A nurse is reviewing the techniques for transferring a client from a bed to a
chair with a group of assistive personnel (AP). Which of the following
... [Show More]
instructions should the nurse include?
ANS: Use lower-body strength
RATIONALE: The nurse should instruct the AP to use lower-body strength when lifting a client to
reduce stress on the back
2. A nurse is participating in a quality improvement study about the
effectiveness of client pain management in the unit. Which of the following
strategies should the nurse use to collect data?
ANS: Review clients' charts for their rating of pain before pain medication was administered and 1 hr
after administration
RATIONALE: The nurse should collect data from clients' charts about pain ratings before and after
pain management interventions
3. A nurse is reinforcing teaching about confidentiality with a client who has a
new diagnosis of HIV. Which of the following information should the nurse
include in the teaching?
ANS: "Your HIV status will be shared with members of your health care team."
RATIONALE: The diagnosis of HIV or AIDS is shared with every member of the healthcare team who
provides direct care for the client, just like any other diagnoses
4. A nurse is planning care for a client who has a history of seizures. Which of
the following pieces of equipment should the nurse place in the client's room?
ANS: Suction catheter
RATIONALE: The nurse should place suction equipment in the room of a client who has a history of
seizures. During a seizure, the client might have excessive oral secretions or might vomit. If the
client's airway becomes occluded, then the nurse will need to suction the oral cavity to maintain a
patent airway A nurse in a provider's office is reviewing the medical record of a client who
requests a prescription for an oral contraceptive. Which of the following
findings should the nurse identify as a contraindication for oral contraceptive
use? ANS: Coronary artery disease
RATIONALE: Coronary artery disease is a contraindication to oral contraceptive use because it
increases the client's risk for myocardial infarction. Other contraindications for receiving oral
contraceptives include gallbladder disease, breast cancer, and hypertension\
6. A nurse is assisting with the care of a school-age child immediately following
surgery. The child weighs 21.8 kg (48 lb) and has a chest tube applied to
suction. Which of the following findings should the nurse report to the
provider?
ANS: 250 mL of sanguineous drainage over the last 3 hr
RATIONALE: The nurse should recognize that if more than 3 mL/kg/her of sanguineous drainage
occurs for more than 3 consecutive hours following surgery, it can indicate active hemorrhaging.
Therefore, 250 mL of sanguineous drainage from the child's chest tube is excessive and the nurse
should report this finding to the provider immediately
7. A nurse is collecting data from a client who is at 30 weeks of gestation and has
gestational diabetes. Which of the following findings should the nurse report
to the provider as an indication of hyperglycemia?
ANS: Polyuria
RATIONALE: The nurse should identify polyuria as an expected finding of hyperglycemia and report
this finding to the provider
8. A nurse is discussing home safety with a group of clients who have type 1
diabetes mellitus. Which of the following client statements indicates an
understanding of the teaching?
ANS: "I will dispose of my needles in a plastic laundry detergent container."
RATIONALE: The nurse should instruct the client to dispose of needles in a puncture-proof container,
such as a plastic laundry detergent container.
9. A nurse is caring for a client who has Alzheimer's disease. Which of the
following actions should the nurse take?
ANS: Encourage the client to reminisce about the past
RATIONALE: The client who has Alzheimer's disease has progressive loss of short-term memory
and might not be able to recall recent happenings and events. This can lead to increased
frustration. However, remote memory remains in place for a longer period of time and can elicit
feelings of happiness
10. A nurse is monitoring a client who is receiving telemetry. Which of the
following ECG findings should the nurse report to the provider?
ANS: PR interval 0.24 second [Show Less]