1. A nurse in a long-term care facility enters the day room and finds the window
curtains on fire. Clients are panicking and the room is filling with smoke. Indicate
the emergency actions the nurse must take. (Move the steps into the box on the
right, placing them in the order of performance. Use all the steps.) <Ans> Remove
the clients from the room
- Activate the fire alarm
- Close the door
- Extinguish the fire
2. A nurse is assessing a client following the application of an aquathermia pad.
Which of the following is the first indication to the nurse that the client is
experiencing a superficial burn injury to the application site?
A. Blistering
B. Erythema
C. Eschar
D. Absence of pain <Ans> B. Erythema
Erythema is an indication that the client has experienced a superficial burn with
damage limited to the epidermis. Other manifestations include edema, pain, and
increased sensitivity to heat.
3. A nurse is assessing a client who is experiencing prostatic hypertrophy. Which
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,of the following findings associated with urinary retention should the nurse
expect? (Select all that apply.) <Ans> Report of feeling pressure
- Tenderness over the symphysis pubis
- Distended bladder
- Voiding 30 mL frequently
Clinical findings of urinary retention include frequent voiding of 25 to 60 mL of urine
4. A nurse is teaching a client who has diabetes about which dietary source
should provide the greatest percentage of calories. Which of the following
statements indicates the client understands the teaching?
A. "Most of my calories each day should be from fats."
B. "I should eat more calories from complex carbohydrates than anything else."
C. "Simple sugars are needed more than other calorie sources."
D. "Protein should be my main source of calories." <Ans> "I should eat more
calories from complex carbohydrates than anything else."
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, The client who has diabetes should consume the majority of calories from complex
carbohydrates, such as whole grains, fruits, and vegetables.
5. A nurse is providing discharge teaching to a client who was recently diag-
nosed with a latex allergy. Which of the following client statements indicates an
understanding of the teaching?
A. "I will apply elastic bandages to cuts."
B. "I will use dishwashing gloves when cleaning the dishes."
C. "I will buy balloons for my son's birthday."
D. "I will use ink pens for writing." <Ans> "I will use ink pens for writing."
The client understands pencil erasers contain latex and should use pens for writing
instead.
6. A nurse is calculating a client's intake and output for an 8-hr shift. The client's
intake included 1,000 mL 0.9% sodium chloride IV, one 6-oz cup of coffee, 6 oz of
water, one 180 mL bowl of soup, 3 oz of flavored gelatin, and 3 oz of ice cream.
How many mL should the nurse document as the client's total intake for the shift?
(Round the answer to the nearest whole number) <Ans> 1720 mL
7. A charge nurse observes a nurse administer intermittent tube feeding via an NG
tube to a client. Which of the following actions should prompt the charge nurse to
intervene?
A. The nurse initiates the feeding after aspirating 50 mL of gastric residual.
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