TRAINER 5
The nurse prepares a patient for an 8:00 AM outpatient electroconvulsive (ECT) treatment. Which of the following questions is MOST important
... [Show More] for the nurse to ask?
1. "Did you have anything to eat or drink before you came in today?"
2. "Have you had any headaches since your last treatment?"
3. "Who came with you to the hospital today?"
4. "Have you had much memory loss since you began your treatments?" (1) correct—client given general anesthesia for ECT; NPO after midnight
A client is diagnosed with a flaccid bladder following a spinal cord injury. The nurse teaches the client about dietary changes. Which of the following beverages, if selected by the client, indicates to the nurse that teaching is effective?
Select all that apply.
1. Lemonade.
2. Prune juice.
3. Milk.
4. Orange juice.
5. Cranberry juice.
The nurse cares for a client with a long history of alcohol and drug dependence. It is MOST important for the nurse to include which of the following as part of the discharge planning?
1. Refer to a social service agency for assistance with housing.
2. Refer to an aftercare center in the community.
3. Encourage participation in Alcoholics Anonymous (AA) meetings with a sponsor.
4. Ask the client to obtain a prescription for an antidepressant medication. Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired?
The client comes to the clinic for hepatitis B vaccine and asks if more than one injection is necessary. Which of the following responses by the nurse is BEST?
1. "A booster shot is required yearly."
2. "Additional injections are given at one and six months."
3. "Repeat doses are given at two and four months."
4. "Revaccination is not required." Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired?
The nurse plans care for a client returning from surgery after a bowel resection with an IV of 0.9 % NaCl infusing at 100 mL/h into the left wrist. Which of the following actions, if performed by the nurse, is BEST?
1. Change the IV tubing each time a new IV solution is hung.
2. Cleanse the IV site with an alcohol swab using long strokes.
3. Limit manipulation of the cannula at the IV insertion site.
4. Adjust the drop rate to keep the total volume of IV fluids on schedule.Strategy: The topic of the question is unstated. Read the answer choices to determine the topic. "BEST" indicates that this is a priority question. All answers are implementations. Determine the outcome of each answer choice. Is it desired?
The nurse notes that one of the staff members caring for clients has a watery discharge from the right eye and the eye appears red. Which of the following actions, if taken by the nurse, is BEST?
1. Send the staff member home.
2. Assess the staff member's compliance with standard precautions.
3. Assign the staff member only to clients with chronic diseases.
4. Reassign the staff member to clean the supply closet. (1) correct—extreme tearing, redness, foreign body sensation are symptoms of viral conjunctivitis; highly contagious; infected employees cannot work until symptoms have resolved in 3 to 7 days
The nursing staff plans to use behavior modification techniques for an elderly woman who constantly screams. Which of the following nursing assessments is necessary to establish a successful program?
1. Monitor the client's ability to complete her activities of daily living (ADL).
2. Assess the client's levels of pain and correlate it with her response to analgesia.
3. Observe the client's behavior at regular intervals to obtain baseline information related to her screaming.
4. Ask the client why she is screaming and document it on her nursing assessment record.
Strategy: Determine what is being assessed in each answer choice and how it relates to screaming.
(1) The nurse observes a student nurse check the placement of a nasogastric (NG) tube prior to
administering an intermittent feeding. Which of the following actions, if performed by the student nurse, requires an intervention by the nurse?
Select all that apply.
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