1. A community health nurse is evaluating eligibility for home assistance for a client
who isquadriplegic. Which of the following actions should the
... [Show More] nurse perform first?
a. Determine the client's living situation.
b. Problem solved with the client.
c. Offer community resources to the client.
d. Assist the client with decision-making.
2. A nurse is discussing care with a newly licensed nurse for a client who practices Orthodox
Judaism. Which of the following meals suggestions by the newly licensed nurse indicates a
needfor further teaching?
a. Chicken breast and boiled potatoes.
b. Carrot sticks and cottage cheese.
c. Grilled cheese an Apple
sauce.d. Roast beef and ice
cream.
3. A nurse is preparing to auscultate a client apical pulse at the point of maximal impulse
(PMI). thenurse should place the diaphragm of the stethoscope at which of the following
locations
a. Within the angle of Louis.
b. 5th intercostal space at the left midclavicular line.
c. Second intercostal space to the right of the sternum.
d. Over the xyphoid process.
4. A nurse is caring for a client who is receiving a blood transfusion at 125 mL/hour and
develops ahemolytic reaction. Which of the following actions should the nurse perform?
a. Infuse 0.9% sodium chloride IV.
b. Administer an anti-pyretic.
c. Decrease the infusion rate to 75 mL/hour.
d. Place the client in a left lateral position
5. A nurse is planning care for a client who is prescribed a cane for ambulation. Which
of thefollowing nursing actions should the nurse include in the plan of care?
a. Remind the client to place the cane on the unaffected side.
b. Adjust the length of the cane to equal the distance from the client's iliac crest to the
floor.
c. Remove the rubber tip from the cane to enhance ambulation.
d. Place the King safely in the closet during naps and at bedtime.
6. Nurse is caring for a client who had a partial laryngectomy and is receiving continuous
enteralfeedings at 65 mL/hour through a gastrostomy tube. Which of the following
findings requires immediate intervention by the nurse?
a. The gastric residual volume is 250 mL following two hours of
infusion.b. The client is lying in a supine position.
c. The infusion pump for administering continuous feeding is turned off.
d. Interior feeding bag and tubing are not dated. [Show Less]