A nurse is caring for a client who fell at a nursing home. The client is oriented to person, place,
and time and can follow directions. Which of the
... [Show More] following actions should the nurse take to
decrease the risk of another fall? (Select all that apply.) - CORRECT ANSWER 1. Make sure
that the client's call light is within reach.
2.Provide the client with nonskid footwear. 3.Complete a fall-risk assessment.
A nurse manager is reviewing with nurses on the unit the care of a client who has had a seizure.
Which of the following statements by a nurse requires further instruction? - CORRECT
ANSWER I will go to the nurses' station for assistance."
A nurse observes smoke coming from under the door of the staff's lounge. Which of the
following actions is the nurse's priority? - CORRECT ANSWER Move clients who are nearby.
A nurse is caring for a client who has a history of falls. Which of the following actions is the
nurse's priority? - CORRECT ANSWER Complete a fall-risk assessment.
A charge nurse is assigning rooms for the clients to be admitted to the unit. To prevent falls,
which of the following clients should the nurse assign to the room closest to the nurses' station? -
CORRECT ANSWER An older adult who is postoperative below-the-knee following a
amputation
A nurse is providing discharge instructions to a client who has a prescription for oxygen use at
home. Which of the following information should the nurse include about home oxygen safety?
(Select all that apply.) - CORRECT ANSWER 1.Nail polish should not be used near a client who
is receiving oxygen.
2.A "No Smoking" sign should be placed on the front door.
3.A fire extinguisher should be readily available in the home.
A nurse educator is presenting a module on basic first aid for newly licensed home health nurses.
The nurse educator evaluates the teaching as effective when the newly licensed nurse states the
client who has heat stroke will have which of the following? - CORRECT ANSWER
Hypotension
A nurse educator is conducting a parenting class for new parents of infants. Which of the
following statements made by a participant indicates understanding of the instructions? -
CORRECT ANSWER "Once my infant starts to push up, I will remove the mobile from over the
crib."
A home health nurse is discussing the dangers of carbon monoxide poisoning with a client.
Which of the following information should the nurse include in her counseling? - CORRECT
ANSWER Carbon monoxide binds with hemoglobin in the body.
A home health nurse is discussing the dangers of food poisoning with a client. Which of the
following information should the nurse including in her counseling? (Select all that apply.) -
CORRECT ANSWER 1.Immunocompromised individuals are at risk for complications from
food poisoning 2.Clients who are at high risk should eat or drink only pasteurized dairy products.
3.Handling raw and fresh food separately can prevent food poisoning.
A nurse is caring for multiple clients during a mass casualty event. Which the following clients is
the priority? - CORRECT ANSWER A client who has partial-thickness and full-thickness burns
to his face, neck, and chest
A nurse educator is discussing the facility protocol in the event of a tornado with the staff. Which
of the following should the nurse include in the instructions? (Select all that apply.) - CORRECT
ANSWER 1.Place blankets over clients who are confined to beds.
2.Move beds away from the windows.
3.Draw shades and close drapes.
An occupational health nurse is caring for an employee who was exposed to an unknown dry
chemical, resulting in a chemical burn. Which of the following interventions should the nurse
include in the plan of care? - CORRECT ANSWER Brush the chemical off the skin and
clothing.
A security officer is reviewing actions to take in the event of a bomb threat by phone to a group
of nurses. Which of the following statements by a nurse indicates understanding of proper
procedure? - CORRECT ANSWER I will listen for background noises."
A nurse on a medical-surgical unit is informed that a mass casualty event occurred in the
community and that it is necessary to discharge stable clients to make beds available for injury
victims. Which of the following clients should the nurse recommend for discharge? (Select all
that apply.) - CORRECT ANSWER 1.A client who is scheduled for elective surgery
2.A client who has chronic hypertension and blood pressure 135/85 mm Hg
A nurse is caring for a client whose partner passed away 4 months ago and who has been
recently diagnosed with diabetes mellitus. He is tearful and states, "How could you possibly
understand what I am going through?" Which of the following responses should the nurse make?
- CORRECT ANSWER "You are right. I cannot really understand. Perhaps you'd like to tell me
more about what you're feeling."
