QUESTIONS AND ANSWERS CORRECTLY VERIFIED
ALREADY GRADED A+
A nurse is caring for a client that has not voided for several hours. When percussing the client's bladder
to assess for distention, the nurse should expect to hear......
Dullness
This indicates a full bladder
-Tympany means empty
-Hyperrenosance is an abnormal pulmonary sound
-Renosance is a vibration
A client is receiving intermittent nasogastric tube feedings. A nurse should aspirate the residual stomach
contents prior to administering a scheduled feeding to.....
Determine absorption of feedings
Which medication should be delivered using the z-track method?
Iron dextran(Imferon) to prevent tissue damage
A nurse is to administer medication to 2 clients sitting in the lounge with several other clients. What
action by the nurse is appropriate?
Check name bands on the clients' arms
,A client is to be checked for residual urine. At which time should the procedure be performed?
Immediately after the client voids
A nurse is to obtain a residual urine specimen from an elderly client whose indwelling foley catheter was
just removed. What is the purpose of a residual urine specimen?
To assess for urinary retention
A nurse is caring for a client receiving intravenous therapy. What would indicate to the nurse that the
intravenous infusion has infiltrated?
Cutaneous tissue at the intravenous site is swollen
-the IV catheter should be removed and a new site should be restarted
Which of the following measures should a nurse include in the plan of care of a patient with
hyperthyroidism?
Keeping the client's environment cool
-A client with hyperthyroidism is heat intolerant
-The client should be encouraged to eat foods high in calories because they are often below their ideal
weight and have difficulty maintaining a healthy weight
, A nurse should reinforce the instructions to the family of a client who has propulsive gait related to
Parkinsons Disease?
Keep the floor of the client's surroundings free of obstacles
-Propulsive gait is a stooping, rigid posture with the head and neck bent forward. Steps tend to
become faster and shorter.
-Encourage the client to ambulate as much as they want in order to maintain activity level
Which of these measures should a nurse emphasize when feeding a client with left side facial paralysis
who has difficulty swallowing?
Placing the food on the unaffected side of the client's mouth
-prevents aspiration
Before assisting a patient who is on day postop OOB for the first time, a nurse should take which action?
Assess pulse and blood pressure in order to assess the client for orthostatic hypotension
Which of these objectives is most important to include in the care of a client with multiple sclerosis?
Prevent contractures
-it will decrease the client's functional abilities
A client who is terminally ill with AIDS is admitted to the hospital. What precaution should be included in
the client's plan of care?
Standard Precautions