A nurse is performing a home safety assessment for a client who is receiving
supplemental oxygen. Which of the following observations should the nurse identify as
proper safety protocol?
-The client uses a wool blanket on their bed.
-The client identifies the location of a fire extinguisher.
-The client stores an extra oxygen tank on its side under their bed.
-The client has a weekly inspection checklist for oxygen equipment. - CORRECT
ANSWERS The client identifies the location of a fire extinguisher.
-The client should be able to identify the location of fire extinguishers in the home and
be aware of how to use them.
A nurse is teaching a client and his family how to care for the client's tracheostomy at
home. Which of the following instructions should the nurse include in the teaching?
-Remove the outer cannula cautiously for routine cleaning.
-Use tracheostomy covers when outdoors.
-Use sterile techniques when performing tracheostomy care at home.
-Cleanse irritated skin with full-strength hydrogen peroxide. - CORRECT ANSWERS
Use tracheostomy covers when outdoors.
-Tracheostomy covers protect the client airway from cold air, dust, and other airborne
particles.
A home health nurse is performing a follow-up visit for a client who has a gastronomy
tube through which they receive intermittent feedings and medications. The client has
recently developed diarrhea. Which of the following findings should the nurse identify as
a possible cause of diarrhea?
-The client is receiving formula at room temperature.
-The feedings infuse at a slow, continuous drip over 8 hr each night.
-The clients caregiver washes out the feeding bag with warm water once every 24 hr.
-The clients caregiver flushes the tubing with water before and after administering
medications. - CORRECT ANSWERS The clients caregiver washes out the feeding
bag with warm water once every 24 hr.
-Feeding bags should be washed out after each feeding and replaced with a new
feeding bag every 24 hr to prevent bacterial contamination. The nurse should reinforce
this information with the clients caregiver to avoid future contamination.
,A nurse is assessing a client who reports increased pain following physical therapy.
Which of the following questions should the nurse ask when assessing the quality of the
client's pain?
-Is your pain constant or intermittent?
-What would you rate your pain as, on a scale of 0 to 10?
-Does the pain radiate?
-Is your pain sharp or dull? - CORRECT ANSWERS "Is your pain sharp or dull?"
-Asking the client whether the pain is sharp, dull, crushing, throbbing, aching, burning,
electric-like, or shooting helps determine the quality of the pain.
A nurse is talking with an older client who is contemplating retirement. The client states,
"I keep thinking about how much I enjoy my job. I'm not sure I want to retire." Which of
the following responses should the nurse make?
-You would have so much more time to spend with your family.
-You should consider getting a part-time job or doing volunteer work.
-Lets talk about how the change in your job status will affect you.
-Why wouldn't you want to retire and relax? - CORRECT ANSWERS "Lets talk about
how the change in your job status will affect you."
-This response is therapeutic because the nurse is encouraging the client to verbalize
feelings about the life transition of retirement.
A nurse is caring for a client who is expressing anger about his diagnosis of colorectal
cancer. Which of the following actions should the nurse take?
-Discuss risk factors for colon cancer.
-Focus teaching on what the client will need to do in the future to manage his illness.
-Provide the client with written information about the phases of loss and grief.
-Reassure the client that this is an expected response to grief. - CORRECT ANSWERS
Reassure the client that this is an expected response to grief.
-During the anger stage of the clients psychosocial adaptation to illness, the nurse
should support the client and explain that this is an expected reaction to a cancer
diagnosis.
A nurse on a medical-surgical unit is caring for a client who has a new prescription for
wrist restrains. Which of the following actions should the nurse take?
-Pad the clients wrists before applying the restrains.
-Evaluate the client's circulation every 8 hr after application.
-Remove the restraints every 4 hr to evaluate the clients status.
-Secure the restraint ties to the bed's side rails. - CORRECT ANSWERS Pad the
clients wrists before applying restrains.
- The use of restraints without padding can abrade the clients skin, resulting in injury.
A nurse is performing a home safety assessment for a client who is receiving
supplemental oxygen. Which of the following observations should the nurse identify as
proper safety protocol?
-The client uses a wool blanket on their bed.
, -The client identifies the location of a fire extinguisher.
-The client stores an extra oxygen tank under their bed.
-The client has a weekly inspection checklist for oxygen equipment. - CORRECT
ANSWERS The client identifies the location of a fire extinguisher.
- The client should be able to identify the location of fire extinguishers in the home and
be aware of how to use them.
A nurse is caring for a client who has a respirator infection. Which of the following
techniques should the nurse use when performing nasotracheal suctioning for the
client?
- Insert the suction catheter while the client is swallowing.
- Apply intermittent suction when withdrawing the catheter.
- Place the catheter in a location that is clean and dry for later use.
- Hold the suction catheter with her dominant hand after donning a sterile glove. -
CORRECT ANSWERS Apply intermittent suction when withdrawing the catheter.
- The nurse should apply intermittent suction during the withdrawal of the catheter to
prevent injury to the mucosa. However, suctioning continuously for more than 10
sections can cause cardiopulmonary compromise.
A nurse is preparing to administer enxaparin subcutaneously to a client. Which of the
following actions should the nurse take?
- Administer the medication with the needle at a 45 degree angle.
- Administer the medication into the client's nondominant arm.
- The Z-track technique involves displacing the skin laterally or downward prior to
administration of an IM injection.
- Massage the injection site after administration. - CORRECT ANSWERS Administer
the medication with the needle at a 45 degree angle.
- The nurse should insert the needle at a 45 to 90 degree angle for a subcutaneous
injection.
A nurse is preparing an education program for staff about advocacy. Which of the
following information should the nurse include.
- Advocacy ensures clients' safety, health, and rights.
- Advocacy ensures that nurses are able to explain their own actions.
- Advocacy ensures that nurses follow through on their promises to clients.
- Advocacy ensures fairness in client care deliver and use of resources. - CORRECT
ANSWERS Advocacy ensures clients' safety, health, and rights.
- Advocacy is a key component of professional nurses' code of ethics. As a client
advocate, the nurse ensures clients' safety, health, and rights, including the right to
privacy, confidentiality, and refusal of care.
A nurse is administering an otic medication to an older adult client. Which of the
following actions should the nurse take to ensure that the medication reaches the inner
ear.
- Press gently on the tragus of the client's ear.
- Pack a small piece of cotton deep into the client's ear canal.