Questions and Answers 100% Pass
In assisting an older adult client prepare to take a tub bath, which nursing action is
most important? - ✔✔Check the bath water temperature.
By rolling contaminated gloves inside-out, the nurse is affecting which step in the chain
of infection? - ✔✔Mode of transmission
The nurse-manager of a skilled nursing (chronic care) unit is instructing UAPs on ways
to prevent complications of immobility. Which intervention should be included in this
instruction? - ✔✔Perform range-of-motion exercises to prevent contractures.
In taking a client's history, the nurse asks about the stool characteristics. Which
description should the nurse report to the health care provider as soon as possible? -
✔✔Daily black, sticky stool
While reviewing the side effects of a newly prescribed medication, a 72-year-old client
notes that one of the side effects is a reduction in sexual drive. Which is the best
response by the nurse? - ✔✔"How will this affect your present sexual activity?"
The nurse is counting a client's respiratory rate. During a 30-second interval, the nurse
counts six respirations and the client coughs three times. In repeating the count for a
second 30-second interval, the nurse counts eight respirations. Which respiratory rate
should the nurse document? - ✔✔16
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, Which action should the nurse implement when providing wound care instructions to a
client who does not speak English? - ✔✔Speak directly to the client, with an interpreter
translating.
A client's blood pressure reading is 156/94 mm Hg. Which action should the nurse take
first? - ✔✔Compare the current reading with the client's previously documented blood
pressure readings.
When turning an immobile bedridden client without assistance, which action by the
nurse best ensures client safety? - ✔✔Put bed rails up on the side of bed opposite from
the nurse.
Which serum laboratory value should the nurse monitor carefully for a client who has a
nasogastric (NG) tube to suction for the past week? - ✔✔Sodium
The nurse observes a UAP taking a client's blood pressure in the lower extremity.
Which observation of this procedure requires the nurse's intervention? - ✔✔The UAP
auscultates the popliteal pulse with the cuff on the lower leg.
After the nurse tells an older client that an IV line needs to be inserted, the client
becomes very apprehensive, loudly verbalizing a dislike for all health care providers
and nurses. How should the nurse respond? - ✔✔Calmly reassure the client that the
discomfort will be temporary.
The nurse who is preparing to give an adolescent client a prescribed antipsychotic
medication notes that parental consent has not been obtained. Which action should the
nurse take? - ✔✔Do not give the medication and document the reason.
A 65-year-old client who attends an adult daycare program and is wheelchair-mobile
has redness in the sacral area. Which instruction is most important for the nurse to
provide? - ✔✔Change positions in the chair at least every hour.
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