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ATI LEADERSHIP PROCTORED 2023
1. A client is brought to the emergency department following a motor-vehicle crash. Drug use is suspected in the crash, and a voided urine specimen is orde... [Show More] red. The client repeatedly refuses to provide the specimen. Which of the following is the appropriate action by the nurse? a. Tell the client that a catheter will be inserted. b. Document the client’s refusal in the chart. c. Assess the client for urinary retention. d. Obtain a provider’s prescription for a blood alcohol level. 2. A nurse is making shift assignments in a hospital. Which of the following tasks is appropriate to assign to a licensed practical nurse? a. Pick up the meal trays after lunch. b. Administer a nasogastric tube feeding. c. Plan break times for assistive personnel. d. Determine adequacy of ventilator settings. 3. A nurse preceptor is evaluating a newly licensed nurse’s competency in assisting with a sterile procedure. Which of the following actions indicates the newly licensed nurse is maintaining sterile technique? (SATA) a. Places sterile items within a 1.25 cm (0.5 in) border around the edges of the sterile field b. Opens the sterile pack by first unfolding the top flap away from her body c. Prepares a container of sterile solution on the field after putting on sterile gloves d. Removes the outside packaging of a sterile instrument before dropping it onto the sterile field e. Holds the sterile solution bottle with the label facing up 4. A nurse enters a client’s room and identifies that the client is receiving too much IV fluid because the IV pump is not working properly. Which of the following actions should the nurse take first? a. Auscultate the client’s lungs. b. Notify the provider. c. Place a faulty equipment tag on the pump. d. Complete an incident report. 5. A nurse is planning care for a group of clients and can delegate care to a licensed practical nurse (LPN) and an assistive personnel. Which of the following tasks should the nurse assign to the LPN? a. Reinforcing teaching with a client who is learning to self-administer insulin b. Ambulating a client who is scheduled for discharge later in the day c. Administering morphine IV bolus to a client who is hr postoperative d. Admitting a new client who has chronic back pain to the unit 6. A nurse is supervising a newly licensed nurse who is performing surgical asepsis. After donning a sterile gown and gloves, which of the following actions by the newly licensed nurse demonstrates correct aseptic technique? a. The nurse applies goggles. b. The nurse turns her back to the sterile field. c. The nurse holds her hands above her waist. d. The nurse puts on a face mask. 7. A nurse who is caring for a group of clients delegates collection of vital signs to an assistive personnel (AP). Which of the following actions should the nurse take to evaluate the delegated task? a. Review vital sign trends at the end of the shift. b. Recheck vital signs that are outside the expected reference range. c. Ask the AP to write a summary of the delegated tasks during the shift. d. Compare the vital signs the AP obtained with those taken by another AP on a previous shift. 8. A nurse is caring for four clients. Which of the following tasks can be delegated to an assistive personnel? a. Obtaining a stool sample from a client who has renal failure b. Monitoring a client who has a fluid restriction c. Assessing a client who just returned from hemodialysis d. Reviewing dietary instructions for a client who has kidney stones 9. A nurse is triaging a group of clients following a disaster. Which of the following clients should the nurse recommend for treatment first? a. A client who has a neck injury and is unable to breathe spontaneously b. A client who has two open chest wounds with a left tracheal deviation c. A client who has major burns over 75% of her body surface area d. A client who has bipolar disorder and is exhibiting signs of hallucination (Class 3) 10. A nurse manager is reviewing guidelines for informed consent with the nursing staff. Which of the following statements by a staff nurse indicates that the teaching was effective? a. “A family member can interpret to obtain informed consent from a client who is deaf.” b. “Consent can be given by a durable power of attorney.” c. “Guardian consent is required for an emancipated minor.” d. “The nurse can answer any questions the client has about the procedure.” 11. A nurse is caring for four clients. For which of the following clients should the nurse collaborate with the facility ethics committee? a. A middle adult client who leaves the facility against medical advice b. An older adult client who has advanced directives on file c. A young adult client who is participating in a medical research study d. An adolescent client whose parents refuse a blood transfusion for religious reasons 12. A nurse in an ambulatory care setting is orient a newly licensed nurse who is preparing to return a call to a client. The nurse should explain that which of the following is an objective of telehealth? a. Assessing client needs b. Developing client treatment protocols c. Providing medication reconciliation d. Establishing communication between providers (Community Health pg. 75) 13. A nurse is providing discharge teaching to a client who has a new diagnosis of diabetes. The client expresses concern about the cost of blood-glucose monitoring supplies. Which of the following actions should the nurse take? a. Refer the client to the social services department. b. Provide the client with a week’s worth of supplies from the hospital (still needs help paying after) c. Ask the provider about the possibility of less frequent monitoring (pt needs to monitor often) d. Recommend the client reuse the testing lancets (breaks the safety & infection protocol) 14. A charge nurse is receiving change-of-shift report. Which of the following situations should the charge nurse address first? a. A nurse on the previous shift wrote an incident report about a medication error. b. Two staff members have called to say they will be absent. c. Transport assistance is unavailable to take a client to occupational therapy. d. The emergency department nurse is waiting to give report on a new admission. 15. A nurse who is precepting a newly licensed nurse is discussing the client assignment for the shift. Which of the following actions should the nurse preceptor take first to demonstrate appropriate time management? a. Complete required tasks. b. Review the client’s new laboratory values. c. Determine client care goals (set/plan goals) d. Document assessment data. 16. A charge nurse is reviewing information about HIPAA with a group of staff nurses. Which of the following statements by a staff nurse indicates understanding? a. “Clients who participate in research studies forfeit their HIPAA right to privacy.” b. “HIPAA allows facility-specific coding of client health care information to ensure privacy.” c. “HIPAA prohibits the uploading of photographs of client’s providers to social media sites.” d. “HIPAA allows clients to request a review of their own medical records.” 17. A nurse is caring for a client who has a tumor. The provider recommends surgery. The client refuses, but the client’s partner wants the surgery performed. Which of the following is the deciding factor in determining if the surgery will be done? a. Whether the client understands the risk of refusing the procedure b. Whether the facility ethics committee reached a consensus on the case c. Whether the partner is the client’s durable power of attorney for health care d. Whether the client’s refusal is based on religious belief 18. A charge nurse is planning the care of four newborns. An assistive personnel and licensed practical nurse are available for staffing. Which of the following tasks should the nurse assign to a licensed practical nurse? a. Conduct the newborn hearing screening. (RN assessment) b. Administer a hepatitis B vaccine. c. Perform a New Ballard screening. (RN assessment) d. Obtain vital signs. (CNA) 19. During a staff meeting a unit manager reviews the results for documenting client education and finds that they are below the benchmark. Which of the following strategies should the nurse manager implement first? a. Train LPNs to reinforce teaching with clients using a standardized teaching plan. b. Determine factors that interfere with the documentation of client education. c. Include documentation of client education as part of unit nurses’ annual performance evaluation. d. Offer incentives for the staff once the unit’s results are back in adherence with the benchmark. 20. A nurse is explaining ethics and values to a newly licensed nurse. The nurse should explain that preventing client injury by removing a fall hazard demonstrates which of the following ethical principles? a. Utility b. Autonomy c. Nonmaleficence d. Veracity ........................................................................................................................................................................................................................CONTINUE. [Show Less]
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NURS 612 FINAL EXAM QUESTIONS AND ANSWERS 100 % CORRECT 2023
