400 HIGH PRIORITY QUESTIONS AND 100%
ACCURATE ANSWERS (GUARANTEED PASS)
1. A .Caregiver .is .planning .to .collect .a .stool .specimen .for .ova .and .parasites .from .a
.client .who .has .diarrhea. .Which .of .the .following .actions .should .the .Caregiver .take
.when .collecting .the .specimen?
A. Instruct .the .client .to .defecate .into .the .toilet .bowl
-incorrect: .The .Caregiver .should .have .the .client .defecate .into .a .bedpan .or .a
.container .for .stool .collection. .The .toilet .water .can .dilute .and .contaminate .the
.liquid .specimen.
B. Transfer .the .specimen .to .a .sterile .container
-incorrect: .The .Caregiver .should .place .the .stool .specimen .in .a .clean .container .using
.a .tongue .depressor.
C. Refrigerate .the .collected .specimen
-incorrect: .The .Caregiver .should .send .the .collected .stool .specimen .immediately .to .the
.laboratory .after .labeling .the .specimen .properly .to .prevent .contamination .with
.microorganisms .and .keep .the .specimen .from .getting .cold.
D. Place .the .stool .specimen .collection .container .in .a .biohazard .bag
-The .Caregiver .should .place .the .specimen .collection .container .in .a .biohazard .bag
.with .the .client .label .on .the .container .and .the .bag .for .easy .identification. .This .will
.also .prevent .contamination .with .microorganisms.
2. A .Caregiver .is .caring .for .a .client .who .has .a .tracheostomy .and .requires
.suctioning. .Which .of .the .following .actions .should .the .Caregiver .take?
A. Hyper .oxygenate .the .client .before .suctioning
-The .Caregiver .should .use .a .manual .resuscitation .bag .to .hyper .oxygenate .the .client
.for .several .minutes .prior .to .suctioning.
B. Insert .the .catheter .during .exhalation
-incorrect: .The .Caregiver .should .insert .the .catheter .during .inhalation
C. Apply .suction .during .insertion .of .the .catheter
-incorrect: .Applying .suction .while .inserting .the .catheter .increases .the .risk .of
.damage .to .the .tracheal .mucosa .and .removes .oxygen .from .the .airways.
D. Apply .suction .for .no .more .than .15 .secs
-incorrect: .The .Caregiver .should .apply .suction .for .no .more .than .10 .seconds
3. A .Caregiver .is .providing .teaching .to .a .client .regarding .protein .intake. .Which
.of .the .following .foods .should .the .Caregiver .include .as .an .example .of .an
.incomplete .protein?
A. Eggs
-incorrect: .this .is .a .complete .protein, .contains .all .of .the .essential .amino .acids
.necessary .for .the .synthesis .of .protein .in .the .body.
B. Soybeans
-incorrect: .this .is .a .complete .protein, .contains .all .of .the .essential .amino .acids
.necessary .for .the .synthesis .of .protein .in .the .body.
C. Lentils
,-Incomplete .proteins .are .missing .1 .or .more .of .the .essential .amino .acids .necessary
.for .the .synthesis .of .protein .in .the .body. .Examples .of .incomplete .proteins .include
.lentils, .vegetables, .grains, .nuts, .and . seeds.
D. Yogurt
-incorrect: .this .is .a .complete .protein, .contains .all .of .the .essential .amino .acids
.necessary .for .the .synthesis .of .protein .in .the .body.
4. A .Caregiver .is .caring .for .a .client .who .was .admitted .to .a .long-term .care .facility
.for .rehabilitation .after .a .total .hip .arthroplasty. .At .which .of .the .following .times
.should .the .Caregiver .begin .discharge .planning?
A. One .week .prior .to .the .client’s .discharge
-incorrect: .Beginning .to .plan .for .the .client’s .discharge .a .week .prior .to .the .event .might
.not .allow .sufficient .time .for .planning. .The .Caregiver .should .begin .discharge .planning .at
.the .time .of .admission. .B. .Upon .the .client’s .admission .to .the .care .facility
-The . Caregiver . should . begin . discharge . planning . at . the . time . that . the . client . is
. admitted . to .the .facility.
C. Once .the .discharge .date .is .identified
-incorrect: .Beginning .to .plan .for .the .client’s .discharge .once .the .discharge .date .is
. identified .might .not .allow .sufficient .time .for .planning. .The .Caregiver .should .begin
.discharge .planning .at .the .time .of .admission.
D. When .the .client .addresses .the .topic .with .the .Caregiver
-incorrect: .Beginning .to .plan .for .the .client’s .discharge .once .the .discharge .date .is
. identified .might .not .allow .sufficient .time .for .planning. .The .Caregiver .should .begin
.discharge .planning .at .the .time .of .admission.
