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A nurse is contributing to the discharge plan of an older adult client who
had a total hip arthroplasty. The client is unable to ambulate independently
and lives alone. Which of the following care settings should the nurse
recommend for this client? ---------CORRECT ANSWER-----------------Skilled
nursing facility
A nurse is reinforcing teaching with the parents of a preschool-age child
who has a new diagnosis of celiac disease. Which of the following foods
should the nurse recommend? ---------CORRECT ANSWER-----------------
Corn tortillas with black beans
A nurse is assisting with the admission of a client who has mononucleosis.
Which of the following isolation precautions should the nurse initiate? -------
--CORRECT ANSWER-----------------Droplet
A nurse is speaking to a client who called the provider's office to report
chest pain and requests clarification on how to take his sublingual
nitroglycerin tablets. Which of the following instructions should the nurse
give the client? ---------CORRECT ANSWER-----------------Wait 5 min
between doses.
A nurse is caring for a client and begins to suspect he is experiencing
transference. Which of the following client statements should the nurse
identify as an indicator of transference? ---------CORRECT ANSWER---------
--------"I feel really close to you because you remind me of my ex-
boyfriend."
,A nurse is caring for a client who has been placed in restraints. Which of
the following is appropriate? ---------CORRECT ANSWER-----------------
Monitor the client's skin integrity on a regular schedule.
A nurse is caring for a client who is newly diagnosed with type 1 diabetes
mellitus. The nurse should recognize that the client needs a referral for
diabetic education when the client does which of the following? ---------
CORRECT ANSWER-----------------States that he will treat hypoglycemic
reactions with 15 g of carbohydrates
A nurse is preparing a client for surgery. The client tells the nurse that he is
concerned about the safety of a large sum of money in his wallet. Which of
the following actions is appropriate for the nurse to take? ---------CORRECT
ANSWER-----------------Contact security personnel to place the money in the
facility safe.
A nurse on a medical-surgical unit is planning care for a group of clients.
Which of the following tasks is appropriate to delegate to an assistive
personnel? ---------CORRECT ANSWER-----------------Administer a large-
volume enema to a client.
A nurse is reviewing the medical record of a client who has sustained a full-
thickness burn and is in the emergent phase of the burn. Which of the
following findings should the nurse expect? ---------CORRECT ANSWER----
-------------Hypercalcemia
,A nurse is collecting data from an 18-month-old toddler at a well-child visit.
Which of the following findings should the nurse report to the provider? -----
----CORRECT ANSWER-----------------The toddler can say four words.
A nurse delegates a task to an assistive personnel (AP) and the AP refuses
the assigned task. Which of the following actions should the nurse take
first? ---------CORRECT ANSWER-----------------Perform the task.
A nurse on a medical unit is observing an assistive personnel (AP)
delivering food trays. Which of the following actions by the AP requires
intervention? ---------CORRECT ANSWER-----------------Providing a ham
and cheese sandwich to a client who follows a kosher diet
A nurse is reinforcing teaching with a client who has a vitamin C deficiency.
Which of the following foods should the nurse include as having the highest
vitamin C content? ---------CORRECT ANSWER-----------------1 cup raw
broccoli
A nurse is assisting with triaging clients in a mass casualty situation. The
nurse should recommend that which of the following clients receive care
first? ---------CORRECT ANSWER-----------------A client who has diminished
breath sounds and paradoxical chest movement
A nurse is working in an urgent care clinic when a client who does not
speak the same language arrives with a laceration that will require suturing.
Which of the following actions appropriate for the nurse to take? ---------
CORRECT ANSWER-----------------Ask an assistive personnel who speaks
the same language as the client to assist in obtaining informed consent.
, A nurse is collecting data from a client who has dehydration and is
receiving continuous IV therapy. Which of the following findings indicates
effectiveness of the IV therapy? ---------CORRECT ANSWER-----------------
BUN 16 mg/dL
A nurse is caring for a child who has terminal cancer. Which of the
following responses by the child's siblings should the nurse expect? ---------
CORRECT ANSWER-----------------The school-age sister is concerned
about the impact of her sibling's death on herself
A nurse is caring for a client who attempted suicide. Which of the following
actions should the nurse take? ---------CORRECT ANSWER-----------------
Serve meals with plastic utensils.
A nurse is removing a female client's indwelling urinary catheter. Which of
the following actions should the nurse take? ---------CORRECT ANSWER---
--------------Withdraw the fluid from the catheter's balloon.
A nurse is collecting data from a parent of a preschooler at a well-child visit.
Which of the following findings is a contraindication to a measles, mumps,
and rubella (MMR) immunization? ---------CORRECT ANSWER----------------
-Long-term use of immunosuppressants
A home health nurse is reinforcing teaching with a client about kitchen
safety. Which of the following instructions should the nurse reinforce about
using a fire extinguisher? ---------CORRECT ANSWER-----------------Sweep
the extinguisher from side to side to put out the fire.