A nurse is preparing to apply a dressing for a client who has a stage 2 pressure injury. Which of the following types of dressing should the nurse use?
(Know all stages and all dressings pertaining to each stage) correct answers Hydrocolloid
-Transparent: stage 1
-Hydrocolloid: stage 2
-Algi...
A nurse is preparing to apply a dressing for a client who has a stage 2 pressure injury.
Which of the following types of dressing should the nurse use?
(Know all stages and all dressings pertaining to each stage) correct answers
Hydrocolloid
A nurse is caring for a client who has a terminal illness and is at the end of life. The
nurse should recognize that which of the following statements by the client's partner
indicates effective coping?
(make sure there is not false hope) correct answers "I am relying on support from out
family during this time"
A nurse is assessing an older adult client's risk for falls. Which of the following
assessments should the nurse use to identify the client's safety needs?
- Lacrimal apparatus
- Pupil Clarity
- Appearance of bulbar conjunctivae
- Visual Fields
- Visual Acuity correct answers -Pupil Clarity
-Visual Fields
-Visual Acuity
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?
- The top of the cane is parallel to the client's waist.
- When walking, the client moves the cane 46 cm forward.
-The client hold the cane on the stronger side of her body.
- The client moves her stronger limb forward with the cane. correct answers The client
hold the cane on the stronger side of her body.
(The top of the cane should be parallel to the client's greater trochanter).
(The client should advance 15-30 cm)
(The client should move the cane with her weaker foot.)
,A nurse is initiating a protective environment for a client who has had an allogeneic
stem cell transplant. Which of the following precautions should the nurse plan for this
client?
-Make sure the client's room has at least six air exchanges per hour.
-Make sure the client wears a mask when outside her room if there is construction in the
area.
-Place the client in a private room with negative-pressure airflow.
-Wear a N95 Respirator when giving the client direct care. correct answers Make sure
the client wears a mask when outside her room if there is a construction in the area
A nurse is providing discharge instructions to a client who will be using a walker. Which
of the following client statements indicates an understanding of the teaching?
-"I can place an extension cord across my living room to plug in my television."
-"I will hire someone to trim the trees that hangs low over the stairs of my front porch."
- "I will place my alarm clock on my bedroom dresser across the room."
-"I will replace the old throw rug in my kitchen with a new one." correct answers "I will
hire someone to trim the trees that hangs low over the stairs of my front porch."
A nurse is preparing to administer enoxaparin subcutaneously to a client. Which of the
following actions should the nurse take?
- Administer the medication with the needle at 45 degree angle.
-Administer the medication into the client's nondominant arm.
-Pull the client's skin lateral or downward prior to administration.
-Massage the injection site after medication. correct answers Administer the medication
with the needle at 45 degree angle.
A nurse manager is preparing to review medication documentation with a group of
newly licensed nurses. Which of the following statements should the nurse manager
plan to include in the teaching.
-"Use the complete name of the medication magnesium sulfate."
-"Delete the space between the numerical dose and the unit of measure."
-"Write the letter U when noting the dosage of Insulin."
-"Use the abbreviation SC when indicating an injection." correct answers "Use the
complete name of the medication magnesium sulfate."
A nurse is talking with the partner of a client who has dementia. The client's partner
expresses frustration about finding time to manage household responsibilities while
caring for their partner. The nurse should identify that the partner is experiencing which
of the following types of role-performing stress?
-Role ambiguity
-Sick role
-Role overload
-Role Conflict correct answers Role Overload.
, (Role ambiguity occurs when people are unclear about the expectations of their role in a
given situation.)
(Sick Role refers to the expectations placed on the individual who has the alteration in
health, rather than the caregiver.)
(Role conflict develops when a person must assume multiple roles that have opposing
expectations.)
A nurse is preparing an education program for staff about advocacy. Which of the
following information should the nurse include?
- Advocacy ensures client's safety, health, and rights.
-Advocacy ensures that nurses are able to explain their own actions.
- Advocacy ensures that nurses follow through on their promises to clients.
- Advocacy ensures fairness in client care delivery and use of resources. correct
answers Advocacy ensures client's safety, health, and rights.
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 NG tube.
-Position the client with HOB elevated to 30 degrees prior to the insertion of the NG
tube.
-Remove the NG tube if the client begins to gag or choke.
-Apply function to the NG tube prior to insertion.
-Have the client take sips of water to promote insertion of the NG tube into the
esophagus. correct answers Have the client take sips of water to promote insertion of
the NG tube into the esophagus.
A nurse is admitting a new client. Which of the following actions should the nurse take
while performing medication reconcilliation?
-Verify the client's name on their identification bracelet with the medication
administration record.
-Call the pharmacy to determine whether the client's medication are available.
-Compare the client's home medications with the provider's prescriptions.
-Place the client's home medication bottles in a secure location. correct answers
Compare the client's home medications with the provider's prescriptions.
A nurse is providing a discharge teaching to a client about self-administering heparin.
Which of the following instructions should the nurse include in the teaching?
-Insert the needle at a 15 degree angle.
-Aspirate for blood return prior to administration.
-Administer the medications in the abdomen.
-Massage the site following the injection. correct answers Administer the medication
into the abdomen.
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?
-During the admission process.
-As soon as the client's condition is stable.
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