prescription to measure their blood pressure daily. Which of the following client statements indicates an understanding of the teaching? a) "I should remove constrictive clothing prior to measuring my blood pressure."- nurse should instruct the client to remove constrictive clothing prior to measuring their blood pressure because constrictive clothing can cause falsely elevated blood pressure readings. 8) A nurse is planning to perform intermittent urinary catheterization for a client who is unable to urinate. Which of the following actions should the nurse take first? a) Perform a bladder scan- 1st action the nurse should take when using the nursing process is to collect data from the client. Therefore, the nurse should evaluate the bladder contents before performing an invasive procedure. A bladder scan determines the amount of urine in the bladder and helps the nurse avoid unnecessary catheterizations. 9) A nurse in a long-term care facility is collecting admission data from a client who uses a hearing aid. Which of the following actions should the nurse take? a) Choose a private room for the interview- nurse should use a private room, which will minimize background noise so the client is able to hear what the nurse is saying. 10) A nurse is reinforcing teaching with a client who speaks a different language than the nurse. Which of the following actions should the nurse take? a) Use printed materials written in the client's language- nurse should use printed materials written in the client's language to reinforce teaching for the client and promote understanding. 11) A nurse is contributing to the plan of care for a client who practices Islam. Which of the following questions should the nurse ask the client to clarify the client's religious preferences? a) "Do you consume pork products?"- Some clients who practice Islam do not consume pork or alcohol. 12) A nurse working in a hospital overhears the following conversation between two other nurses on the elevator. Which of the following actions should the nurse take? a) Tell the nurses to change the topic of conversation- nurse has the responsibility to protect the client's right to confidentiality and should intervene on the client's behalf. A breach of client confidentiality can result in liability for those involved. 13) A nurse is reinforcing teaching with the partner of a client who is immobile. Which of the following instructions should the nurse give the partner about turning the client in bed? a) "Tighten your stomach muscles."- nurse should instruct the client's partner to tighten the abdominal and gluteal muscles to help protect their back.