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A nurse is caring for a client who has dementia. Which of the
following interventions should the nurse take to minimize the
risk for injury for this client?
a) use a bed exit alarm system
b) raise 4 side rails while client is in bed
c) apply one soft wrist restraint
d) dim the lights in the client's room - ...----ANSWER ----...A
A nurse is implementing a plan of care for a client who is at
risk for falls. Which of the following is an appropriate nursing
action?
a) implement a regular toileting schedule
b) encourage the client to wear athletic socks when
ambulating
c) place all 4 bed rails in the upright position
c) require a family member to remain at the bedside -
...----ANSWER ----...A
Which of the following techniques should the nurse use when
performing nasotracheal suctioning for a client?
a) insert the suction catheter while the client is swallowing
,b) apply intermittent suction when withdrawing the catheter
c) place the catheter in a location that is clean and dry for later
use
d) hold the suction catheter with the clean, non-dominant hand
- ...----ANSWER
----...B
A nurse is caring for a client following an acute myocardial
infarction. The client is concerned that providing self-care will
be difficult due to extreme fatigue. Which of the following
strategies should the nurse implement to promote the client's
independence?
a) request an occupational therapy consult to determine the
need for assistive devices
b) assign assistive personnel to perform self-care tasks for
client
c) instruct the client to focus on gradually resuming self-
care tasks
d) ask the client if a family member is available to assist
with his care - ...----ANSWER ----...C
A nurse is reviewing the medical records of a client who has a
pressure ulcer. Which of the following is an expected finding?
a) serum albumin level of 3 g/dL
b) HDL level of 90 mg/dL
c) Norton scale score of 18
d) Braden scale score of 20 - ...----ANSWER ----...A
,A nurse is caring for a client who needs a 24-hr urine
collection initiated. Which of the following client statements
indicates an understanding of the procedure?
a) "I had a bowel movement, but I was able to save the urine"
b) "I have a specimen in the bathroom from about 30 minutes
ago"
c) "I flushed what I urinated at 7 am and have saved the rest
since"
d) "I drink a lot, so I will fill up the bottle and complete the
test quickly" - ...----ANSWER ----...C
A nurse is caring for a client who has an NG tube that is to be
irrigated every 8 hr. Which of the following should be used to
irrigate the tube in order to maintain fluid and electrolyte
balance?
a) tap water
b) sterile water
c) 0.9% sodium chloride
d) 0.45% sodium chloride - ...----ANSWER -
---...C
A nurse is reinforcing teaching regarding the use of a cane to
a client who has left-leg weakness. Which of the following
should the nurse include in the teaching?
a) use the cane on the weak side of the body
b) advance the cane and the atrong leg simultaneously
c) maintain two points of support on the floor
, d) advance the cane 30 to 45 cm (12-18 in) with each step - ...-
---ANSWER ----...C
Which of the following should indicate to a nurse the need to
suction a client's tracheostomy?
a) irritability
b) hypotension
c) flushing
d) bradycardia - ...----ANSWER ----...A
A nurse is caring for a client who has a prescription for wound
irrigation. Which of the following actions should the nurse
take?
a) wear sterile gloves when removing the old dressing
b) warm the irrigation solution to 40.5C (105F)
c) cleanse the wound from the center outwards
d) use a 20 mL syringe to irrigate the wound - ...----ANSWER
----...C
A nurse is providing teaching about a clear liquid diet. Which
of the following should the nurse instruct the client to avoid?
a) lemon-lime sports drinks
b) ginger ale
c) black coffee
d) orange sherbet - ...----ANSWER -
---...D