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CORRECT SOLUTIONS
◉A nurse is caring for a client who has visual loss. Which os the
following actions should the nurse implement?
A. Remove all objects from the client's bedside table
B. Instruct the client to open items in the food tray
C. Walk a step behind the client when assisting with ambulation
D. Count steps to the bathroom with the client . Answer: D
Orient the client to the room to reduce the risk of falls
◉A nurse is discussing activity modification with a client who had a
right total hip arthroplasty. Which of the following statements should the
nurse include in the information?
A. Plan to sit in a straight-backed chair when out of bed
B. Place a pillow between your legs when lying in bed
C. You can cross your legs at the ankles when sitting
D. You should bend at the waist when tying your shoes . Answer: B
Prevent adduction of the hip and possible dislocation
,◉A nurse is teaching a newly licensed nurse about preventing a catheter-
associated urinary tract infection for a client who has an indwelling
urinary catheter. Which of the following instructions should the nurse
include?
A. Ensure the urinary catheter tubing is not kinked
B. Rest the catheter bag on the floor when the client is sitting in a chair
C. Clean the perineal area with an antiseptic solution
D. Empty the collection bag for the client every 12 hr . Answer: A
Kinks can cause blockage of urinary flow and result in a UTI
◉A nurse is planning wound management for a client who has a stage 3
pressure injury. Which of the following interventions should the nurse
include in the plan?
A. Measure the depth of the wound with a cotton-tipped applicator
B. Measure the wound using a reusable tape measure
C. Cover the wound bed with dry gauze dressings
D. Cleanse the wound with soap and water . Answer: A
Check wound for tunneling
◉A nurse is planning care for four clients following chase-of-shift
report. Which of the following clients is the nurse's priority?
A. A client who had a stroke and has expressive aphasia
B. A client who has a hemoglobin of 11g/dL and requires 1 unit of blood
,C. A client who has asthma and a peak expiratory flow rate in the green
zone
D. A client who has peptic ulcer disease and a rigid abdomen . Answer:
D
The client is unstable and a rigid abdomen is a manifestation of a
perforated peptic ulcer and could lead to septicemia and shock.
◉A nurse is planning care for four clients following chase-of-shift
report. Which of the following clients should the nurse see first?
A. A client who is receiving propranolol and has a HR of 55/min
B. A client who is receiving warfarin and has an INR of 2.5
C. A client who has a pacemaker and has persistent hiccuping
D. A client who has cholecystitis and reports rebound tenderness .
Answer: C
Hiccuping is a manifestation of a dislocation of the pacemaker lead and
could lead to bradycardia and decreased CO
◉A nurse is reviewing the laboratory data of a client who is taking the
herbal supplement feverfew to reduce the frequency of migraine
headaches. The nurse should identify that which of the following
findings indicates a potential contraindication to taking this herbal
supplement?
A. Potassium 3.5mEq/L
B. Platelet count 100,000/mm3
C.Cholesterol 250mg/dL
, D. Urine bilirubin 0.2mg/dL . Answer: B
Feverfew can lead to platelet dysfunction by suppressing platelet
aggregation. A patient with a decreased platelet count should not take
fever few because it can increase the risk of bleeding. Monitor for
bleeding and impaired coagulation while taking feverfew
Ranges:
-Platelet 150,000-450,000/mm3
-Potassium 3.5-5mEq/L
-Cholesterol <200mg/dL
-Urine Bilirubin 0.0mg/dL
◉A nurse is caring for a client who is postoperative and has a history of
heart failure. The client reports slight dyspnea when ambulating. Which
of the following findings should the nurse expect when performing a
skin assessment?
A. Petechiae over the client's chest and abdomen
B. Tenting of the skin on the client's arm
C. Shiny areas on the client's ankles and feet
D. Dry, flaky skin on the client's arms and hands . Answer: C
Edema is an expected finding for HF with dyspnea with exertion.
Edematous skin appears taut and shiny, and can also look swollen and
blanched.