a nurse at a rehabilitation facility is assisting with the admission of a client who has left hemiplegia following a stroke which of the following actions should the nurse take first
Written for
University Of Texas - Arlington
NUR N5315
All documents for this subject (10)
Seller
Follow
mikaelso
Reviews received
Content preview
PN FUNDAMENTALS VATI COMPLETE SOLUTION 2022
100% VERIFIED
1. A nurse at a rehabilitation facility is assisting with the admission of a client who has left
hemiplegia following a stroke. Which of the following actions should the nurse take first? ANS:
Determine the client's mental status
2. A nurse is planning care for a client who practices Judaism. Which of the following questions
should the nurse ask the client to better understand how he practices Judaism? ANS: "Do you
observe the Sabbath?"
3. A nurse is caring for a client who has a visual impairment. When setting up the client's meal
tray, the nurse should take which of the following actions? ANS: Describe food placement
using the numbers on the face of a clock
4. A nurse is reinforcing teaching with a male client about clean intermittent self-catheterization.
Which of the following instructions should the nurse include? ANS: Wash the catheter with
soap and water after use
5. A nurse is caring for a client who has a terminal illness. Which of the following is an expected
response by a family member during the anger stage of grieving? ANS: The family member
criticizes care provided by the nurse
6. A nurse is assisting with the plan of care for a client who is dying. Which of the following
interventions should the nurse include in the plan of care? ANS: Allow family to assist the
client with personal hygiene
7. A nurse is preparing to collect blood samples from an older adult client. Which of the following
actions should the nurse take when performing venipuncture? ANS: Apply the tourniquet over
the client's sleeve
8. A nurse is collecting data from a client who is receiving a continuous IV infusion of lactated
Ringer's for dehydration. Which of the following findings indicates infiltration of the solution into
the subcutaneous area? ANS: The area around the infusion site is cool to the touch
9. A nurse is reinforcing teaching about home safety with a client who is at risk for falls. Which of
the following client statements indicates an understanding of the teaching? ANS: I will secure
all of my electrical cords to the baseboard
10. A nurse is reinforcing teaching about sleep promotion with a client who reports having difficulty
sleeping. Which of the following client statements indicates an understanding of the teaching?
ANS: I should play music that relaxes me before I go to bed
11. A nurse is reinforcing teaching with the partner of a client who has left-sided weakness about
how to safely move the client from a bed to a chair at home. which of the following statements
by the partner indicates an understanding of the teaching? ANS: I'll bend at the knees when
lifting to get better leverage
, 12. 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? ANS: Participate in
screenings for tuberculosis
13. A nurse is monitoring an assistive personnel (AP) who is measuring a client's oxygen
saturation using a pulse oximeter. Which of the following observations by the nurse indicates
that the AP is correctly performing the task? ANS: The AP chooses a site with a capillary refill
of less than 2 seconds.
14. A nurse is reviewing the laboratory results of a client who has malnutrition and has been
receiving total parenteral nutrition (TPN). The nurse should identify that which of the following
laboratory values indicates the treatment has been effective? ANS: Prealbumin 28 mg/dL
15. A nurse is preparing to perform wound irrigation for a client who has a stage IV pressure ulcer.
Which of the following images indicates the appropriate supply the nurse should plan to use?
ANS: Nurse should select a 30 to 60 mL syringe and use an 18 to 19 gauge needle to irrigate
the client's wound.
16. A nurse is caring for a client who has vancomycin-resistant enterococci (VRE) in a wound.
Which of the following actions should the nurse take to control the transmission of this
infection? ANS: Wear a gown when assisting the client with hygiene care
17. A nurse is contributing to the plan of care for a client who follows a kosher diet. Which of the
following dietary interventions should the nurse expect to include in the plan? ANS: Withhold
foods that contain both meat and dairy products
18. A nurse is caring for a client who states that he is concerned that his neighbor, who works as
an assistive personnel (AP) on another inpatient unit, will access his records and share his
information with others. Which of the following is an appropriate response by the nurse? ANS:
"only those who are involved with some aspect of your care may access your health care
information"
19. A nurse is preparing to administer a medication intramuscularly to an adult client. Which of the
following is the preferred site for administering the medication to this client? ANS:
Ventrogluteal
20. A nurse is reinforcing discharge teaching about preventing thrombophlebitis with a client who
is postoperative. Which of the following statements by the client indicates an understanding of
the teaching? ANS: "I will do leg exercises every 1 to 2 hours while I am awake"
21. 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? ANS: Identify areas of
concern
22. A nurse is providing change-of-shift report for a client who had a stroke 48 hr ago. Which of
the following information should the nurse include in the report? ANS: The client's Glasgow
coma scale score
The benefits of buying summaries with Stuvia:
Guaranteed quality through customer reviews
Stuvia customers have reviewed more than 700,000 summaries. This how you know that you are buying the best documents.
Quick and easy check-out
You can quickly pay through credit card or Stuvia-credit for the summaries. There is no membership needed.
Focus on what matters
Your fellow students write the study notes themselves, which is why the documents are always reliable and up-to-date. This ensures you quickly get to the core!
Frequently asked questions
What do I get when I buy this document?
You get a PDF, available immediately after your purchase. The purchased document is accessible anytime, anywhere and indefinitely through your profile.
Satisfaction guarantee: how does it work?
Our satisfaction guarantee ensures that you always find a study document that suits you well. You fill out a form, and our customer service team takes care of the rest.
Who am I buying these notes from?
Stuvia is a marketplace, so you are not buying this document from us, but from seller mikaelso. Stuvia facilitates payment to the seller.
Will I be stuck with a subscription?
No, you only buy these notes for $9.49. You're not tied to anything after your purchase.