Terms in this set (125)
D
Rationale: Because a shower is most beneficial for the client in terms of h
the client should receive teaching first, respecting any personal beliefs suc
cultural or spiritual values. After client teaching, the client may still choose
or B. Brochures reinforce the teaching.
A 20-year-old female client with a
noticeable body odor has refused to
shower for the last 3 days. She states, "I
have been told that it is harmful to bathe
during my period." Which action should
the nurse take first?
A.
Accept and document the client's wish to
refrain from bathing.
B.
Offer to give the client a bed bath,
avoiding the perineal area.
C.
Obtain written brochures about
menstruation to give to the client.
D.
Teach the importance of personal hygiene
during menstruation with the client.
, B
Rationale: The most important teaching is to change positions frequently b
pressure is the most significant factor related to the development of press
ulcers. Increased vitamin and fluid intake may also be beneficial and prom
A 65-year-old client who attends an adult healing and reduce further risk. Option D is an intervention of last resort b
daycare program and is wheelchair this will be very expensive for the client.
mobile has redness in the sacral area.
Which instruction is most important for the
nurse to provide?
A.
"Take a vitamin supplement tablet once a
day."
B.
"Change positions in the chair frequently"
C.
"Increase daily intake of water or other
oral fluids."
D.
"Purchase a newer model wheelchair."
, A, B, D, E
Rationale: The nurse must recommend high calorie/high nutrition foods fo
client who is unintentionally losing weight. The candy bar is high calorie, b
empty in nutritional value. The remaining selections are high calorie/high n
A 75-year-old client states to the nurse, "I
am just not hungry anymore." The client
has lost 10 pounds/4.53 kg in the past 4
months. Which snacks will the nurse
recommend to the client? (Select all that
apply.)
A.
Nuts
B.
Milkshakes
C.
Chocolate candy bar
D.
Peanut butter and crackers
E.
Glass of whole fat milk
, A, B, E
Rationale:As long as the client is not on a fluid restriction, offer no less tha
mL of fluid to keep the body well hydrated and keep respiratory secretions
Ambulation is key for this client. Sitting at the side of the bed is not a repla
for ambulating. Having the client sit up helps expand the lungs. Taking dee
A 76-year-old client has returned from breaths, through coughing or incentive spirometry, helps expand the lungs
surgery. The nurse plans on decreasing decrease atelectasis.
the chance of respiratory compromise for
this client. What will the nurse include in
this client's plan of care? (Select all that
apply.)
A.
Raise the head of the bed to no less than
a 45 degrees angle.
B.
Have the client use an incentive
spirometer 10 times every hour while
awake.
C.
Limit total fluid intake to no more than
1000 mL/day.
D.
Have the client sit on the side of the bed
instead of getting up and walking.
E.
Ask the client to take deep breaths and
cough five times every hour while awake.
D
Rationale: Because a shower is most beneficial for the client in terms of h
the client should receive teaching first, respecting any personal beliefs suc
cultural or spiritual values. After client teaching, the client may still choose
or B. Brochures reinforce the teaching.
A 20-year-old female client with a
noticeable body odor has refused to
shower for the last 3 days. She states, "I
have been told that it is harmful to bathe
during my period." Which action should
the nurse take first?
A.
Accept and document the client's wish to
refrain from bathing.
B.
Offer to give the client a bed bath,
avoiding the perineal area.
C.
Obtain written brochures about
menstruation to give to the client.
D.
Teach the importance of personal hygiene
during menstruation with the client.
, B
Rationale: The most important teaching is to change positions frequently b
pressure is the most significant factor related to the development of press
ulcers. Increased vitamin and fluid intake may also be beneficial and prom
A 65-year-old client who attends an adult healing and reduce further risk. Option D is an intervention of last resort b
daycare program and is wheelchair this will be very expensive for the client.
mobile has redness in the sacral area.
Which instruction is most important for the
nurse to provide?
A.
"Take a vitamin supplement tablet once a
day."
B.
"Change positions in the chair frequently"
C.
"Increase daily intake of water or other
oral fluids."
D.
"Purchase a newer model wheelchair."
, A, B, D, E
Rationale: The nurse must recommend high calorie/high nutrition foods fo
client who is unintentionally losing weight. The candy bar is high calorie, b
empty in nutritional value. The remaining selections are high calorie/high n
A 75-year-old client states to the nurse, "I
am just not hungry anymore." The client
has lost 10 pounds/4.53 kg in the past 4
months. Which snacks will the nurse
recommend to the client? (Select all that
apply.)
A.
Nuts
B.
Milkshakes
C.
Chocolate candy bar
D.
Peanut butter and crackers
E.
Glass of whole fat milk
, A, B, E
Rationale:As long as the client is not on a fluid restriction, offer no less tha
mL of fluid to keep the body well hydrated and keep respiratory secretions
Ambulation is key for this client. Sitting at the side of the bed is not a repla
for ambulating. Having the client sit up helps expand the lungs. Taking dee
A 76-year-old client has returned from breaths, through coughing or incentive spirometry, helps expand the lungs
surgery. The nurse plans on decreasing decrease atelectasis.
the chance of respiratory compromise for
this client. What will the nurse include in
this client's plan of care? (Select all that
apply.)
A.
Raise the head of the bed to no less than
a 45 degrees angle.
B.
Have the client use an incentive
spirometer 10 times every hour while
awake.
C.
Limit total fluid intake to no more than
1000 mL/day.
D.
Have the client sit on the side of the bed
instead of getting up and walking.
E.
Ask the client to take deep breaths and
cough five times every hour while awake.
