A nurse is caring for a client that has not voided for several hours. When percussing the client's bladder to
assess for distention, the nurse should expect to hear......
:-- Dullness
This indicates a full bladder
-Tympany means empty
-Hyperrenosance is an abnormal pulmonary s...
A nurse is caring for a client that has not voided for several hours. When percussing the client's bladder to
assess for distention, the nurse should expect to hear......
:-- Dullness
This indicates a full bladder
-Tympany means empty
-Hyperrenosance is an abnormal pulmonary sound
-Renosance is a vibration
A client is receiving intermittent nasogastric tube feedings. A nurse should aspirate the residual stomach
contents prior to administering a scheduled feeding to.....
:-- Determine absorption of feedings
Which medication should be delivered using the z-track method?
:-- Iron dextran(Imferon) to prevent tissue damage
A nurse is to administer medication to 2 clients sitting in the lounge with several other clients. What action by
the nurse is appropriate?
:-- Check name bands on the clients' arms
A client is to be checked for residual urine. At which time should the procedure be performed?
:-- Immediately after the client voids
A nurse is to obtain a residual urine specimen from an elderly client whose indwelling foley catheter was just
removed. What is the purpose of a residual urine specimen?
, 2
Elscores: Aug. 27, 24- 2024/2025
A nurse is caring for a client receiving intravenous therapy. What would indicate to the nurse that the
intravenous infusion has infiltrated?
:-- Cutaneous tissue at the intravenous site is swollen
-the IV catheter should be removed and a new site should be restarted
Which of the following measures should a nurse include in the plan of care of a patient with hyperthyroidism?
:-- Keeping the client's environment cool
-A client with hyperthyroidism is heat intolerant
-The client should be encouraged to eat foods high in calories because they are often below their ideal weight
and have difficulty maintaining a healthy weight
A nurse should reinforce the instructions to the family of a client who has propulsive gait related to Parkinsons
Disease?
:-- Keep the floor of the client's surroundings free of obstacles
-Propulsive gait is a stooping, rigid posture with the head and neck bent forward. Steps tend to become faster
and shorter.
-Encourage the client to ambulate as much as they want in order to maintain activity level
Which of these measures should a nurse emphasize when feeding a client with left side facial paralysis who has
difficulty swallowing?
:-- Placing the food on the unaffected side of the client's mouth
-prevents aspiration
Before assisting a patient who is on day postop OOB for the first time, a nurse should take which action?
:-- Assess pulse and blood pressure in order to assess the client for orthostatic
hypotension
Which of these objectives is most important to include in the care of a client with multiple sclerosis?
:-- Prevent contractures
-it will decrease the client's functional abilities
A client who is terminally ill with AIDS is admitted to the hospital. What precaution should be included in the
client's plan of care?
:-- Standard Precautions
A nurse is caring for a client who had a right lower lobectomy and has a closed water-sealed chest drainage
system in place. Which action should the nurse include as part of the plan of care?
:-- Keep the system below the level of the client's waist
-prevents backflow of fluids
A client who is suspected of having a hiatal hernia is admitted to the hospital. Which question is important for
the nurse to ask?
:-- "Do you experience heartburn after a large meal?"
-They need to eat small, frequent meals
A nurse discovers flames in a wastebasket in the room of a client who is a paraplegic. What action should the
nurse take first?
:-- Rescue the client
A nurse is caring for a client whose arms are in restraints. When is it essential for the nurse to remove the
restraints?
:-- Every 2hours to check circulation
-Manual restraints can decrease circulation
A nurse is instructing an adult client on the correct technique for ear drop instillation. What action by the
client indicates the need for further teaching?
:-- The client pulls the ear lobe down and back when administering the ear drops
-Ages 3 and up should be pulled up and outward
A nurse obtains lab results for a client prior to surgery. What should the nurse report to the physician?
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