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A charge nurse in a long-term care unit is planning care for a group of clients.
Which of the following care tasks should the nurse plan to delegate to an
assistive personnel?
a) Evaluating the effectiveness of acetaminophen administered 30 min ago to a
client who reported a headache
b) Discussing upcoming dietary changes with a client who has new prescription
for a low-cholesterol diet
c) Measuring urine output every 2 hr for a client recently diagnosed with a
urinary tract
d) Inserting a temporary nasogastric tube for a client who has a prescription for
laboratory analysis of stomach content - ANSWER-c) Measuring urine output
every 2 hr for a client recently diagnosed with a urinary tract
A nurse is assisting with the plan of care for a client who has Alzheimer's
disease. Which of the following actions should the nurse recommend for the
plan of care?
a) Encourage the clients to talk about current events
b) Give directions using simple phrases
c) Orient the client to time and place twice per day
d) Rotate assistive personnel to help the client with ADLs - ANSWER-b) Give
directions using simple phrases
,A nurse is reinforcing teaching with a group of expectant parents regarding the
proper use of a car seat. Which of the following statements by a parent indicates
an understanding of the teaching?
a) "I will secure the seatbelt across my newborn's lap"
b) "I can move my child to a booster seat when she weighs 20 pound" (40lb)
c) "I will turn the car seat forward-facing when child is 10 months old" (2year
or20lb)
d) "I can place a rolled towel on each side of my newborn's head until he can
hold his head" - ANSWER-d) "I can place a rolled towel on each side of my
newborn's head until he can hold his head"
A nurse is reinforcing teaching about self-administration of nasal drops with a
client. Which of the following positions should the nurse recommend for
instillation of the drops?
A. Sims'
B. Prone
C. Supine
D. Orthopneic - ANSWER-C. Supine
A nurse is collecting data from the guardian of a toddler during a well-child
visit. The guardian express concerns to the nurse because his child has a poor
appetite, but drinks a quart of milk each day. The nurse should identify that this
practice places the toddler at risk for which of the following condition?
a) Celiac disease
b) Lactose intolerance
c) Acute renal failure
d) Iron-deficiency anemia - ANSWER-d) Iron-deficiency anemia
A nurse is collecting data from a client who has gastrostomy tube and is
experiencing diarrhea. Which of the following factor should the nurse identify
as a potential cause of the diarrhea?
,A. The formula infusion rate of the feeding was too slow.
B. The formula was given immediately following removal from the refrigerator.
C. The feeding tube was partially obstructed during the infusion.
D. The client is experiencing delayed gastric emptying. - ANSWER-B. The
formula was given immediately following removal from the refrigerator.
A nurse is reinforcing discharge teaching about limiting sodium intake with a
client who has a new diagnosis of cardiomyopathy. Which of the following
client responses indicates an understanding of the teaching?
A. "I can have mustard on my sandwiches."
B. "I can season foods with celery salt."
C. "I can have a frozen juice bar for dessert."
D. "I can drink vegetable juice with my meals." - ANSWER-C. "I can have a
frozen juice bar for dessert."
A nurse is assisting with planning care for a newly admitted client who has
anorexia nervosa. Which of the following interventions should the nurse
recommend to include in the plan of care?
a) Encourage the client to gain 2.3 kg (5 lb) per week
b) Monitor the client 15 min after meals
c) Weigh the client each morning after voiding
d) Reinforce teaching about healthy eating during meals - ANSWER-c) Weigh
the client each morning after voiding
A nurse is caring for a new born following a circumcision. Which of the
following manifestations indicates the newborn is experiencing pain?
A. Lip smacking
B. Diaphoresis
C. Hypoglycemia
D. Transient strabismus - ANSWER-A. Lip smacking
, A nurse is caring for a client who is using a non-rebreather mask for oxygen
delivery. The nurse should identify which of the following as an indication that
the equipment is functioning properly?
a) Air is heard escaping from around the mask
b) The flow control meter dial is at the correct setting
c) The attached reservoir bag is inflated
d) The exhalation ports are covered during inspiration and expiration -
ANSWER-c) The attached reservoir bag is inflated
A nurse is contributing to the discharge plans for four clients.The nurse should
identify that which of the following clients requires an interdisciplinary care
conference?
A. A client who had surgery for cataract removal and lives in a rural location
B. A client who has hemiparesis and lives alone.
C. A client who requires assistance to pay for dressing supplies
D. A clients who requires instruction regarding medication administration. -
ANSWER-B. A client who has hemiparesis and lives alone.
A nurse is caring for a client who is receiving total parenteral nutrition. Which
of the following laboratory results indicates a possible complication of this
therapy?
A. Serum calcium 12.5 mg/dL
B. BUN 16 mg/dL
C. Serum potassium 4.6 mEq/L
D. WBC count 8,000/mm3 - ANSWER-A. Serum calcium 12.5 mg/dL
A nurse is collecting health history data from a client who has hemorrhoids.
Which of the following findings should the nurse expect?
A. Chronic constipation
B. Excessive flatulence