A nurse is caring for a client awaiting transport to the surgical suite for a coronary artery bypass
graft. Just as the transport team arrives, the nurse takes the client's vital signs and notes an
elevation in blood pressure and heart rate. The nurse should recognize this response as which
part of the general adaptation syndrome (GAS)? - CORRECT ANSWER Alarm reaction
A nurse is caring for a client who has left-sided hemiplegia resulting from a cerebrovascular
accident. The client works as a carpenter and is now experiencing a situational role change based
on physical limitations. The client is the primary wage earner in the family. Which of the
following describes the client's role problem? - CORRECT ANSWER Role conflict
A nurse is caring for a client who has a new diagnosis of type 2 diabetes mellitus. Which of the
following nursing interventions for stress, coping, and adherence to the treatment plan should the
nurse initiate at this time? (Select all that apply.) - CORRECT ANSWER 1.Allow the client to
provide input in the treatment plan.
2.Assist the client with time management, and address the client's priorities.
3.Encourage the client in the expression of feelings and concerns.
A nurse is caring for a family who is experiencing a crisis. Which of the following approaches
should the nurse use when working with a family using an open structure for coping with crisis?
- CORRECT ANSWER Convening a family meeting
A nurse is caring for a client who has terminal lung cancer. The nurse observes the client's
family assisting with all ADLS. Which of the following rationales for self-care should the nurse
communicate to the family? - CORRECT ANSWER The client's sense of loss can be lessened
through retaining control of certain areas of her life.
A nurse is caring for a client who has stage IV lung cancer and is 3 days postoperative following
a wedge resection. The client states, "I told myself that I would go through with the surgery and
quit smoking, if I could just live long enough to attend my daughter's wedding." Based on
Kübler-Ross' model, which stage of grief is the client experiencing? - CORRECT ANSWER
Bargaining
A nurse is caring for a client who has a terminal illness. Death is expected within 24 hr. The
client's family is at the bedside and asks the nurse about anticipated findings at this time. Which
of the following findings should the nurse include in the discussion? - CORRECT ANSWER
Decreased muscle tone
A nurse is assisting a newly licensed nurse with postmortem care of a client. The family wishes
to view the body. Which of the following statements by the newly licensed nurse indicate an
understanding of the procedure? (Select all that apply.) - CORRECT ANSWER 1. I will apply
fresh linens and place a clean gown on the body."
2. I will remove all equipment from the bedside."
3. "I will dim the lights in the room."
A nurse in a provider's office is preparing to assess a client's skin as part of a comprehensive
physical examination. Which of the following findings should the nurse expect? (Select all that
apply.) - CORRECT ANSWER 1.Capillary refill less than 3 seconds
2.Thick skin on the soles of the feet 3.Numerous light brown macules on the face
A nurse is assessing an older adult client who has significant tenting of the skin over his forearm.
Which of the following factors should the nurse consider as a cause for this finding? (Select all
that apply) - CORRECT ANSWER 1.Loss of adipose tissue
2.Dehydration
3.Diminished skin elasticity
A nurse is assessing postoperative circulation of the lower extremities for a client who had knee
surgery. The nurse should include which of the following? (Select all that apply.) - CORRECT
ANSWER Skin color
Edema
Skin temperature
A nurse is performing skin assessments on a group of clients. vesicles? Which of the following
lesions should the nurse identify as (Select all that apply) - CORRECT ANSWER Herpes
simplex
Varicella
A nurse is performing an integumentary assessment for a group of clients. Which of the
following findings should the nurse recognize as requiring immediate intervention? - CORRECT
ANSWER Cyanosis
A nurse in a provider's office is preparing to assess a young adult male client's musculoskeletal
system as part of a comprehensive physical examination. Which of the following findings should
the nurse expect? (Select all that apply.) - CORRECT ANSWER Concave lumbar spine
posteriorly
Muscles slightly larger on his dominant side
A nurse is assessing a client's neurosensory system. To evaluate stereognosis, the nurse should
ask the client to close his eyes and identify which of the following items? - CORRECT
ANSWER A familiar object she places in his hand [Show Less]