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Asnursesatsaslong-
termscaresfacilitysisscaringsforsasclientswhosrequiressoralssuctioning.sWhichs
ofsthesfollowingssuppliessshouldsthesnursesplanstosusesforsthisstask?s-
sCORRECTsANSWER✔yankeursscatheter
rationale:sAsYankauerscathetersissascleanssuctionscathetersusedswhensperfor
mingsoralsandsoropharyngealssuctioningstosremovessecretionssfromsthesclie
nt'ssmouthstosfacilitatesbreathingsorsobtainsassamplesforsdiagnosticsevaluati
on.
Asnursesinsaslong-
termscaresfacilitysissservingsonsthesethicsscommittee,swhichsissaddressingsas
clientscaresdilemma.sWhichsofsthesfollowingsstrategiesswillsfacilitatesresolv
ingsthesdilemma?s(Selectsallsthatsapply.)s-
sCORRECTsANSWER✔[1]sdetermine sthesfactssrelatedstosthesdilemma.
[2]sidentifyspossiblessolution
[3]considersthesclientswishes
Asnursesisstalkingswithsasclientswhosessonsdiedsinsasmotor-
vehiclescrashs2sweekssago.sThesclientsstates,s"lsreallysthoughtsI'dsbesbackstos
mysusualsroutinessbysnow,sbutsIscan'tsthinksofsanythingselsesexceptsthatsmys
sonsissgone."sWhichsOfsthesfollowingsresponsessshouldsthesnursesmake?s-
,CORRECTsANSWER✔Grievingsforsyourssonsisshardswork.sitswillstakesa
s
ssmuchstimesassyousneedstoscomestostermsswithsyoursloss.
Asnursesissreinforcingsteachingswithsasclientsaboutscancersprevention.sThes
nursesshouldsincludesthatsfrequentsconsumptionsofswhichsofsthesfollowingsf
oodssincreasessthesrisksforsdevelopingscancer?s-
sCORRECTsANSWER✔Lamb
rationale:sincludingstunasfishsreducessrisksofsdevelopingscancer.
includingspoultrysreducessrisk,
Asnursesnoticessansassistivespersonnels(AP)stakingsasnapsinsthesbreaksrooms
duringsmealstime.sThesnursesalsosnotessthatsthesAPsissdrowsyswhilesperfor
mingsroutinestasks.sWhichsofsthesfollowingsactionssshouldsthesnursestake?s-
sCORRECTsANSWER✔Reportsthesobservation saboutsthesAPstosthesUnits
nursesmanager
Asnursesonsaspediatricsunitsisscollectingsdatasfromsfoursnewlysadmittedsclie
nts.sWhichsofsthesfollowingsclientssshouldsthesnursesidentifysassbeingsatsris
ksforsurinarysretention?s-
sCORRECTsANSWER✔Asschoolsageschildswhoshassallergic srhinitissands
isstakingsdiphenhydramine.
Asnursesisscaringsforsasclientsfollowingsasbronchoscopy.sWhichsofsthesfollo
wingsactionssshouldsthesnursestakesfirst?s-
sCORRECTsANSWER✔checksforsgagsreflex
,Asnursesissassistingswithsthesadmissionsofsasclientswhoshassaslatexsallergy.sT
hesnursesshouldsidentifysthatswhichsofsthesfollowingssuppliesshassthespotent
ialstoscontainslatex?s-
sCORRECTsANSWER✔Indwellingsurinaryscatheter
AsnursesissperformingspostmortemscaresforsasclientspriorstosthesarrivalsOfsth
esclient'ssfamilysforsviewingsOfsthesbody.sWhichsOfsthesfollowingsactionsss
houldsthesnursestake?s-
sCORRECTsANSWER✔Gentlysclosesthesclient's seyelids
Asnursesissreinforcingsteachingswithsasclientswhoshassdumpingssyndromesa
boutsmeasuresstosreducesmanifestations.sWhichsofsthesfollowingsinstructio
nssshouldsthesnursesincludesinsthesteaching?s-
sCORRECTsANSWER✔avoidsfoodsshighsinssugarscontent.
rationale:sThesnursesshouldsinstructsthesclientstosavoidssweetsfoods,swhichs
oftensincreasesthesmanifestationssofsdumpingssyndrome.sThesesmanifestati
onssincludesnausea,ssweating,sabdominalspain,sdiarrhea,sandsweakness.
Asnursesisscollectingsdatasfromsasclientswhosissexperiencingsassituationalscri
sissfollowingstheslosssofsasjob.sThesclientsstates,s"lsdon'tsthinksIscansgosthrou
ghsthissagain."sWhichsofsthesfollowingsactionssissthesnurse'sspriority?s-
sCORRECTsANSWER✔Determinesifsthesclientsissexperiencingspsychoti
csthinking.
Asnursesisscontributingstosthesplansofscaresforsasclientsfollowingsastransureth
ralsresectionsofsthesprostates(TURP).sWhichsofsthesfollowingsinterventionss
, shouldsthesnursesinclude?s-
sCORRECTsANSWER✔Irrigate sthesbladdersusingssterilestechnique
AsnursesisscaringsforsansinfantswhosissreceivingsIVsfluidssforsdehydration.s
Whichsofsthesfollowingsshouldsthesnursesrecognizesassaspositivesresponsest
osthestherapy?s-sCORRECTsANSWER✔Moistsmucussmembranes.
Asnursesissassistingswithsthesadmissionsofsasclientswhosissexperiencingsalco
holswithdrawal.sWhichsofsthesfollowingsmedicationssshouldsthesnursesexpe
ctsthesproviderstosprescribesforsthesclient?s-
sCORRECTsANSWER✔Chlordiazepoxide
rationale:sThesnursesshouldsexpectstosadministerschlordiazepoxidestosdecre
asesanxietysandsthesrisksforsseizuressassociatedswithsalcoholswithdrawal.
Asnursesisscaringsforsasclientswhosissscheduledsforssurgerysinsthesmorning.s
Thesnurseslearnssthatsthesclientshassdecidedsnotstoshavessurgerysevensthoug
hstheyshavesalreadyssignedsthesinformedsconsentsform.sWhichsofsthesfollow
ingsactionssshouldsthesnursestake?s-
sCORRECTsANSWER✔reportsthessituation stosthesproviderswhosobtained
sinformedsconsent.
Asnursesisscollectingsdatasfromsasclientswhosissinsseverespain.sWhichsofsthes
followingsquestionssshouldsthesnursesasksfirst?s-
sCORRECTsANSWER✔wheresissyourspainslocated