1. Assessing orientation to person, place, and time helps determine State of consciousness 2. under most conditions, adult patients should be able to... [Show More] repeat a series of numbers. five to eight 3. Recent memory may be tested by showing the patient four items and asking him or her to list the items about 10 minutes later 4. Which condition is considered progressive rather than reversible? Dementia 5. An older adult is administered the Set Test and scores a 14. The nurse interprets this score as indicative of dementia 6. Which of the following is usually related to structural diseases of the brain? Dementia 7. A state of impaired cognition, consciousness, mood and behavioral dysfunction of acute onset refers to Delirium 8. The mini-mental state examination should be administered for a patient who gets lost in her or his neighborhood 9. The mini-mental state examination may be used to estimate cognitive changes quantitatively 10. While interviewing a 70-year-old female clinic patient, she tells you that she takes ginkgo biloba and St John's wort. You make a short note to check for results of the Mini-mental state examination 11. For purpose of examination and communication of physical findings, the breast is divided into four quadrants plus a tail 12. When conducting a clinical breast examination, the examiner should Inspect both breasts simultaneously 13. Which breast change is typical after menopause? thickening of the inframammary ridge 14. in a woman complaining of a breast lump, it is most important to ask about its relationship to menses 15. A 50 year old woman presents as a new patient. which finding in her personal and social history would increase her risk profile for developing breast cancer? nulliparity ..........................................................................................................................................................................................................................CONTINUE. [Show Less]
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HESI EXIT RN 2022 V3 160 Questions 2023
1. A male client with stomach cancer returns to the unit following a total gastrectomy. He has a nasogastric tube to suction and is receiving Lactated Ring... [Show More] er’s solution at 75 mL/hour IV. One hour after admission to the unit, the nurse notes 300 mL of blood in the suction canister, the client’s heart rate is 155 beats/minute, and his blood pressure is 78/48 mmHg. In addition to reporting the finding to the surgeon. Which action should the nurse implement first? a. Measure and document the client’s urinary output. b. Request the client’s reserved unit if packed red blood cells. c. Prepare the placement of a central venous catheter. d. Increase the infusion rate of Lactated Ringer’s solution. 2. an adult male who fell 20 feet from the roof of this home has multiple injuries, including a right pneumothorax. Chest tubes were inserted in the emergency department prior to his transfer to the intensive care unit (ICU). the nurse notes that the suction control chamber is bubbling at the - 10 cm H2O mark, with fluctuation in the water seal, and over the past hour 75 ml of bright red blood is measured in the collection chamber. Which intervention should the nurse implement? a. Add sterile water to the suction control chamber. b. Give blood from the collection chamber as autotransfusion c. Manipulate blood in tubing to drain into chamber. d. Increase wall suction to eliminate fluctuation in water seal. 3. A client who received hemodialysis yesterday is experiencing a blood pressure of 200/100 mmHg, heart rate 110 beats/minute, and respiratory rate 36 breaths/minute. The client is manifesting shortness of breath, bilateral 2+ pedal edema, and an oxygen saturation on room air of 89%. Which action should the nurse take first? a. Elevate the foot of the bed. b. Restrict the client’s fluid. c. Begin supplemental oxygen. d. Prepare the client for hemodialysis. 4. A client with Addison’s crisis is admitted for treatment with adrenal cortical supplementation. Based on the client’s admitting diagnosis, which findings require immediate action by the nurse? (Select all that apply) a. Headache and tremors b. Irregular heart rate c. Skin hyperpigmentation d. Postural hypotension e. Pallor and diaphoresis 5. An older client is admitted with fluid volume deficit and dehydration. Which assessment finding is the best indicator of hydration that the nurse should report to the healthcare provider? a. Urine specific gravity is 1.040 b. Systolic blood pressure decreases 10 points when standing. c. The client denies being thirsty. d. Skin tenting occurs when the client’s forearm is pinched. 6. After an inservice about electronic health record (EHR) security and safeguarding client information, the nurse observes a colleague going home with printed copies of client information in a uniform pocket. Which action should the nurse take? a. File a detailed incident report with the specific hiring facility. b. Warn the colleague that their actions are unprofessional. c. Comment anonymously about the action of a staff discussion board. d. Communicate the colleague’s actions to the unit charge nurse. 