Questions and Correct A+ Answers
A nurse is providing discharge teaching for a client who has a new precription for a
home oxygen concentrator. Which of th following instructions should the nurse provide
to the client and his family? (Select all that apply)
- Check the cord routinely for frays or tearing
- Consider purchasing a generator for power backup
- Observe for signs of hypoxia
A charge nurse is observing a newly licensed nurse prepare a sterile feild for a dressing
change. Which of the following actions by the newly licensed nurse requires intervention
by the charge nurse?
The newly licensed nurse places the cap of a bottle of sterile saline solution on the
sterile feild
A charge nurse is discussing the responsibility of nurses caring for clients who have a
Clostridium difficile infection. Which of the following information should the nurse include
in the teaching?
Have family members wear a gown and gloves when visting
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A nurse is teaching an older adult client who is at ris for osteoporosis about beginning a
program of regular physical activity. Which of the following types of activity should the
nurse recommend?
Walking briskly
,A nurse is preparing to delegate client care tasks to an assistive personnel (AP). Which
of the following tasks should the nurse delegate?
Ambulating a client who is postoperative
A nurse is preparing a heparin infusion for a client who was admitted to the facility with
deep-vein thrombosis. The prescription reads: 25,000 units of heparin in 0.9% sodium
chloride 250 mL to infuse at 800 units/hr. At what rate should the nurse set the infusion
pump? (Round to the nearest whole number)
8 mL/hr
A community health nurse is checking blood pressures for a group of clients at a
community health screening. Which of the following clients is at an increased risk for
hypertension?
A client who smokes one pack of cigarettes each day
A nurse is reviewing a clients medication prescription that reads, "digoxin 0.25 by mouth
every day." Which of the following components of the precription should the nurse verify
with the proivder?
Medication dose
A nurse is reviewing protocol in preparation for suctioning secretions from a client who
has a new tracheostomy. Which of the following actions should the nurse plan to take?
Select a suction catheter that is half the size of the lumen
A nurse is caring for a group of clients on a medical-surgical unit. In which of the
following situations does the nurse demonstrate the ethical priniciple of veracity?
A client who is unaware of her recen cancer diagnosis asks the nurse if she has cancer,
and the nurse responds affirmatively
A nurse in the emergency department (ED) is caring for a client who reports abdominak
pain.
Nurses' Notes:
, 1200: Client arrives to ED and reports abdominal pain and no bowel movement for the
past 7 days. Client is undergoing chemotherapy for pancreatic cancer and has been
taking 40 mg oxycodone extended-release tablets daily for the past 3 months. Client
states they have attempted to relieve constipation for the last 7 days with bisacodyl
suppositories and magnesium citrate oral suspension. Client reports that neither therapy
initiated defecation.
1230:Client transported for abdominal x-ray.
1245:Client returned from x-ray. Provider prescribes a hypertonic cleansing enema.
1300:Procedure explained to client who verbalized understanding.
Diagnostic Results:
1245: Abdominal x-ray indicates a large amount of fecal material throughout the colon.
No evidence of gastrointestinal obstruction observed.
Based on the client's clinical findings, which of the following actions should the nurse
take? (Select all that apply)
- Assist the client to a left side-lying position with the right knee flexed is correct. The
nurse should place the client in a left side-lying position with the right knee flexed prior
to administering an enema. Because the provider prescribed a cleansing enema for the
client, the nurse should prepare the client for the procedure.
- Administer a cleansing enema is correct. The nurse should administer a cleansing
enema for the client as a result of the provider's prescription. A cleansing enema is
intended to assist with bowel elimination and remove any impacted fecal matter
indicated by the abdominal x-ray.
- Auscultate the client's bowel sounds is correct. The nurse should auscultate the
client's bowel sounds to determine the status of the client's peristalsis. This is a
necessary part of determining the presence of bowel sounds, which are an indication of
the status of the client's gastrointestinal tract.
- Perform a manual digital examination of the client's rectum is correct. The nurse
should perform a manual digital examination of the client's rectum to determine if