D439 EXAM QUESTIONS AND CORRECT
ANSWERS!!
The nurse is caring for four clients. The client with which clinical manifestation requires
immediate attention from the nurse?
Respiratory rate of 25 breaths per minute after resting for 3 minutes after activity
The nurse places a client who had abdominal surgery in the semi-Fowler position. The
client states, "I prefer to lie flat when in bed. I feel like I am almost sitting up." Which is an
appropriate response by the nurse?
"Lifting your chest above your abdomen facilitates drainage in your wound drains."
The nurse is educating a client who has just been prescribed a diuretic about how to safely
perform activities of daily living. Which statement should the nurse include in the teaching
Change positions slowly to minimize orthostatic hypotension
The nurse recognizes that which statements made by a patient indicate an understanding of
behaviors that will promote sleep? (Select all that apply.)
"I will not watch television in bed."
"I will not drink caffeine later in the day."
"I will start to exercise regularly during the day."
Your patient is being discharged home and will be required to self-administer injectable
Heparin. You are observing the patient administer their scheduled dose of Heparin to
confirm that the patient knows how to do it correctly. What action by the patient requires
you to re-educate them about how to administer Heparin?
The patient injects the needle 1 inch away from the umbilicus
, A nurse caring for patients in a long-term care facility is often required to collect urine
specimens from patients for laboratory testing. Which techniques for urine collection are
performed correctly? Select all that apply.
The nurse collects about 3 mL of urine from a patient's indwelling catheter to send for a urine
culture.
The nurse discards the first urine of the day when performing a 24-hour urine specimen
collection on a patient.
The nurse is caring for a 60-year-old client with a diagnosis of C-diff and is incontinent
who requires frequent linen changes. What should the nurse be most concerned for
Impaired skin integrity
The nurse is making an occupied bed. Which nursing action is most important
Ensuring that the client's head is supported and is in functional alignment
When giving a client a bed bath, a nurse washes the client's extremities from distal to
proximal. Which of the following rationales best supports this nursing action?
Stimulates Venous return
The nurse is caring for a debilitated female client with nocturia. Which nursing
intervention is the priority when planning to meet this client's needs
Positioning a bedside commode near the bed
The nurse plans to teach a client with hemiparesis to use a cane. Which should the nurse
teach the client to do? Select all that apply.
Hold the cane in the strong hand when walking
The nurse is caring for a group of clients in the post anesthesia care unit. Which response
by a client in the post anesthesia care unit is the priority concern for the nurse?
Reduced level of consciousness
ANSWERS!!
The nurse is caring for four clients. The client with which clinical manifestation requires
immediate attention from the nurse?
Respiratory rate of 25 breaths per minute after resting for 3 minutes after activity
The nurse places a client who had abdominal surgery in the semi-Fowler position. The
client states, "I prefer to lie flat when in bed. I feel like I am almost sitting up." Which is an
appropriate response by the nurse?
"Lifting your chest above your abdomen facilitates drainage in your wound drains."
The nurse is educating a client who has just been prescribed a diuretic about how to safely
perform activities of daily living. Which statement should the nurse include in the teaching
Change positions slowly to minimize orthostatic hypotension
The nurse recognizes that which statements made by a patient indicate an understanding of
behaviors that will promote sleep? (Select all that apply.)
"I will not watch television in bed."
"I will not drink caffeine later in the day."
"I will start to exercise regularly during the day."
Your patient is being discharged home and will be required to self-administer injectable
Heparin. You are observing the patient administer their scheduled dose of Heparin to
confirm that the patient knows how to do it correctly. What action by the patient requires
you to re-educate them about how to administer Heparin?
The patient injects the needle 1 inch away from the umbilicus
, A nurse caring for patients in a long-term care facility is often required to collect urine
specimens from patients for laboratory testing. Which techniques for urine collection are
performed correctly? Select all that apply.
The nurse collects about 3 mL of urine from a patient's indwelling catheter to send for a urine
culture.
The nurse discards the first urine of the day when performing a 24-hour urine specimen
collection on a patient.
The nurse is caring for a 60-year-old client with a diagnosis of C-diff and is incontinent
who requires frequent linen changes. What should the nurse be most concerned for
Impaired skin integrity
The nurse is making an occupied bed. Which nursing action is most important
Ensuring that the client's head is supported and is in functional alignment
When giving a client a bed bath, a nurse washes the client's extremities from distal to
proximal. Which of the following rationales best supports this nursing action?
Stimulates Venous return
The nurse is caring for a debilitated female client with nocturia. Which nursing
intervention is the priority when planning to meet this client's needs
Positioning a bedside commode near the bed
The nurse plans to teach a client with hemiparesis to use a cane. Which should the nurse
teach the client to do? Select all that apply.
Hold the cane in the strong hand when walking
The nurse is caring for a group of clients in the post anesthesia care unit. Which response
by a client in the post anesthesia care unit is the priority concern for the nurse?
Reduced level of consciousness
