Question:
skin tenting is a sign of
Answer:
fluid volume deficit (dehydration)
Question:
Which intervention would the community-based nurse perform to assist a
college student addicted to cocaine? Select all that apply.
Answer:
Assess, the frequency of abuse
Assess the nature of use
Assess the amount of consumption
,Question:
The newly hired nurse is assigned to a very disoriented client with soft wrist
restraints. The nurse asks the head nurse for the purpose of the client's
restraints. Which response by the head nurse is correct?
Answer:
The restraints discourage the client from ambulating alone."
Question:
The nurse is preparing to examine a client's abdomen. Identify the proper
order of the steps in the assessment of the abdomen, using the numbers 1-4,
with 1 = the first technique and 4 = the last technique:
Answer:
Inspections (eyes) auscultation, percussion, palpate
Question:
focused assessment
Answer:
assessment conducted to assess a specific problem; focuses on pertinent
history and body regions
,Question:
The nurse assesses a client with reports of abdominal pain. Which initial
action by the nurse is correct?
Answer:
Assess the symptomatic quadrant last " start with furthest away from the
problem and work your way
Question:
A postoperative client is being assessed by the nurse. Which assessment
finding does the nurse document as subjective?
Answer:
pain description
Question:
Which of the following is the nurse's legal responsibility when applying
restraints?
Answer:
Document the client's behavior.
Document the type of restraint used.
Obtain a written order from the physician except in an emergency, when the
client must be protected from injury to himself or others.
All of the above. (D)
, Question:
A client with an indwelling catheter reports a need to void. What is the
priority intervention for the nurse to perform?
Answer:
Check to see if the catheter is patent
Question:
The teaching plan for a client with diarrhea should include which
intervention?
Answer:
A. Drinking at least eight glasses of fluid each day
Question:
When administering a cleansing enema, which techniques should the nurse
use?
Answer:
Assist the client to a left side-lying (Sims) position
Raise container, release clamps, and allow solution to fill tubing before
administration.
Clamp tubing after solution is instilled
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