7. The nurse is evaluating a tertiary prevention program for clients with cardiovascular disease implemented in a rural health clinic. Which outcome indicate the program is effective? a. At-risk clients received an increased number of routine health screenings. b. Clients reported having new confidence in making healthy food choices. c. Clients who incurred disease complications promptly received rehabilitation. d. Client relapse rate of 30% in a 5-year community-wide anti-smoking campaign. 8. The nurse is caring for a client with chronic obstructive pulmonary disease (COPD) who uses oxygen at 2 L/minute per nasal cannula continuously. The nurse observes that the client is having increased shortness of breath with respirations at 23 breaths/minute. Which action should the nurse implement first? a. Determine if the client is experiencing any anxiety. b. Auscultate the client’s bilateral lung sounds and oxygen saturation. c. Notify the healthcare provider about the client’s distress. d. Assess the delivery mechanism of the oxygen tank, tubing, and cannula. 9. Which statement by a client who is 24 hours post-subtotal thyroidectomy requires an immediate investigation by the nurse? a. “When I get out of bed quickly, I feel a little dizzy.” b. “The dressing over my incision feels like it is too tight.” c. “I’m most comfortable when the head of the bed is raised.” d. “This IV infusion makes me urinate more often than usual.” 10. An older adult male who is in his early 70’s is admitted to the emergency department because of a COPD exacerbation. This client is struggling to breathe and the healthcare team is preparing for endotracheal intubation. The spouse’s wife, who is 30 years younger than the client, asks the nurse to stop the procedure and provide the nurse a copy of the client’s living will. Which action should the nurse take? a. Facilitate a family meeting with the palliative care team. b. Notify the healthcare provider of the client’s wishes. c. Place a certified copy of the living will in the client’s record. d. Alert the nursing staff of the client’s don’t resuscitate status. 11. An unlicensed assistive personnel (UAP) is assigned to provide personal care for a client whose prescribed activity is bedrest with bedside commode use. The UAP reports to the nurse that the client is so obese that the UAP feels unable to safely assist the client in transferring from the bed to the bedside commode. How should the nurse respond? a. Determine the client’s level of mobility and need for assistance. b. Instruct the UAP that all clients deserve equal care. c. Advice the client to maintain bedrest so that safety can be ensured. d. Assign another UAP to care for the client. 12. A nurse determines that more than 25% of the students at a middle school are overweight. The nurse presents the information at the parent-teacher meeting. What action is most important for the nurse to include in the meeting? a. Provide information on ways to increase activity for the family. b. Have several teachers talk about health risks associated with obesity. c. Distribute a shopping list of suggested healthy snack items. d. Determine the parents’ degree of concern about their children’s weight. 13. After several months of chronic fatigue, morning stiffness, and join pain, a young adult is diagnosed with rheumatoid arthritis, and the healthcare provider prescribes prednisone. Which education should the nurse provide the client with regard to taking prednisone? a. Take prednisone doses before meals on an empty stomach. b. Wear sunglasses when exposed to bright sunlight. c. If sequential doses are missed, notify the healthcare provider. d. Schedule a monthly laboratory visit for a complete blood count. 14. The psychiatric nurse is caring for clients on an adolescent unit. Which client requires the nurse’s immediate attention? a. A 16-year-old client diagnosed with major depression who refuses to participate in group. b. A 14-year-old client with anorexia nervosa who is refusing to eat the evening snack. c. An 18-year-old client with antisocial behavior who is being yelled at by other clients d. A 17-year-old client diagnosed with bipolar disorder who is pacing around the lobby.. 15. The nurse caring for a child with mononucleosis can expect the child to exhibit which symptoms? a. Positive Epstein-Barr, and malaise. b. Ear pain and fever. c. Elevated WBC and sedimentation rate. d. Increased BUN and serum creatinine. ..........................................................................................................................................................................................................................CONTINUE. [Show Less]
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Nursing Leadership Exam 2 Questions and Answers
