COMPREHENSIVE ANSWERS.
A nurse is preparing to administer a cleansing enema to a client. Which of
the following actions should the nurse take? - CorreCt Answers -Hold the
container of solution 30 cm (12in) above the anus.
A nurse is caring for a client who invested a poison and is now experiencing
a seizure. Which of the following is the priority action the nurse should
take? - CorreCt Answers -Check the patency of the clients airway
A nurse is completing discharge teaching with a client. Of the following
barriers to learning the nurse identifies with this client, which should the
nurse interpret as a need to postpone the session? - CorreCt Answers -Pain
A nurse is completing an 8hr I&O record for a client who consumed 4 Oz
juice, 6 Oz hot tea, 100 mL ice chips, an IV bonus of 159 mL, and 8 Oz
broth. The nurse should record how many mL of intake on the clients
record? - CorreCt Answers -
A nurse is caring for a client who has a prescription for a stool test for
guaiac. The nurse understands the purpose of the test is to check the stool
for which of the following substances? - CorreCt Answers -Blood
A nurse is instructing a young adult client about healthful sleep habits.
Which of the following statements should the nurse identify as an
indication that the client needs further teaching? - CorreCt Answers -I
watch television until I fall asleep at night
, A nurse is giving a presentation about client confidentiality to a group of
newly licensed nurses. Which of the following is an example of a violation
of confidentiality? - CorreCt Answers -Reporting laboratory findings to a
member of the clients family
An assistive personnel reports a clients vital signs as tympanic temp 98.8,
pulse 92/min, resp rate 18/min, and BP 98/58. Which of the following vital
signs should the nurse re-measure? - CorreCt Answers -BP
A nurse is caring for a client who requires droplet precautions. Which of the
following ppe should the nurse wear when setting up the clients meal tray? -
CorreCt Answers -Mask
A nurse is assessing a clients radial pulse and determines that the pulse is
irregular. Which of the following actions should the nurse take? - CorreCt
Answers -Assess the apical pulse for a full min
A nurse is caring for a client who had urinary incotinence. Which of the
following actions should the nurse implement to improve the development
of skin breakdown? - CorreCt Answers -Apply a moisture barrier ointment
to the clients skin.
A nurse is caring for several clients who are at various developmental
stages. The nurse should explain that, according to Erickson, acceptance of
death is a primary task of which of the following stages of psychosocial
development? - CorreCt Answers -