(2024/2025) (All 55 Q&A) (100% Verified Q&A)
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The home health nurse visits an elderly client who lives at home with her husband. The
client is experiencing frequent episodes of diarrhea and bowel incontinence. Which
problem, for which the client is at risk, has the greatest priority when planning the
client's care?
A. fluid volume imbalance
B. impaired skin integrity
C. caregiver role strain
D. disturbed sleep pattern - A. fluid volume imbalance
A nurse observes a student nurse taking a copy of a client's medication administration
record. When questioned, the student states, "Another student is scheduled to
administer medications for this client tomorrow, so I am going to make a copy to help
my friend prepare for tomorrow's clinical". What response should the nurse provide
first?
A. Ask the nursing supervisor to meet with the students
B. Ask the client if permission was obtained from the client
C. explain the records are hospital property and may not be removed
D. notify the student's clinical instructor of the situation - C. explain the records are
hospital property and may not be removed
After a client has been premedicated for surgery with an opioid analgesic, the nurse
discovers that the operative permit has not been signed. What action should the nurse
implement?
A. read the consent form to the client before witnessing the client's signature
B. determine if the client's spouse is willing to sign the consent form
C. notify the surgeon that the consent form has not been signed
D. administer an opioid antagonist prior to obtaining the client's signature - C. notify the
surgeon that the consent form has not been signed
A client who has been on bedrest for several days now has a prescription to progress
activity as tolerated. When the nurse assists the client out of bed for the first time, the
client becomes dizzy. What action should the nurse implement?
A. Instruct the patient to remain on bedrest until the healthcare provider is contracted
B. encourage the client to take several slow, deep breaths while ambulating
C. advise the client to sit on the side of the bed for a few minutes before standing again
, D. help the client to remain standing by the bedside until the dizziness is relieved - C.
advise the client to sit on the side of the bed for a few minutes before standing again
The charge nurse observes an unlicensed assistive personnel (UAP) bending at the
waist to lift a 20-pound box of medical supplies off the treatment room floor. What
instruction should the charge nurse provide to the UAP?
A. ask another staff member for assistance
B. request that supplies are delivered in smaller containers
C. push the box against the wall to provide support while lifting
D. bend at the knees when lifting heavy objects - D. bend at the knees when lifting
heavy objects
An older female client with rheumatoid arthritis is complaining of severe joint pain that is
caused by the weight of the linen on her legs. What action should the nurse implement
first?
A. apply flannel pajamas to provide warmth
B. administer a PRN dose of ibuprofen
C. Drape the sheets over the foot board of the bed
D. perform ROM exercises in a warm tub - C. Drape the sheets over the foot board of
the bed
A client is admitted to the hospital with intractable pain. When instruction should the
nurse provide the unlicensed assistive personnel (UAP) who is preparing to assist this
client with a bed bath?
A. a client's pain will be difficult to manage, since the cause is still unknown
B. take measures to promote as much comfort as possible
C. report any signs of drug addiction to the nurse immediately
D. wait until the client's pain is gone before assisting with personal care - B. take
measures to promote as much comfort as possible
A male client arrives at the out patient surgery center for a scheduled needle aspiration
of the knee. He tells the nurse that he has already given verbal consent for the
procedure to the health care provider. What action should the nurse implement?
A. verify the client's consent with the health care provider
B. document that the client has given consent for the needle aspiration
C. witness the client's signature on the consent form
D. notify the healthcare provider that the client is ready for the procedure - C. witness
the client's signature on the consent form
In assessing a client's femoral pulse, the nurse must use deep pulsation to feel the
pulsation while the client is in a supine position. What action should the nurse
implement?
A. document the presence and volume of the pulse palpated
B. elevate the head of the bed and attempt to palpate the site again
C. record the presence of pitting edema in the inguinal area