Communication Leadership 1. The process in which information, perception, and understanding are transmitted from person to person is: a. articulation. ... [Show More] b. communication. c. evaluation. d. pronunciation. Communication is the process in which information, perception, and understanding are transmitted from person to person. 2. Unspoken affective or expressive behaviors best describe which type of communication? a. Effective communication b. Ineffective communication c. Non-verbal communication d. Verbal communication Non-verbal communication is unspoken. It is composed of affective or expressive behaviors. 3. A communication model that focuses on compassion, expression of emotion, and providing validation via support is the: a. validation, emotion, reassurance, activity (VERA) framework. b. situation, background, assessment, and recommendation (SBAR) Communication Theory. c. nonviolent communication (NVC) model. d. Human Relationship Model. The VERA (validation, emotion, reassurance, activity) framework for communication was developed to meet a need for nursing students who were at a loss to communicate with persons with communication difficulties (Hawkes et al., 2015). 4. A human communication activity designed to influence another to change attitudes or alter behaviors by the use of techniques such as argument, reasoning, or pleading is known as: a. advisement. b. consultation. c. persuasion. d. suggestion. Persuasion is a human communication activity designed to influence another to change attitudes or alter behaviors by the use of techniques such as argument, reasoning, or pleading. 5. Which of the following is true about negotiation? a. It commonly results in a win-lose situation. b. It is aimed at solving problems, conflicts, or disputes. c. It is used only in contract and labor union disputes. d. It is the exchanging of favors or trading activity. Negotiation is a dialogical discussion between two or more parties to arrive at an agreement about some issue. It is used to solve problems, conflicts, or disputes. 6. A nursing preceptor is giving feedback to a new nurse who currently is being oriented. Her preceptor suggests a better method of interacting with a family member by saying, “You might want to be cognizant of your non-verbal behaviors when talking with clients. Rather than continuing to chart when you are talking with an American family, stop charting, move closer to the family and client, look at them during the conversation, and take time to let them share their concerns.” This preceptor is giving advice about: a. interpersonal communication. b. clarity. c. image. d. intention. If the verbal message is clear, but the non-verbal communication is not congruent, then listeners may misinterpret, distrust, or not even hear the intended message. In this situation, the nurse’s non-verbal behavior may suggest that she is not interested in interacting with the family. 7. The transformational leader engages staff by: a. punishing errors. b. sharing vision and decision making. c. taking a top-down approach to leadership. d. making unilateral decisions for the team. Effective transformational nurse leaders will engage their staff through role modeling and mentorship of inclusion behaviors such as developing rapport, sharing vision and decision making, providing constructive feedback, and communicating successful outcomes. The communication of transformational leaders is focused on positive interchanges, rather than punishment, and inclusion in decision making versus authoritarianism. 8. An example of an external variable that may affect communication is: a. circumstance. b. personality. c. thoughts. d. feelings. Communication may be affected by the interaction of external variables (others, a situation) and internal variables (you). Internal factors are the only thing under our own control. We have little control over others or the situation, because those are external to us. 9. communication patterns exist between colleagues and serve to contribute to a hostile work environment, high turnover, burnout, and job dissatisfaction. a. Defensive b. Disruptive c. Negotiating d. Humanizing Documentation in literature is extensive regarding disruptive and distracting communication interactions not only between nurses and colleagues but also between nurses and patients. The research indicates that nursing personnel experience high turnover rates, job dissatisfaction, and burnout; many registered nurses are leaving the profession. The work environment is described as hostile to nurses, and patient outcomes of increased severity of illness and mortality have been directly related to poor communication skills of the staff. 