level 3 practice a/t/i
1. A nurse is caring for an older adult client who has kidney failure. The client tells the
nurse that she has decided to stop hemodialysis treatment. Which of the following
actions by the nurse is appropriate in regard to serving as the client's advocate Ans:
Supporting the client's decision regarding treatment
-The nurse's role as client advocate is to support the client's decision to discontinue treatmen
2. A nurse is caring for an older adult client. The client received 0.9% sodium
chloride 1 L over 4 hr instead of over 8 hr as prescribed.Which of the following entries
is the appropriate documentation of this occurrence in the client's medical record
Ans: 0.9% sodium chloride 1 L IV infused over 4 hr. Vital signs stable.- The nurse should
document the amount of fluid, how long it took to infuse, and the client's physical status.
3. When planning care for a child who has increased intracranial pressure (ICP),
which of the following should the nurse include in the child's plan of care Ans:
Maintain head in midline. -The child's head should be maintained in a midline position to
promote venous return and prevent an increase in ICP.
4. : Sleepy/Widening pulse pressure//decerebrate posturing.....
Sleepiness exhibited by the client is correct. Sleepiness or difficulty arousing the client from
sleep is an indication of increased ICP.//
Widening pulse pressure is correct. A widening pulse pressure (increase in systolic with
,concurrent decrease in diastolic blood pressure) is an indication of increased ICP.//
Decerebrate posturing is correct. Both decerebrate and decorticate posturing indi- cate
increased ICP.
5. A nurse is talking with a client who is beginning chemotherapy. She tells the nurse
that she is mourning the loss of her hair. Which of the following actions should the
nurse take first Ans: Discuss the importance of hair with the client.--The first action the
nurse should take using the nursing process is to assess the client. By identifying the
importance of hair to the client, the nurse can acknowledge the importance of the expected
loss to the client and assist the client with anticipatory grieving.
6. : an inability to manage finances.--
Clients who are in stage 4 have difficulty with tasks that require planning and math skills,
such as managing finances.
7. : Fine and gross motor skill challenges-
Fine and gross motor skill challenges are manifestations of spastic cerebral palsy.
8. : Discontinue the infusion.--A report of pain and a red line extending outward from the
insertion site are manifestations of phlebitis and indicates that the client is at the
, greatest risk from injury to the vein; therefore, the first action the nurse should take is to
discontinue the infusion.
9. A client who is being discharged today asks the nurse for supplies for
her wound dressing. Which of the following actions should the nurse take to ensure
quality, cost-effective care Ans: Provide enough supplies for 1 to 2 days.-Al- though woun
care supplies for home use are typically purchased by clients after leaving the facility, it ma
be necessary to provide adequate supplies for the imme- diate discharge period.
10. A nurse is administering baclofen for a client who has a spinal cord injury.
Which of the following should the nurse document as a therapeutic outcome Ans:
Decrease in flexor and extensor spasticity-
Baclofen decreases the frequency and severity of muscle spasms, allowing for improved
muscle function.
11. A nurse is providing postoperative instructions about complete proteins to a
client following a below-the-knee amputation.Which of the following food choices
indicates a need for additional instruction Ans: Pinto beans-
Pinto beans are a plant protein; therefore, this food choice is an incomplete protein.
12. A community health nurse is asked to give a health education program to a group of
African-American men age 40 to 75. Considering the health concerns of this group,
which of the following topics is most important to include in the program Ans:
1. A nurse is caring for an older adult client who has kidney failure. The client tells the
nurse that she has decided to stop hemodialysis treatment. Which of the following
actions by the nurse is appropriate in regard to serving as the client's advocate Ans:
Supporting the client's decision regarding treatment
-The nurse's role as client advocate is to support the client's decision to discontinue treatmen
2. A nurse is caring for an older adult client. The client received 0.9% sodium
chloride 1 L over 4 hr instead of over 8 hr as prescribed.Which of the following entries
is the appropriate documentation of this occurrence in the client's medical record
Ans: 0.9% sodium chloride 1 L IV infused over 4 hr. Vital signs stable.- The nurse should
document the amount of fluid, how long it took to infuse, and the client's physical status.
3. When planning care for a child who has increased intracranial pressure (ICP),
which of the following should the nurse include in the child's plan of care Ans:
Maintain head in midline. -The child's head should be maintained in a midline position to
promote venous return and prevent an increase in ICP.
4. : Sleepy/Widening pulse pressure//decerebrate posturing.....
Sleepiness exhibited by the client is correct. Sleepiness or difficulty arousing the client from
sleep is an indication of increased ICP.//
Widening pulse pressure is correct. A widening pulse pressure (increase in systolic with
,concurrent decrease in diastolic blood pressure) is an indication of increased ICP.//
Decerebrate posturing is correct. Both decerebrate and decorticate posturing indi- cate
increased ICP.
5. A nurse is talking with a client who is beginning chemotherapy. She tells the nurse
that she is mourning the loss of her hair. Which of the following actions should the
nurse take first Ans: Discuss the importance of hair with the client.--The first action the
nurse should take using the nursing process is to assess the client. By identifying the
importance of hair to the client, the nurse can acknowledge the importance of the expected
loss to the client and assist the client with anticipatory grieving.
6. : an inability to manage finances.--
Clients who are in stage 4 have difficulty with tasks that require planning and math skills,
such as managing finances.
7. : Fine and gross motor skill challenges-
Fine and gross motor skill challenges are manifestations of spastic cerebral palsy.
8. : Discontinue the infusion.--A report of pain and a red line extending outward from the
insertion site are manifestations of phlebitis and indicates that the client is at the
, greatest risk from injury to the vein; therefore, the first action the nurse should take is to
discontinue the infusion.
9. A client who is being discharged today asks the nurse for supplies for
her wound dressing. Which of the following actions should the nurse take to ensure
quality, cost-effective care Ans: Provide enough supplies for 1 to 2 days.-Al- though woun
care supplies for home use are typically purchased by clients after leaving the facility, it ma
be necessary to provide adequate supplies for the imme- diate discharge period.
10. A nurse is administering baclofen for a client who has a spinal cord injury.
Which of the following should the nurse document as a therapeutic outcome Ans:
Decrease in flexor and extensor spasticity-
Baclofen decreases the frequency and severity of muscle spasms, allowing for improved
muscle function.
11. A nurse is providing postoperative instructions about complete proteins to a
client following a below-the-knee amputation.Which of the following food choices
indicates a need for additional instruction Ans: Pinto beans-
Pinto beans are a plant protein; therefore, this food choice is an incomplete protein.
12. A community health nurse is asked to give a health education program to a group of
African-American men age 40 to 75. Considering the health concerns of this group,
which of the following topics is most important to include in the program Ans:
