QUESTIONS AND ANSWERS
Asnursesissevaluatingsasclient'ssusesofsascane.sWhichsofsthesfollowingsactionssshouldsthesn
ursesidentifysassansindicationsofscorrectsuse?
1.sThestopsofsthescanesissparallelstosthesclient'sswaist.
2.sWhenswalking,sthesclientsmovessthescanes46scms(18sin)sforward.
3.sThesclientsholdssthescanesonsthesstrongerssidesofshersbody.
4.sThesclientsmovesshersstrongerslimbsforwardswithsthescane.s-sans✔✔3
Thesclientsshouldsholdsthescanesonsthesstrongerssidesofshersbodystosincreasessupportsands
maintainsalignment.
Asnursesreceivessasreportsaboutsasclientswhoshass0.9%ssodiumschloridesinfusingsIVsats125
mL/hr.sWhensthesnursesperformssthesinitialsassessment,shesnotessthatsthesclientshassrecei
vedsonlys80mLsoverstheslasts2shr.sWhichsofsthesfollowingsactionssshouldsthesnursestakesfirs
t?s
1.sRepositionsthesclient.
2.sDocumentsthesclient'ssIVsintakesinsthesmedicalsrecord.
3.sRequestsasnewsIVsfluidsprescription.
4.sChecksthesIVstubingsforsobstruction.s-sans✔✔4
Thesfirstsactionsthesnursesshouldstakesusingsthesnursingsprocesssisstosassesssthesclient.sIfs
checkingsthesIVstubingsandsverifyingsansobstruction,sthesnursesmightsbesablestosfacilitatest
hesflowsofsfluidsthroughsthestubing.sThisscouldsre-
establishsthesinfusionsratesthesprovidersprescribed.
AsnursesisscaringsforsasclientswhosrequiressansNGstubesforsstomachsdecompression.sWhic
hsofsthesfollowingsactionssshouldsthesnursestakeswhensinsertingsthesNGstube?
1.sPositionsthesclientswithsthesheadsofsthesbedselevatedstos30°spriorstosinsertionsofsthesNGst
ube.
2.sRemovesthesNGstubesifsthesclientsbeginsstosgagsorschoke.
3.sApplyssuctionstosthesNGstubespriorstosinsertion.
4.sHavesthesclientstakessipssofswaterstospromotesinsertionsofsthesNGstubesintosthesesophag
us.s-sans✔✔4
TakingssipssofswatersassthesNGstubespassessthroughsthesoropharynxswillsclosesthesepiglott
issoversthestracheasandspreventsthestubesfromspassingsintosthestrachea.
Asnursesissreviewingsasclient'ssfluidsandselectrolytesstatus.sWhichsofsthesfollowingsfindingss
shouldsthesnursesreportstosthesprovider?
1.sBUNs15smg/dL
2.sCreatinines0.8smg/dL
3.sSodiums143smEq/L
, 4.sPotassiums5.4smEq/Ls-sans✔✔4
Thissvaluesissabovesthesexpectedsreferencesrangesofs3.5stos5smEq/L,ssosthesnursesshoulds
reportsthissfindingstosthesprovider.sThissclientsissatsrisksforsdysrhythmias.
Asnursesissprovidingsdischargesinstructionsstosasclientswhoswillsbesusingsaswalker.sWhichso
fsthesfollowingsclientsstatementssindicatessansunderstandingsofsthesteaching?
1."Iscansplacesansextensionscordsacrosssmyslivingsroomstosplugsinsmystelevision."
2.s"Iswillshiressomeonestostrimsthestreesthatshangsslowsoversthesstairssofsmysfrontsporch."
3.s"Iswillsplacesmysalarmsclocksonsmysbedroomsdressersacrosssthesroom."
4.s"Iswillsreplacesthesoldsthrowsrugsinsmyskitchenswithsasnewsone."s-sans✔✔2
Clearingsstairssofsanysobjectsthatscouldscausesthesclientstostripsorsrequiresthemstosbendsov
erswhileswalkingswillsdecreasesthesrisksforsfalls.
Asnursesissplanningscaresforsasclientswhoshasshadsasstroke,sresultingsinsaphasiasandsdysph
agia.sWhichsofsthesfollowingstaskssshouldsthesnursesassignstosansassistivespersonnel?sSA
TA
1.sAssiststhesclientswithsaspartialsbedsbath.
2.sMeasuresthesclient'ssBPsaftersthesnursesadministerssansantihypertensivesmedication.
3.sTeststhesclient'ssswallowingsabilitysbysprovidingsthickenedsliquids.
4.sUsesascommunicationsboardstosaskswhatsthesclientswantssforslunch.
5.sIrrigatesthesclient'ssindwellingsurinaryscatheter.s-sans✔✔1,s2,s4
AssistingsasclientswithsasbedsbathsposessminimalsriskstosthesclientsandsisswithinsthesAP'ssra
ngesofsfunction.
Measuringsasclient'ssBPsposessminimalsriskstosthesclientsandsisswithinsthesAP'ssrangesofsfu
nction.
UsingsascommunicationsboardsposessminimalsriskstosthesclientsandsisswithinsthesAP'ssrang
esofsfunction.
Asnursesisscaringsforsasclientswhosissexpressingsangersaboutshissdiagnosissofscolorectalsca
ncer.sWhichsofsthesfollowingsactionssshouldsthesnursestake?
1.sDiscusssthesrisksfactorssforscolonscancer.
2.sFocussteachingsonswhatsthesclientswillsneedstosdosinsthesfuturestosmanageshissillness.
3.sProvidesthesclientswithswrittensinformationsaboutsthesphasessofslosssandsgrief.
4.sReassuresthesclientsthatsthississansexpectedsresponsestosgrief.s-sans✔✔4
Duringsthesangersstagesofsthesclient'sspsychosocialsadaptationstosillness,sthesnursesshould
ssupportsthesclientsandsexplainsthatsthississansexpectedsreactionstosascancersdiagnosis.
Asnursesisspreparingstosapplysasdressingsforsasclientswhoshassasstages2spressuresinjury.sW
hichsofsthesfollowingstypessofsdressingssshouldsthesnursesuse?s
1.sAlginate
2.sGauze
3.sTransparent
4.sHydrocolloids-sans✔✔4
Hydrocolloidsdressingsspromoteshealingsinsstages2spressuresinjuriessbyscreatingsasmoists
woundsbed.