10. Over lunch in the cafeteria, student nurses are sharing educational information about the patients for whom they are caring. This is a(n): a. breach of beneficence. b. example of maleficence. c. potential assault and battery charge. d violation of the Health Insurance Portability and Accountability Act (HIPAA). . HIPAA provisions have heightened awareness about and encouraged strategies to protect a patient’s privacy in health care transactions. This is an example of breach of confidentiality. 11. Interpersonal communication is defined as: a. the conscious intent by one individual to modify the thoughts or behaviors of others. b. a combination of written and spoken communication. c. a theory used to describe a manner of communicating. d. communication between two or more individuals involving face-to-face interaction. Interpersonal communication is defined as communication between two or more individuals involving face-to-face interaction while all parties are aware of the others on an ongoing basis. 12. Organizational tones are based mostly on: a. unspoken cultural norms. b. commitment to success. c. communication behavior. d. leadership styles. The entire tone of the organization is based mostly on unspoken cultural norms. Because nurses make up the bulk of the health care workforce, having nurse leaders at the helm of the organization can influence the culture and climate of the organization as a whole. 13. Which communication technique is most effective when handling patient complaints? a. Persuasion b. Bargaining c. Negotiation d. Non-verbal cues Negotiation is a dialogical discussion between two or more parties to arrive at an agreement about some issue. 14. A communication system developed originally to address communication patterns in critical situations is: a. VERA framework. b. NVC model. c. crucial conversations. d. TeamSTEPPS. Communication effectiveness becomes crucial in times of emergency or disaster. TeamSTEPPS was initially developed to address communication issues between nurses and providers during critical patient events. 15. The number one cause of preventable medical errors is: a. hostile work environments. b. poor communication. c. ineffective leadership. d. staff competency. The Agency for Healthcare Research and Quality (AHRQ) has collected data regarding patient safety over many years. They discovered that poor communication was the number one cause of preventable medical errors (Kleiner et al., 2014). After discovering the staggering number of preventable medical errors and recognizing that communication problems were cited as the number one contributor, the AHRQ partnered with the Department of Defense (DOD) and developed the TeamSTEPPS program (AHRQ, 2016). ...........................................................................................................................................................................................................CONTINUE. [Show Less]
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NCLEX RN Cardiovascular Questions & Answers Revision Guide 2023
A client admitted to the hospital with chest pain and a history of type 2 diabetes mellitus is scheduled for cardiac catheterization. Which medication woul... [Show More] d need to be withheld for 24 hours before the procedure and for 48 hours after the procedure? 1. Glipizide 2. Metformin 3. Repaglinide 4. Regular insulin 2. A client who had cardiac surgery 24 hours ago has had a urine output averaging 20 mL/hour for 2 hours. The client received a single bolus of 500 mL of intravenous fluid. Urine output for the subsequent hour was 25 mL. Daily laboratory results indicate that the blood urea nitrogen level is 45 mg/dL (16 mmol/L) and the serum creatinine level is 2.2 mg/dL (194 mcmol/L). On the basis of these findings, the nurse would anticipate that the client is at risk for which problem? 1. Hypovolemia 2. Acute kidney injury 3. Glomerulonephritis 4. Urinary tract infection 3. The nurse is reviewing an electrocardiogram rhythm strip. The P waves and QRS complexes are regular. The PR interval is 0.16 seconds, and QRS complexes measure 0.06 seconds. The overall heart rate is 64 beats/minute. Which action should the nurse take? 1. Check vital signs. 2. Check laboratory test results. 3. Notify the health care provider. 4. Continue to monitor for any rhythm change. 4. A client is wearing a continuous cardiac monitor, which begins to sound its alarm. The nurse sees no electrocardiographic complexes on the screen. Which is the priority nursing action? 1. Call a code. 2. Call the health care provider. 3. Check the client's status and lead placement. 4. Press the recorder button on the electrocardiogram console. 5. The nurse is evaluating a client's response to cardioversion. Which assessment would be the priority? 1. Blood pressure 2. Status of airway 3. Oxygen flow rate 4. Level of consciousness 6. The nurse is caring for a client who has just had implantation of an automatic internal cardioverter-defibrillator. The nurse should assess which item based on priority? 