5. A .Caregiver .is .preparing .to .administer .a .cleansing .enema .to .a .client.
.Which .of .the .following .actions .should .the .Caregiver .plan .to .take?
A. Insert .the .rectal .tube .15.2 .cm .(6 .in)
-incorrect: .The .Caregiver .should .insert .the .rectal .tube .7 .to .10 .cm .(3 .to .4 .in)
B. Wear .sterile .gloves .to .insert .the .tubing
-incorrect: .The .Caregiver .should .wear .clean .(nonsterile) .gloves .to .prevent .contamination.
C. Position .the .client .on .his .left .side
-Positioning .is .an .important .aspect .of .administering .an .enema. .Having .the .client .lie
. on .his .left .side .facilitates .the .flow .of .the .enema .solution .into .the .sigmoid .and
.descending .colon.
D. Hold .the .solution .bag .91 .cm .(36 .inch) .above .the .client’s .rectum
-incorrect: .The .Caregiver .should .hold .the .solution .bag .30 .cm .(12 .in) .above .the .client’s
.rectum .for .a .low .enema .and .45 .cm .(18 .in) .for .a .high .enema. .If .the .Caregiver .holds
.the .solution .bag .too .high, .the .solution .might .run .in .too .fast, .causing .discomfort .and
.spasms .that .make .retaining .the .enema .more .difficult.
5. A .Caregiver .is .caring .for .a .client .who .has .bilateral .cats .on .her .hands. .Which
. of .the .following .actions .should .the .Caregiver .take .when .assisting .the .client
.with .feeding?
A. Sit .at .the .bedside .when .feeding .the .client
-The .Caregiver .should .avoid .appearing .to .be .in .a .hurry. .Sitting .at .the .bedside .provides
.the .client .with .the .Caregiver’s .full .attention .during .the .feeding
,B. Order .pureed .foods
-incorrect: .Without .any .mouth .or .throat .injuries .that .make .chewing .or .swallowing
.difficult, .the .client .should .be . served .foods .of . an .appropriate .variety .of .textures. .Pureed
.foods .are .for .clients .who .cannot .chew, .have .difficulty .swallowing, .or .do .not .have .teeth.
C. Make .sure .feedings .are .provided .at .room .temperature
-incorrect: .The .Caregiver .should .ask .the .client .if .the .food .is .the .correct .temperature
D. Offer .the .client .a .drink .of .fluid .after .every .bite
-incorrect: .If .the .client .is .unable .to .communicate, .the .Caregiver .should .offer .the .client
.fluids .after .every .3 .or .4 .mouthfuls. .However, .there .is .no .indication .that .this .client .is
.unable .to .communicate. .Therefore, .the .client .should .tell .the .Caregiver .when .she
.would .like .a .drink.
6. A .Caregiver .is .administering .an .IM .injection .to .a .5-month-old .infant.
.Which .of .the .following .injection .sites .should .the .Caregiver .use?
A. Deltoid
-incorrect: .The .Caregiver .can .use .the .deltoid .muscle .for .injecting .small .volumes .of
.medication .for .children .18 .months .of .age .or .older, .but .its .proximity .to .several
.nerves .and .arteries .make .it .a .riskier .choice.
B. Ventrogluteal
-incorrect: .This .is .a .safe .site .for .IM .injections .for .clients .older .than .7 .months.
C. Vastus .lateralis
-The .Caregiver .should .use .the .vastus .lateralis .site .over .the .anterior .thigh .for .IM
.injections .for .infants .and .children.
D. Dorsogluteal
-incorrect: .This .site .is .unsafe .to .use .because .of .its .proximity .to .the .sciatic .nerve .and .the
.superior .gluteal .nerve .and .artery.
7. A .Caregiver .is .caring .for .a .client .who .has .major .fecal .incontinence .and
.reports .irritation .in .the .perianal .area. .Which .of .the .following .actions .should .the
.Caregiver .take .first?
A. Apply .a .fecal .collection .system
-incorrect: .The .Caregiver .should .apply .a .fecal .collection .system .to .divert .the .feces
.away .from .the .area .of .skin .irritation; .however, .there .is .another .action .the .Caregiver
.should .take .first.
B. Apply .a .barrier .cream
-incorrect: .The .Caregiver .should .apply .a .barrier .cream .to .decrease .skin .breakdown
.in .the .perianal .area .from .the .feces; .however, .there .is .another .action .the .Caregiver
.should .take .first.
