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A nurse is collecting data from a client who has an elevated
temperature with no sweating. Which of the following findings is an
indication of hypernatremia?
Thirst
Muscle twitching
Headache
Abdominal cramps
Thirst.
Rationale:
Thirst, combined with an elevated temperature and a lack of sweating,
can be an indication of hypernatremia.
A nurse is caring for a client who reports difficulty sleeping due to the
noise on the nursing unit. Which of the following actions should the
nurse take to reduce environmental noise?
Close the door to the client's room.
Turn off the alarms and beeps on monitoring equipment.
Conduct change-of-shift report outside the client's door.
, Keep the television on low in the client's room.
Close the door to the client's room.
Rationale:
The nurse should close the door to the client's room whenever
possible to reduce environmental noise.
A nurse is reinforcing teaching about health promotion with a
client. Which of the following actions should the nurse take first to
promote effective learning?
Identify areas of concern.
Prioritize learning objectives.
Demonstrate psychomotor skills.
Observe nonverbal communication.
Identify areas of concern.
Rationale:
The first action the nurse should take when using the nursing process
is to collect data from the client. Identifying and understanding the
client's concerns prior to reinforcing teaching promotes effective
learning.
A home health nurse is assisting with the plan of care for a
client. Which of the following should the nurse include during the
orientation phase of the helping relationship?
Review current client data.
Assist to meet client goals.
, Review shared memories of interactions with client.
Clarify the role of this individual nurse.
Clarify the role of this individual nurse.
Rationale:
The nurse should plan to establish a warm, caring relationship while
clarifying the role of each participant, which occurs during the
orientation phase of the relationship.
A nurse is preparing to assist with the admission of a client who has
pneumonia. Which of the following observations about the client's
room requires immediate attention?
The wall BP gauge is missing.
The room has no IV infusion pump.
The examination light above the bed does not work.
The wheel locks on the bed are malfunctioning.
The wheel locks on the bed are malfunctioning.
Rationale:
The greatest risk to this client is injury from a fall when getting into or
out of a bed that is unstable due to malfunctioning locks. Therefore,
the priority is to report and replace the bed before admitting the
client to the room.
A nurse is reinforcing teaching about health promotion with an older
adult client. Which of the following instructions to the client is an
example of secondary prevention?
, Participate in screenings for tuberculosis.
Follow dietary recommendations to reduce the risk for
osteoporosis.
Limit alcohol intake to one drink per day.
Perform yoga exercises three times per week.
Participate in screenings for tuberculosis.
Rationale:
The nurse should encourage the client to participate in screenings for
tuberculosis, a secondary prevention measure. Secondary prevention
measures focus on diagnosis and early intervention.
A licensed practical nurse (LPN) is receiving change-of-shift report for a
client who had a stroke. For which of the following tasks should the
nurse request assistance from a registered nurse (RN)?
Administering a cleansing enema
Staging a pressure ulcer
Inserting an indwelling urinary catheter
Performing passive range-of-motion exercises
Staging a pressure ulcer.
Rationale:
An LPN can collect data for the client and report findings to an RN.
However, staging a pressure ulcer requires advance knowledge and
skill, and is outside the scope of practice of an LPN. An RN should
assess the stage of a complex wound, such as a pressure ulcer, and