Which of these instructions should a nurse include in the teaching plan for a client who had removal
of a cataract in the left eye?
a. "Forcefully cough
... [Show More] and take deep breaths every two hoursto keep your airway clear."
b. "Perform the prescribed eye exercises each day to strengthen your eye muscles."
c. "Rinse your eyes with saline each morning to prevent postoperative infection."
d. "Take the prescribed stoolsoftener to avoid increasing intraocular pressure."
A client vomits during a continuous nasogastric tube feeding. A nurse should stop the feeding and take
which of these actions?
a. Suction the nasogastric tube.
b. Flush the tube with 30 mL of sterile water.
c. Remove the nasogastric tube.
d. Check the residual volume.
Which of these actions best demonstrates cultural sensitivity by a nurse?
a. The nurse talksin a slow-paced speech.
b. The nurse asks clients about their beliefs and practicestoward pregnancy.
c. The nurse uses charts and diagrams when teaching pregnant clients.
d. The nurse can speak several different languages.
Which of these manifestations should a nurse expect to observe in a 3-month-old infant who is
diagnosed with dehydration?
a. Hyperreflexia.
b. Tachycardia.
c. Bradypnea.
d. Agitation.
When assessing a client's risk of developing nosocomial infection, a nurse plans to determine potential
entry portals, which include:
a. the urinary meatus.
b. vomitus.
c. contaminated water.
d. sexual intercourse.
A client who is on the inpatient psychiatric unit has a history of violence. Which of these actions
should a nurse take if the client is agitated?
a. Encourage the client to verbalize feelings.
b. Lock the client in a secluded room.
c. Ask the other clientsto give feedback regarding the client's behavior.
d. Ignore the client'sinappropriate behavior.
Which of these measures should a nurse include when planning care for a school-aged child during a
sickle cell crisis episode?
a. Monitoring forsigns of bleeding.
b. Providing pain relief.
c. Administering cool sponge bathsto reduce fevers.
d. Offering a high calorie diet.
Which of these instructions should a nurse include in the plan of care for a 32-week gestation client
who had an amniocentesis today?
a. "Drink at least six glasses of fluids during the next six hours after the test."
b. "Call the clinic if you experience any abdominal cramps."
c. "Don't be concerned if you have some vaginal spotting in the next 12 hours."
d. "When you get home, stay on bed-rest for the next 48 hours."
An adolescent has a nursing diagnosis of fatigue related to inadequate intake of iron-rich foods.
Selection of which of these lunches by the client indicates a correct understanding of foods high in
iron content?
a. Peanut butter and jam sandwich.
b. Chicken nuggets with rice.
c. Tuna salad sandwich.
d. Beefburger with cheese.
A client has been admitted with acute pancreatitis. Which of these laboratory test results supports
this diagnosis?
a. Elevated serum potassium level.
b. Elevated serum amylase level.
c. Elevated serum sodium level.
d. Elevated serum creatinine level.
Which of these manifestations, if assessed in a client who is two-hours postoperative after abdominal
surgery, should a nurse report immediately?
a. Vomiting and a pulse rate of 106/minute.
b. Respiratory rate of 12/minute and urine dribbling.
c. Blood pressure of 100/60 mm Hg and wound discomfort.
d. Urine output of 100 mL/hr and flushed skin.
Which of these observations of a student nurse's behavior while interacting with a client who is crying
indicates a correct understanding of therapeutic communication?
a. The student maintains continuous eye contact with the client.
b. The student places one arm around the client's shoulder?
c. The student sits quietly next to the client.
d. The student leaves the room to provide privacy for the client.
Which of these actions should a nurse take initially if a client who is diagnosed with diabetes mellitus
develops tremors and ataxia?
a. Measure the client's blood sugar level.
b. Administer a concentrated form glucose to the client.
c. Administer a prn dose of insulin.
d. Measure the client's urine for ketones.
An elderly client is at increased risk of developing drug toxicity to prescribed medications due to
declining hepatic and renal functioning. Which of these strategies should a nurse plan to decrease this
risk?
a. Increasing the time interval between medication doses.
b. Limiting the client's oral fluid intake.
c. Administering the medications with meals.
d. Encouraging the client to void every three to four hours.
A client has persistent paranoid delusions that the food on the unit is poisoned. Which of these
measures should a nurse include in the client's care plan?
a. Explaining that staff does not poison clients.
b. Focusing on how the hospital staff helps clients. [Show Less]