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
... [Show More] 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 ANSWER 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 ANSWER 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 ANSWER 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 ANSWER - 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 ANSWER 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 ANSWER 3. Have a second nurse
witness the disposal of remaining medication. [Show Less]