A nurse is reinforcing teaching with a client about living wills. Which of the following client
statements indicates an understanding of the teaching? - ANSWER "The living will
directs my medical care when I am unable to make decisions. "
A nurse is reinforcing preoperative teaching with a client who speaks a different language
than the nurse. Which of the following actions should the nurse take? -
ANSWER Provide handouts written in the client's primary language.
A nurse is caring for a client who has recently undergone a total bilateral mastectomy. Which
of the following statements by the client requires immediate action by the nurse? -
ANSWER "When I look at myself in the mirror, I don't know if I can go on."
A nurse is caring for a post-op client who is at risk for thrombus formation. Which of the
following interventions should the nurse delegate to an assistive personnel (AP)? -
ANSWER Apply thromboembolic stockings.
A nurse is contributing to the plan of care for a client who has a positive throat culture for
streptococci. Which of the following interventions should the nurse recommend to be
included in the plan of care? - ANSWER Ensure that the client wears surgical mask
during transportation throughout the facility.
A nurse is speaking with a client who has type 2 diabetes mellitus and a prescription for
insulin. The client verbalizes anger about having to take insulin. Which of the following
responses should the nurse make? - ANSWER "I see that you are angry. Let's sit down
and talk."
1
, A nurse is calculating the intake and output for a client over the last 8hr. The client is
receiving a continuous IV infusion at 150mL/hr and had 4 oz of juice and 0.5L of water. How
many mL of fluid should the nurse document as the client's intake for the last 8 hr? -
ANSWER 1820mL
A nurse is reinforcing teaching with a client about the prevention of stress injuries. Which of
the following instructions should the nurse include? - ANSWER "When lifting a heavy
object, keep it close to your body."
A nurse is caring for a client who is refusing medical treatment. Which of the following
actions should the nurse take? - ANSWER Document the client's refusal of the
treatment.
A nurse is reinforcing teaching with a client who has a partial hearing loss about how to
modify the home environment. Which of the following is priority modification that the nurse
should include? - ANSWER Flashing smoke alarm
A nurse is repositioning a client who has quadriplegia and is in the supine position. Which of
the following actions should the nurse take to prevent client musculoskeletal injury? -
ANSWER Internally rotate the client's hips by using trochanter roll.
A nurse is assisting with the care of a recently deceased client. Which of the following
actions should the nurse complete prior to the family viewing the body? -
ANSWER Clean soiled areas of the body.
A nurse is reinforcing pre-op teaching with a client about how to turn, cough, and deep
breathe. Which of the following statements by the client indicates an understanding of the
teaching? - ANSWER "This can help prevent pneumonia."
2
statements indicates an understanding of the teaching? - ANSWER "The living will
directs my medical care when I am unable to make decisions. "
A nurse is reinforcing preoperative teaching with a client who speaks a different language
than the nurse. Which of the following actions should the nurse take? -
ANSWER Provide handouts written in the client's primary language.
A nurse is caring for a client who has recently undergone a total bilateral mastectomy. Which
of the following statements by the client requires immediate action by the nurse? -
ANSWER "When I look at myself in the mirror, I don't know if I can go on."
A nurse is caring for a post-op client who is at risk for thrombus formation. Which of the
following interventions should the nurse delegate to an assistive personnel (AP)? -
ANSWER Apply thromboembolic stockings.
A nurse is contributing to the plan of care for a client who has a positive throat culture for
streptococci. Which of the following interventions should the nurse recommend to be
included in the plan of care? - ANSWER Ensure that the client wears surgical mask
during transportation throughout the facility.
A nurse is speaking with a client who has type 2 diabetes mellitus and a prescription for
insulin. The client verbalizes anger about having to take insulin. Which of the following
responses should the nurse make? - ANSWER "I see that you are angry. Let's sit down
and talk."
1
, A nurse is calculating the intake and output for a client over the last 8hr. The client is
receiving a continuous IV infusion at 150mL/hr and had 4 oz of juice and 0.5L of water. How
many mL of fluid should the nurse document as the client's intake for the last 8 hr? -
ANSWER 1820mL
A nurse is reinforcing teaching with a client about the prevention of stress injuries. Which of
the following instructions should the nurse include? - ANSWER "When lifting a heavy
object, keep it close to your body."
A nurse is caring for a client who is refusing medical treatment. Which of the following
actions should the nurse take? - ANSWER Document the client's refusal of the
treatment.
A nurse is reinforcing teaching with a client who has a partial hearing loss about how to
modify the home environment. Which of the following is priority modification that the nurse
should include? - ANSWER Flashing smoke alarm
A nurse is repositioning a client who has quadriplegia and is in the supine position. Which of
the following actions should the nurse take to prevent client musculoskeletal injury? -
ANSWER Internally rotate the client's hips by using trochanter roll.
A nurse is assisting with the care of a recently deceased client. Which of the following
actions should the nurse complete prior to the family viewing the body? -
ANSWER Clean soiled areas of the body.
A nurse is reinforcing pre-op teaching with a client about how to turn, cough, and deep
breathe. Which of the following statements by the client indicates an understanding of the
teaching? - ANSWER "This can help prevent pneumonia."
2