C. Cleanse .and .dry .the .area
-incorrect: .The .Caregiver .should .cleanse .and .dry .the .perianal .area .to .decrease .skin
.irritation; .however, .there .is .another .action .the .Caregiver .should .take .first.
D. Check .the .client’s .perineum
-The .Caregiver .should .apply .the .nursing .process .priority-setting .framework .to .plan
.care .and .prioritize .nursing .actions. .Each .step . of .the .nursing .process .builds .on .the
.previous .step, .beginning .with .an .assessment .or .data .collection. .Before .the .Caregiver .can
.formulate .a .plan .of .action, .implement .a .nursing .intervention, .or .notify .a .provider .of .a
.change .in .the .client’s .status, .the .Caregiver .must .first .collect .adequate .data .from .the
.client. .Assessing .or .collecting .additional .data .will .provide .the .Caregiver .with
.knowledge .to .make .an .appropriate .decision. .The .priority .nursing .action .is .for .the
.Caregiver .to .collect .more .data .by .assessing .the .area .of .irritation.
, 9. A .Caregiver .is .caring .for .a .client .who .is .receiving .IV .therapy .via .a .peripheral
.catheter. .The .Caregiver .should .identify .that .which .of .the .following .findings .is .an
.indication .of .infiltration?
A. Redness .at .the .infusion .site
-incorrect: .Redness .at .the .infusion .site .is .an .indication .of .phlebitis .or .infection.
B. Edema .at .the .infusion .site
-Edema .due .to .fluid .entering .subcutaneous .tissue .is .an .indication .of .infiltration.
C. Warmth .at .the .infusion .site
-incorrect: .Warmth .at .the .infusion .site .is .an .indication .of .phlebitis .or .infection.
D. Oozing .of .blood .at .the .infusion .site
-incorrect: .Oozing .of .blood .at .the .infusion .site .is .an .indication .that .the .IV .system .is .not .intact.
10. A .Caregiver .is .caring .for .a .client .who .reports .not .sleeping .at .night, .which
.interferes .with .her .ability .to .function .during .the .day. .Which .of .the .following
.interventions .should .the .Caregiver .suggest .to .this .client?
A. Avoid .beverages .that .contain .caffeine
-Caffeine .is .a .stimulant. .The .Caregiver .should .suggest .that .the .client .avoid
.caffeinated .beverages.
B. Take .a .sleep .medication .regularly .at .bedtime
-incorrect: .Sleep-promoting .medication .is .a .last .resort. .The .Caregiver .should .not .suggest
.this .type .of .medication .for .the .client .before .recommending .other .nonpharmacological
.interventions.
C. Watch .television .for .30 .minutes .in .bed .to .relax .prior .to .falling .asleep
-incorrect: .Clients .should .associate .going .to .bed .with .sleep. .Therefore, .the .client .should
.not .get .into .bed .until .she .is .sleepy.
D. Advise .the .client .to .take .several .naps .during .the .day
-incorrect: .Napping .in .the .daytime .can .prevent .sound .sleep .at .night
11. A .Caregiver .is .conducting .an .admission .interview .with .a .client. .Which .of .the
.following .pieces .of .assessment .information .should .the .Caregiver .collect .during .the
.introductory .phase .of .the .interview? .A. .Clients .level .of .comfort .and .ability .to
.participate .in .the . .interview
-The .Caregiver .should .assess .the .client’s .level .of .comfort .and .establish .a .rapport .during
.the .introductory .or .orientation .phase. .The .Caregiver .should .engage .in .active .listening
.and .present .a .relaxed .attitude .to .place .the .client .at .ease . and .encourage .client
.participation. .This .will .assist .the .Caregiver .in .gaining .the .necessary .data .to .formulate
.appropriate .nursing .diagnoses .and .outcomes.
B. . Previous .illnesses .and .surgeries
-incorrect: .The .Caregiver .should .assess .the .client’s .health .history, .including .previous
.illnesses . and .surgeries, .during .the .working .phase .of .the .interview.
C. . Events .surrounding .the .client’s .recent .illness
-incorrect: .The .Caregiver .should .assess .the .client’s .health .history, .including .events
.surrounding .the .recent .or .current .illness, .during .the .working .phase .of .the .interview.
D. . Sociocultural .history
-incorrect: .The .Caregiver .should .assess .the .client’s .sociocultural .history .during .the
.working .phase .of .the .interview.
12. A .Caregiver .is .performing .an .abdominal .assessment .of .a .client. .Which .of
.the .following .positions .should .the .Caregiver .tell .the .client .to .assume .for .this
.examination?
A. Lithotomy