1 A client newly diagnosed with type 2 diabetes mellitus has returned for a 6-week
follow-up visit. The nurse should know that which of the following
... [Show More] behaviors
indicates that the client has adapted successfully to a situational role change?
Plans three meals a day and avoids snacks
Monitors blood glucose once a day
Adjusts employment hours to a regular schedule
Walks barefoot at home to prevent fungal infections
2 After a client views a video on an operative procedure, the best practice for the nurse
is to
evaluate and document what the client learned.
give the client a handout outlining information relayed in the video.
ask the client to sign the informed consent.
have the client sign the teaching tool signifying completion of video viewing.
3 Which of the following nursing actions best promotes client safety when transcribing
providers' orders?
Verify the order sheet contains the correct client identification.
Check with another nurse for clarification of a confusing order.
Perform transcription in a quiet area.
Process orders in the sequence in which they are written.
4 A nurse is caring for a client who has a nursing diagnosis of impaired swallowing
following a cerebrovascular accident (stroke). Which of the following nursing
interventions is appropriate for this client?
Provide nasotracheal suctioning.
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Offer clear liquids.
Restrict fluid intake.
5 A nurse is caring for a client who gave birth 10 hr earlier. The client is in the takingin phase of psychosocial and maternal adaptation. Which of the following is the most
appropriate nursing intervention at this time?
Instruct the client about infant and self-care.
Encourage the mother to send her infant to the well-infant nursery so that she
can rest.
Listen to the mother's verbalization of her pregnancy and birth experience.
Provide opportunities for the mother to be independent in self-care.
6 A nurse is caring for a client following a thyroidectomy. For which of the following
complications should the nurse assess the client?
Hypokalemia
Muscular depression
Hyperglycemia
Laryngeal stridor
7 A nurse is assessing a client who has a nasogastric feeding tube in place. Which of
the following actions should the nurse take to prevent aspiration?
Check for gastric residual every hour and hold the feeding if greater than 50
mL.
Flush and clamp the nasogastric tube between feedings.
Keep the head of the client's bed elevated at least 30° at all times.
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8 A nurse is teaching a client how to perform Kegel exercises. Which of the following
client statements indicates understanding of the teaching?
³,ZLOOGHWHUPLQHZKLFKPXVFOHVWRFRQWUDct by stopping and starting my
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³,ZLOOWU\WRKROGP\XULQHIRUDOLWWOHZKLOHDIWHU,ILUVWIeel the urge to
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9 A nurse is caring for a client with a terminal illness. The nurse recognizes that the
IDPLO\¶VSULRULW\Qeed for support will most likely occur when
meeting with a social worker about financial concerns related to continuing
care.
learning about hospice care and how to access services.
making decisions about measures to prolong life and provide comfort.
meeting with a member of their spiritual community to discuss funeral
arrangements.
10 A nurse is developing a discharge plan of care for an older adult client on a
rehabilitation unit following a cerebrovascular accident. Which of the following has
the highest priority when planning care to facilitate a timely discharge?
Arranging for transportation
Identifying supportive family members
Encouraging participation in physical therapy
Consulting nutritional support services
11 A client with HIV is admitted to the medical-surgical unit with a respiratory
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room every day. Which of the following is the appropriate nursing action?
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Request that the family bring potted plants instead.
Teach the family that fresh plants of any type are prohibited.
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bed.
12 Which of the following is the highest priority for the circulating nurse in maintaining
a safe operating room environment?
Sterilizing the instruments after the procedure
Reviewing the preoperative assessment
Washing hands using foot-operated faucets
Reporting any breaks in the sterile technique
13 A client with a tracheostomy is being sent home to be cared for by the spouse. The
nurse should include which of the following information in discharge teaching?
How to change the nondisposable tracheostomy tube daily
How to properly operate the portable suction machine
How to change the tracheostomy dressing using clean technique
How to tie the tracheostomy tube snugly in place with the knot over the back
of the neck
14 During the first 24 hr following a soft-tissue injury to the right ankle, which of the
following nursing interventions will help reduce the client's discomfort?
Apply an ice pack to the ankle for 20 to 30 min at a time.
Keep the ankle in a dependent position.
Place a heating pad on the ankle.
Soak the ankle in room temperature water with Epsom salts.
15 A nurse is caring for a client with a mental health disorder. The client is agitated, and
the nurse is concerned that the client may become aggressive. Fearful for his own
safety, the nurse escorts the client to a room and locks her inside against her will.
This action
could initiate an involuntary commitment for the client.
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could result in charges of false imprisonment for the nurse.
is appropriate prRYLGHGWKDWDSURYLGHU¶VRUGHULVVXEVHTXHQWO\REWDLQHG
16 When instructing a client with an L1-2 spinal cord injury regarding self-care
adaptations, which of the following is an appropriate recommendation?
Self-catheterization is an option when you feel the sensation of a full bladder.
Arrange for a home health aide to bathe you twice a week.
Adaptive devices are available to help you put on your shoes.
Home delivery of meals is an option you may want to consider.
17 A 1-year-old child is prescribed ibuprofen after having a febrile seizure. The nurse
should teach the parents that the best way to administer the medication is
a chewable tablet.
an elixir.
an enteric coated tablet.
a suppository.
18 Which of the following strategies best ensures that all nurses on staff have certain
skills and knowledge?
Providing nurse mentors
Offering self-study modules
Holding quarterly in-services
Completing annual competence assessments
19 Which of the following manifestations should a nurse expect to find in a client
whose blood glucose is 650 mg/dL?
Slow, shallow respirations
Headache
Fruity breath odor
Cool, clammy skin
20 A nurse is caring for a client diagnosed with depression who has been prescribed a
tricyclic antidepressant. The nurse should recognize that which of the following [Show Less]