1) A nurse is performing a Romberg's test during the physical assessment of a client. Which of the following techniques should the nurse use?
ANS: Have
... [Show More] the client stand with her arms at her side and her feet together.
2) A nurse is planning an deduction session for an older adult client who has just learned that she has type 2 diabetes mellitus. Which of the following strategies should the nurse plan to use with this client?
ANS: Allow extra time for the client to respond to questions
3) A nurse is teaching an older client who is at risk for osteoporosis about beginning a program of regular physical activity. Which of the following types of activity should the nurse recommend?
ANS: Walking briskly
4) A nurse is assessing an adult client who has been immobile for the past 3 weeks. The nurse should identify that which of the following findings requires further intervention?
ANS: Erythema on pressure points
5) A nurse is preparing to administer 0.5 mL of oral single-dose liquid medication to a client. Which of the following actions should the nurse take?
ANS: Gently shake the container of medication prior to administration.
6) A nurse is responding to a call light and finds a client lying on the bathroom floor. Which of the following actions should the nurse take first?
ANS: Check the client for injuries
7) A nurse is caring for a client who is expressing anger over his diagnosis of colorectal cancer. Which of the following actions should the nurse take?
ANS: Reassure the client that this is an expected response to grief.
8) A nurse in a clinic is caring for a middle adult client who states, "The doctor says that, since I am at an average risk for colon cancer, I should have routine screening. What does that involve?" Which of the following responses should the nurse make?
ANS: "You should have a fecal occult blood test every year."
9) A nurse is preparing to administer multiple medications to a client who has an enteral feeding tube. Which of the following actions should the nurse plan to take?
ANS: Flush the tube with 15 mL of sterile water.
10) A nurse is caring for a client who has a prescription for wound irrigation. Which of the following actions should the nurse take?
ANS: Cleanse the wound from the center outward.
11) A nurse is providing care to four clients. Which of the following situations requires the nurse the complete an incident report?
ANS: A client who has an IV infusion pump receives an additional 250 mL of IV fluid.
12) A nurse is caring for a client receiving fluid through a peripheral IV catheter. Which of the following findings at the IV site should the nurse identify as infiltration?
ANS: Skin blanching
13) A nurse is preparing a change-of-shift report. Which of the following tools or documents should the nurse use to communicate continuity of care?
ANS: Situation, background, assessment, and recommendation (SBAR)
14) A nurse is admitting a client who has an abdominal wound with a large amount of purulent drainage. Which of the following types of transmission precautions should the nurse initiate?
ANS: Contact precautions
15) A nurse is caring for a client who is having difficulty breathing. The client is lying in bed with a nasal cannula delivering oxygen. Which of the following interventions should the nurse take first?
ANS: Assist the client to an upright position.
16) A nurse is reviewin..........................................................................................................................................................................................................................................continued [Show Less]