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hh Style Qs & Case Scenarios – Verified Rationales –
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hh 100% Guarantee Pass hh hh
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1.
Anurseiscaringforaclientwhohashaddiarrheaforthepast4days.When assessingthe client,
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thenurseshouldexpectwhichofthefollowingfindings? Select all.
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A. Bradycardia
B. Hypotension
C. Fever
D. Poorskinturgor hh hh
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, E. Peripheraledema hh
h h Answer B,C,D hh h h
fever=caused by dehydration tachycardia not
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brady
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hypotension because of decreased BP from dehydrationfluid
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overload=peripheraledema
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2.
2. A nurse is preparing to administer a cleansing enema to an adult client in preparation
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foradiagnosticprocedure.Whichofthefollowingareappropriate steps for the nurse to
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take? Select all.
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A. Warm the enema prior to instillation
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B. Position the client on the left side w/the right leg flexed forward
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C. Lubricate the rectal tube or nozzle hh hh hh hh hh
D. Slowlyinserttherectaltubeabout2inches h h h h h h h
E. Hangtheenemacontainer24inchesabovetheclient'sanus
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, Answer A,B,C
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, Rationale-Distheappropriatelengthofinsertionforachild,3-4foranadult.
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-24 inches istoohigh &willcauseittoruntofast&possiblepainfuldistention ofthecolon,18 inches is therecommendedheight
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3. CananRNdelegatetotheLPNtoprovidetracheostomycaretoaclient with
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hh pneumonia?
AnswerYes.
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4. A nurse ona med-surg unit has received change-of-shift report &will
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hh clients.Whichofthefollowingclient'sneedsmaythenurseassign to an assistive
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hh personnel (AP)? hh
A. Feedingaclientwhowasadmitted24hrsagow/aspirationpneumonia h h h h h h h h h h
B. Reinforcingteachingw/aclientwhoislearningtowalkusingaquadcane h h h h h h h h h h h h
C. Reapplyingacondomcatheterforaclientwhohasurinaryincontinence h h h h h h h h hh h
D. Applying a sterile dressing to a pressure ulcer h h h h h h h h h h h h h h
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