A nurse is evaluating a client's use of a cane. Which of the following actions should the nurse identify as an indication of correct use?
1. The top of the cane is parallel to the client's waist.
2. When walking, the client moves the cane 46 cm (18 in) forward.
3. The client holds the cane on th...
A nurse is evaluating a client's use of a cane. Which of the following actions
shouldidentify
nurse the as an indication of
correct
1. The top use?of the cane is parallel to the
client's
2. Whenwaist.walking, the client moves the cane 46 cm (18 in)
forward.
3. The client holds the cane on the stronger side of
herThe
4. body.
client moves her stronger limb forward with the cane. correct
answers
The client3 should hold the cane on the stronger side of her body to increase
support and
maintain
alignment.
A nurse receives a report about a client who has 0.9% sodium chloride
infusing
125mL/hr. IV When
at the nurse performs the initial assessment, he notes that
the clientonly
received has 80mL over the last 2 hr. Which of the following actions
should the nurse
take
first?
1. Reposition the
client.
2. Document the client's IV intake in the medical
record.
3. Request a new IV fluid
prescription.
4. Check the IV tubing for obstruction. correct
answers
The 4
first action the nurse should take using the nursing process is to assess
the client.the
checking If IV tubing and verifying an obstruction, the nurse might be able
to facilitate
the flow of fluid through the tubing. This could re-establish the infusion rate
the provider
prescribe
d.
A nurse is caring for a client who requires an NG tube for stomach
decompression.
Which of the following actions should the nurse take when inserting the
NGPosition
1. tube? the client with the head of the bed elevated to 30° prior to
insertion of the NG
tube
.2. Remove the NG tube if the client begins to gag or
choke.
3. Apply suction to the NG tube prior to
insertion.
4. Have the client take sips of water to promote insertion of the NG
tube into thecorrect
esophagus.
answers
Taking sips
4 of water as the NG tube passes through the oropharynx will
close the over the trachea and prevent the tube from passing into
epiglottis
the trachea.
A nurse is reviewing a client's fluid and electrolyte status. Which of the
following
should thefindings
nurse report to the
provider?
1. BUN 15
mg/dL
2. Creatinine 0.8
mg/dL
3. Sodium 143
mEq/L
4. Potassium 5.4 mEq/L correct
answers 4
, This value is above the expected reference range of 3.5 to 5 mEq/L, so
the nurse
should report this finding to the provider. This client is at risk for
dysrhythmias.
A nurse is providing discharge instructions to a client who will be using a
of the following
walker. Which client statements indicates an understanding of the
teaching?
1."I can place an extension cord across my living room to plug in my
television."
2. "I will hire someone to trim the tree that hangs low over the stairs of my
front
3. porch."
"I will place my alarm clock on my bedroom dresser across
the"Iroom."
4. will replace the old throw rug in my kitchen with a new one."
correct answers
Clearing stairs of2any object that could cause the client to trip or require
themwhile
over to bend walking will decrease the risk
for falls.
A nurse is planning care for a client who has had a stroke, resulting in
aphasia andWhich of the following tasks should the nurse assign to an
dysphagia.
assistive
personnel?
SATA
1. Assist the client with a partial bed
bath.
2. Measure the client's BP after the nurse administers an antihypertensive
medication.
3. Test the client's swallowing ability by providing
thickened
4. liquids.
Use a communication board to ask what the client wants
forIrrigate
5. lunch. the client's indwelling urinary catheter. correct
answers 1,
Assisting 2, 4 with a bed bath poses minimal risk to the client and is
a client
within of
range the AP's
function.
Measuring a client's BP poses minimal risk to the client and is within the
AP's range of
functio
n.
Using a communication board poses minimal risk to the client and is
within of
range the AP's
function.
A nurse is caring for a client who is expressing anger about his diagnosis of
colorectal
cancer. Which of the following actions should the
nurse
1. take?the risk factors for colon
Discuss
2. Focus teaching on what the client will need to do in the future to manage
cancer.
hisProvide
3. illness. the client with written information about the phases of
loss
4. and grief.
Reassure the client that this is an expected response to grief. correct
answersthe
During 4 anger stage of the client's psychosocial adaptation to
illness, support
should the nurse the client and explain that this is an expected reaction
to a cancer
diagnosi
s.
A nurse is preparing to apply a dressing for a client who has a stage 2
pressure
Which of injury.
the following types of dressings should the
nurse use?
1.
Alginate
2.
Gauze
3.
Transparent
4. Hydrocolloid correct
answers 4 dressings promote healing in stage 2 pressure injuries by
Hydrocolloid
wound
creating a moist
bed.
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