A nurse is teaching a client and his family how to care for the client's tracheostomy at home. Which of the following instructions is appropriate for the client and family?
1. Remove the outer cannula cautiously for routine cleaning.
2. Use tracheostomy covers when outdoors.
3. Use sterile tec...
A nurse is teaching a client and his family how to care for the client's tracheostomy at
home. Which of the following instructions is appropriate for the client and family?
1. Remove the outer cannula cautiously for routine cleaning.
2. Use tracheostomy covers when outdoors.
3. Use sterile technique when performing tracheostomy care at home.
4. Cleanse irritated skin with full-strength hydrogen peroxide. correct answers 2. Use
tracheostomy covers when outdoors.
A nurse is giving an end-of-shift report about a client admitted earlier that day with
pneumonia. Which of the following pieces of information is most essential to provide?
1. Admitting diagnosis
2. Diagnostic test results
3. Body temperature
4. Breath sounds correct answers 4. Breath sounds
**ABCs**
A nurse is checking blood pressures at a community health screening. Which of the
following clients is at high risk for primary hypertension?
1. A client who is pregnant
2. A client who has an elevated LDL
3. A client who takes oral contraceptives
4. A client who has kidney disease correct answers 2. A client who has an elevated
LDL
A nurse is planning care for a client who has had a stroke resulting in aphasia and
dysphagia. Which of the following tasks should the nurse assign to an AP? (Select all
that apply.)
- Assist the client with a partial bed bath.
- Measure the client's BP after the nurse administers an antihypertensive medication.
- Test the client's swallowing ability by providing thickened liquids.
- Use a communication board to ask what the client wants for lunch.
- Irrigate the client's indwelling urinary catheter. correct answers - Assist the client with
a partial bed bath.
- Measure the client's BP after the nurse administers an antihypertensive medication.
- Use a communication board to ask what the client wants for lunch.
,A nurse is caring for a client who is combative in the emergency department. The
provider orders wrist restraints after the client attempts to assault the admitting nurse.
Which of the following actions is appropriate for the nurse to take?
1. Tie restraints to the lower edge of the side rail.
2. Remove each restraint one at a time every 2 hr.
3. Ensure 3 finger-widths of space between the restraint and the client's wrist.
4. Use a square knot to securely tie the restraints to the bed. correct answers 2.
Remove each restraint one at a time every 2 hr.
**To perform ROM exercises and neurovascular checks**
A nurse is preparing to administer morphine 4 mg IV bolus to a client. Available is
morphine 5mg/mL. Which of the following is an appropriate nursing intervention?
1. Return the unused medication to the automatic dispensing system.
2. Keep the remaining medication at the client's bedside for later use.
3. Have a second nurse witness the disposal of remaining medication.
4. Lock remaining medication in secure cabinet. correct answers 3. Have a second
nurse witness the disposal of remaining medication.
A nurse is caring for a client who asks about the purpose of advance directives. Which
of the following is an appropriate response by the nurse?
1. "It allows the court to overrule an adult client's refusal of medical treatment."
2. "It permits a client to withhold medical information from health care personnel."
3. "It indicates the form of treatment a client is willing to accept in the event of a serious
illness."
4. "It allows health care personnel in the emergency department to stabilize a client's
condition." correct answers 3. "It indicates the form of treatment a client is willing to
accept in the event of a serious illness."
A nurse finds a client on the floor upon entering the client's room. The roommate reports
that the client was trying to get out of bed and fell over the bedrail onto the floor. Which
of the following is correct documentation of this incident?
1. Incident report completed.
2. Client climbed over the bedrails.
3. Client found lying on floor.
4. Client was trying to get out of bed. correct answers 3. Client found lying on floor.
**remember, be Objective in documentation**
A client who is postoperative is verbalizing pain as a 2 on a pain scale of 0 to 10. The
nurse understands that the preoperative teaching regarding pain control has been
effective when the client states which of the following?
,1. "I think I should take my pain medication more often, since it is not controlling my
pain."
2. "Breathing faster will help me keep my mind off of the pain."
3. "It may help me to listen to music while I'm lying in bed."
4. "I don't want to walk today, because I'm experiencing some pain." correct answers 3.
"It may help me to listen to music while I'm lying in bed."
**nonpharmacological intervention to pain**
A client demonstrates anger when the nurse does not respond within 5 min of ringing for
the nurse. Which of the following is an appropriate response by the nurse?
1. "I'm sorry, but another client needed my attention."
2. "I arrived as soon as I could. What can I do for you?"
3. "It must be frustrating. I have a few minutes now."
4. "We had an emergency on the unit, but now I'm here." correct answers 3. "It must be
frustrating. I have a few minutes now."
**therapeutic by acknowledging client's feelings**
A nurse is admitting a client who is having an exacerbation of heart failure. In planning
this client's care, when should the nurse initiate discharge planning?
1. During the admission process
2. As soon as the client's condition is stable
3. During the initial team conference
4. After consulting with the client's family correct answers 1. During the admission
process
**discharge planning starts at admission (patient needs for during and after hospital)**
A nurse manager is overseeing the care of a unit. Which of the following should the
nurse manager identify as a violation of HIPPA guidelines?
1. The assigned nurse reviews the medical chart with a nursing student.
2. A nursing student discusses a client's status with the assigned nurse at the bedside.
3. The assigned nurse returns a call to a client's Power of Attorney to discuss the
client's care.
4. A nursing student consults a former classmate to assist with her documentation.
correct answers 4. A nursing student consults a former classmate to assist with her
documentation.
**only those in direct care**
, A nurse is teaching a client about self-administering NPH insulin. Which of the following
actions by the client indicates a need for further teaching?
1. The client inserts the needle at a 30°-angle.
2. The client rolls the vial between both hands.
3. The client holds the syringe in place for 5 seconds following injection.
4. The client uses her anterior thigh as the injection site. correct answers 1. The client
inserts the needle at a 30°-angle.
**Insert needle at 45° to 90° (depending on adipose/fat tissue)**
A nurse is reviewing a client's fluid and electrolyte status. Which of the following findings
should the nurse report to the provider?
A nurse contacts the facility's interpreter to explain a therapeutic procedure for a client
who does not speak English. Which of the following guidelines should the nurse follow
when working with the interpreter?
1. Speak slowly to allow the interpreter to interpret each word.
2. Explain the purpose of the communication to the interpreter.
3. Address the interpreter when explaining the procedure information.
4. Supplement words with gestures and nonverbal reinforcement. correct answers 2.
Explain the purpose of the communication to the interpreter.
A nurse is preparing to perform nasopharyngeal suctioning for a client who is unable to
cough up excessive secretions. Which of the following actions is appropriate?
1. Use the clean technique throughout the procedure.
2. Insert the catheter as the client exhales.
3. Apply suction for up the 20 seconds.
4. Perform suctioning while removing the catheter. correct answers 4. Perform
suctioning while removing the catheter.
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