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A small bore feeding tube is placed. Which technique will the nurse use to best verify tube placement?

Abdominal x ray

A nurse is teaching a client who has left hemiparesis how to use a cane. Which of the following instructions should the nurse include?

Advance the right leg and the cane together to support the weaker leg

A nurse is admitting a client who reports anorexia and is experiencing malnutrition. Which of the following laboratory findings should the nurse expect to be altered.

Albumin

A nurse is caring for a client who has urinary incontinence. Which of the following actions should the nurse implement to prevent the development of skin breakdown?

Apply a moisture barrier ointment to the clients skin

A patient is experiencing oliguria. Which action should the nurse perform first?

Assess for bladder distention

The nurse is caring for a patient who has not had a bowel movement for 2 days. Which is the priority nursing intervention for this patient?

Assess the patients usual pattern of bowel movements

A nurse is providing instructions for a 52 year old client who is scheduled for a colonoscopy. The client reports that he has not had the procedure before and is very anxious about the feeling pain during the procedure. Which of the following responses by the nurse is appropriate?

Before the examination, your provider will give you a sedative that will make you sleepy.

A nurse is caring for a client who is postoperative following an appendectomy. The surgeon initially prescribes a clear liquid diet. Which of the following items should the nurse offer the client?

Broth

A nurse is helping an older adult client ambulate in the hallway for the first time since admission. The client has brought her standard walker from home. To ensure proper use of the walker and the safety of the client, which of the following actions should the nurse take?

Check that the client lifts the walker and then places it down infront of her.

A nurse is caring for a client who is 2 days postoperative following abdominal surgery and observes that the clients wound has eviscerated. After calling for help. Which of the following actions should the nurse take first?

Cover the area with a sterile dressing, moistened with 0.9% sodium chloride irrigation.

Lifestyle changes to promote healthy urinary elimination pattern include which of the following? Select 3 answers

Drinking 2-3L of fluid daily Avoiding bladder irritants Voiding regularly

A nurse is caring for an older adult client who reports taking bisacodyl tablets daily. Which of the following responses should the nurse make?

Excessive laxative use may cause an electrolyte imbalance

A nurse is teaching a client who has constipation. Which of the following should the nurse discuss as causes of constipation. Select 3 answers

Excessive laxative use. Ignoring the urge to defecate. Inadequate fluid intake.

A nurse is caring for a client who has a large leg lesion. Which of the following foods should the nurse suggest to the client to provide the most protein for wound healing?

Grilled salmon

A nurse is caring for a hospitalized patient with a urinary catheter. Which nursing action best prevents the patient from acquiring an infection?

Maintaining a closed urinary drainage system.

A nurse is planning care for a group of clients. Which task will the nurse assign the nursing assistive personnel?

Obtaining a midstream urine specimen

A nurse is helping a client with hemiparesis take a few steps. The client is using a cane and a gait belt has been applied. Where should the nurse stand in relation to the client

On the clients weak side.

A nurse is caring for a client who has not voided for 8 hours following the removal of an indwelling urinary catheter. Which of the following should the nurse take first?

Perform a bladder scan

A nurse is assessing a client who has newly created colostomy. Which of the following findings should the nurse report to the provider?

Purplish color stoma

The nurse is caring for a patient who is taking narcotic pain medication after surgery. Which breakfast choices will prevent constipation and promote return to regular bowel function?

Raisin bran with skim milk, fresh fruit, and wheat toast

A nurse is planning care for a client who is confined to bed. Which of the following actions should the nurse include in the pain?

Reposition the client every 2 hrs.

In providing client education for a patient on a low fat diet. Which information is important for the nurse to share?

Saturated fats are found mostly in animal sources

A nurse is assessing a clients wound dressing, and observes a watery red drainage. The nurse should document this drainage as which of the following?

Serosanguineous

A nurse is caring for a client who has stage 3 pressure injury. The nurse should recognize that which of the following laboratory findings will affect wound healing.

Serum albumin 3.2 g/dL

A nurse is assessing a client and discovers the infusion pump with the clients total parenteral nutrition (TPN) solution is not infusing. The nurse should monitor the client for which of the following conditions?

Shakiness and diaphoresis

A nurse is caring for a client who requires total parenteral nutrition (TPN). Which of the following actions should the nurse take when finding that the TPN solution is infusing too rapidly?

Stop the TPN infusion

A nurse is teaching a health promotion class about isotonic exercises. Which type of activities will the nurse give as examples? Select 3 answers

Swimming Cycling Walking

A nurse in a long term care facility is caring for an older adult client who has dementia and begins to have frequent episodes of urinary incontinence. After the provider determines no medical cause for the clients incontinence, which of the following interventions should the nurse initiate to manage this behavior?

Take the client to the bathroom every 2 hrs.

A nurse is planning care fro an older adult client who is at risk for developing pressure injuries. Which of the following interventions should the nurse use to help maintain the integrity of the clients skin?

Use a transfer device to lift the client up in bed.

A nurse is implementing a bowel training program for a client. For the program to be effective, the nurse should take the client to the toilet at which of the following time?

When the client has the urge to defecate

Upon palpation, the nurse notices that the bladder is firm and distended. The patient expresses an urge to urinate. Which question is most appropriate?

When was the last time you voided?

Click to highlight the documentation in the clients medical record that requires further action by the nurse. To deselect information, click on the information again. What to highlight:

temperature, 38.9 C; WBC 12,000; increased redness at wound border and purulent drainage noted. **Deselect Hct 38%**