1. Anxiety level of the client and family 2. Presence of a Medic-Alert card for the client to carry 3. Knowledge of restrictions on post-discharge physical activity 4. Activation status of the device, heart rate cutoff, and number of shocks it is programmed to deliver 7. A client's electrocardiogram strip shows atrial and ventricular rates of 110 beats/minute. The PR interval is 0.14 seconds, the QRS complex measures 0.08 seconds, and the PP and RR intervals are regular. How should the nurse correctly interpret this rhythm? 1. Sinus tachycardia 2. Sinus bradycardia 3. Sinus dysrhythmia 4. Normal sinus rhythm 8. The nurse is assessing the neurovascular status of a client who returned to the surgical nursing unit 4 hours ago after undergoing aortoiliac bypass graft. The affected leg is warm, and the nurse notes redness and edema. The pedal pulse is palpable and unchanged from admission. How should the nurse correctly interpret the client's neurovascular status? 1. The neurovascular status is normal because of increased blood flow through the leg. 2. The neurovascular status is moderately impaired, and the surgeon should be called. 3. The neurovascular status is slightly deteriorating and should be monitored for another hour. 4. The neurovascular status is adequate from an arterial approach, but venous complications are arising. 9. The nurse is evaluating the condition of a client after pericardiocentesis performed to treat cardiac tamponade. Which observation would indicate that the procedure was effective? 1. Muffled heart sounds 2. A rise in blood pressure 3. Jugular venous distention 4. Client expressions of dyspnea 10. A client with variant angina is scheduled to receive an oral calcium channel blocker twice daily. Which statement by the client indicates theneed for further teaching? 1. "I should notify my doctor if my feet or legs start to swell." 2. "My doctor told me to call his office if my pulse rate decreases below 60." 3. "Avoiding grapefruit juice will definitely be a challenge for me, since I usually drink it every morning with breakfast." 4. "My spouse told me that since I have developed this problem, we are going to stop walking in the mall every morning." 11. The nurse is monitoring a client with acute pericarditis for signs of cardiac tamponade. Which assessment finding indicates the presence of this complication? 1. Flat neck veins 2. A pulse rate of 60 beats/minute 3. Muffled or distant heart sounds 4. Wheezing on auscultation of the lungs 12. The home care nurse is providing instructions to a client with an arterial ischemic leg ulcer about home care management and self-care management. Which statement, if made by the client, indicates a need for further instruction? 1. "I need to be sure not to go barefoot around the house." 2. "If I cut my toenails, I need to be sure that I cut them straight across." 3. "It is all right to apply lanolin to my feet, but I shouldn't place it between my toes." 4. "I need to be sure that I elevate my leg above the level of my heart for at least an hour every day." 13. The nurse is providing instructions to a client with a diagnosis of hypertension regarding high-sodium items to be avoided. The nurse instructs the client to avoid consuming which item? 1. Bananas 2. Broccoli 3. Antacids 4. Cantaloupe 14. The nurse is preparing discharge instructions for a client with Raynaud's disease. The nurse should plan to provide which instruction to the client? 1. Use nail polish to protect the nail beds from injury. 2. Wear gloves for all activities involving the use of both hands. 3. Stop smoking because it causes cutaneous blood vessel spasm. 4. Always wear warm clothing, even in warm climates, to prevent vasoconstriction. 15. The nurse is developing a plan of care for a client with varicose veins in whom skin breakdown occurred over the varicosities as a result of secondary infection. Which is a priority intervention? 1. Keep the legs aligned with the heart. 2. Elevate the legs higher than the heart. 3. Clean the skin with alcohol every hour. 4. Position the client onto the side during every shift. Rationale: In the client with a venous disorder, the legs are elevated above the level of the heart to assist with the return of venous blood to the heart. Alcohol is very irritating and drying to tissues and should not be used in areas of skin breakdown. Option 4 specifies infrequent care intervals, so it is not the priority intervention. ......................................................................................................................................................................................................................CONTINUE. [Show Less]
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