Question 1 See full question
A physician orders hourly urine output measurement for a postoperative client with an indwelling
catheter. The nurse
... [Show More] records the following amounts of output for 2 consecutive hours: 8 a.m. (0800): 50
ml; 9 a.m. (0900): 60 ml. Based on these amounts, which action should the nurse take?
You Selected:
Irrigate the indwelling urinary catheter.
Correct response:
Continue to monitor and record hourly urine output.
Explanation:
Remediation:
Question 2 See full question
A nurse is performing a sterile dressing change. Which action contaminates the sterile field?
You Selected:
Holding sterile objects above the waist
Correct response:
Pouring solution onto a sterile field cloth
Explanation:
Remediation:
Question 3 See full question
When bandaging a client's ankle, the nurse should use which technique?
You Selected:
Spiral reverse
Correct response:
Figure-eight
Explanation:
Remediation:
Question 4 See full question
A client who's scheduled for open-heart surgery in 2 days has been having circulation problems in the
feet and legs. The physician orders antiembolism stockings. The nurse is teaching the client about this
treatment. What is the purpose of antiembolism stockings?You Selected:
To decrease arterial blood circulation to the legs and feet
Correct response:
To reduce or prevent edema of the legs and feet
Explanation:
Remediation:
Question 5 See full question
A primary unit nurse tells the nurse-manager that a newly hired registered nurse needs an additional
week of orientation in order to function effectively on the staff. Which action is most appropriate for the
nurse-manager to take?
You Selected:
Tell the primary nurse that the new nurse must finish orientation within 6 weeks because of a
staffing shortage.
Correct response:
Meet with the new nurse and the primary nurse and help set up an additional week of
orientation.
Explanation:
Question 6 See full question
For a client with a nursing diagnosis of Insomnia, the nurse should use which measure to promote sleep?
You Selected:
Serving the client a cup of coffee and a snack in the evening
Correct response:
Playing soft or soothing music
Explanation:
Remediation:
Question 7 See full question
During the termination phase of a nurse-client relationship, which intervention may lead to client
confusion?
You Selected:
Having the client express sadness that the relationship is ending
Correct response: Introducing new issues to the client
Explanation:
Remediation:
Question 8 See full question
A nurse notes that a client's I.V. insertion site is red, swollen, and warm to the touch. Which action
should the nurse take first?
You Selected:
Discontinue the I.V. infusion.
Correct response:
Discontinue the I.V. infusion.
Explanation:
Remediation:
Question 9 See full question
A client is to receive a glycerin suppository. Which nursing action is appropriate when administering a
suppository?
You Selected:
Instructing the client to bear down during insertion
Correct response:
Applying a lubricant to the suppository
Explanation:
Remediation:
Question 10 See full question
A client is to be discharged on daily medication delivered by a transdermal disk. Which statement
indicates the need for further medication teaching?
You Selected:
"I'll avoid touching the gel in the disk."
Correct response:
"I'll place the disk on the same spot each day."
Explanation:
Remediation:Question 11 See full question
Which moral principle is a nurse applying when she decides what is best for a client and acting without
consulting the individual?
You Selected:
Autonomy
Correct response:
Paternalism
Explanation:
Question 12 See full question
Which description about crackles are true?
You Selected:
They may be fine or coarse.
Correct response:
They may be fine or coarse.
Explanation:
Remediation:
Question 13 See full question
A nurse must assess skin turgor in an elderly client. When evaluating skin turgor, the nurse should
remember that:
You Selected:
normal skin turgor is moist and boggy.
Correct response:
inelastic skin turgor is a normal part of aging.
Explanation:
Remediation:
Question 14 See full question
A nurse is reviewing a client's arterial blood gas (ABG) report. Which ABG value reflects the acid
concentration in the client's blood?
You Selected:
HCO3–Correct response:
pH
Explanation:
Remediation:
Question 15 See full question
The nurse is receiving over the telephone a laboratory results report of a neonate's blood glucose level.
The nurse should:
You Selected:
indicate to the caller that the nurse cannot receive verbal results from laboratory tests for
neonates, and ask the laboratory to bring the written results to the nursery.
Correct response:
write down the results, read back the results to the caller from the laboratory, and receive
confirmation from the caller that the nurse understands the results.
Explanation:
Question 16 See full question
The nurse is planning care for a group of pregnant clients. Which client should be referred to a health
care provider (HCP) immediately?
You Selected:
a woman who is at 37 weeks' gestation and has insulin-dependent diabetes experiencing two to
three hyperglycemic episodes weekly
Correct response:
a woman at 32 weeks' gestation who is preeclamptic with +3 proteinuria
Explanation:
Remediation:
Question 17 See full question
A client who has been recently diagnosed with acquired immunodeficiency syndrome (AIDS) inquires
about hospice services. The nurse explains that hospice care is appropriate:
You Selected:
for clients with an inevitable death within weeks to months.
Correct response:
for clients with an inevitable death within weeks to months.Explanation:
Remediation:
Question 18 See full question
A client tells the nurse on admission that she is uneasy about having to leave her children with a relative
while being in the hospital for surgery. What should the nurse do?
You Selected:
Contact the relative to determine their capacity to be an adequate care provider.
Correct response:
Gather more information about the client's feelings about the childcare arrangements.
Explanation:
Remediation:
Question 19 See full question
A client says, “I hate the idea of being an invalid after they cut off my leg.” Which response by the nurse
would be the most therapeutic?
You Selected:
"You are lucky to have a wife to care for you."
Correct response:
"Tell me more about how you are feeling."
Explanation:
Remediation:
Question 20 See full question
The nurse is caring for a client from Southeast Asia who has HIV-AIDS. The client does not speak or
comprehend the English languag [Show Less]