Practice Assessment A learning activity
A nurse is preparing to transfer a client who has right-sided weakness from the bed to a chair. In what order should the nurse take the following actions to assist the client?
1. First find out how much weight the client can bear 2.Position the chair on the left side of the bed first since they have right sided weakness 3. Have the client sit and dangle his feet at the bedside 4. Use the stand-and-pivot technique to move the client to the chair safety
A nurse is caring for a client who has had his diet prescription changed to a mechanical soft diet. Which of the following food items should the nurse remove from the client's breakfast tray?
A fried egg is not part of this diet. Scrambled or poached eggs are an acceptable replacement
A nurse is using an open irrigation technique to irrigate a client's indwelling urinary catheter. Which of the following actions should the nurse take?
Calculate the fluid use for irrigation and subtract it from the client's urinary output
A nurse is giving discharge instructions to a client who will require oxygen therapy at home. Which of the following statements should the nurse identify as an indication that the client understands how to manage this therapy at home?
Check the tv cables and wires because oxygen is a highly flammable gas, so they have to be careful to make sure it does not create any electrical sparks
A nurse is planning an education session for an older adult client who has just learned that she has type 2 diabetes mellitus. Which of the following strategies should the nurse plan to use with this client?
Older clients often process information at slower rates
A nurse in a surgical suite notes documentation on a client's medical record that he has a latex allergy. In preparation for the client's medical record that he has a latex allergy. In preparation for the client's procedure, which of the following precautions should the nurse take?
Wrap monitoring cords with stockinette and tape them in case, many monitoring devices and cords contain latex. The nurse should prevent any contact of these with the client's skin by covering them with a nonlatex barrier material
A nurse is caring for a client who has herpes zoster and asks the nurse about the use of complementary and alternative therapies for pain control. the nurse should inform the client that his condition is a contradiction for which?
Acupuncture because it could increase the risk of further infection with open portal on the skin's surface.
When administering IV fluid what is priority assessment for A/E
Auscultate lung sounds because the priority assessment should always be the ABC's. They want to monitor for fluid-volume excess.
A nurse is caring for a client who require a 24-hour urine collection. Which of the following statements by the client indicates an understanding of the teaching?
For a 24-hr urine collection, the client should discard the first voiding and save all subsequent voidings
A nurse is reviewing protocol in preparation for suctioning secretions from a client who has a new tracheostomy. Which of the following actions should the nurse plan to take?
Select a suction catheter that is half the size of the lumen to prevent hypoxemia and trauma to the mucosa
A nurse is caring for a client receiving fluid through a peripheral IV catheter. Which of the following findings at the IV site should the nurse identify as infiltration?
Skin blanching, edema, and coolness are all signs for infiltration.
A nurse is planning to insert a peripheral iv for a older adult. which action should the nurse plan to take?
Putting the client's arm in a dependent position will cause the veins to dilate due to gravity
A nurse is providing care to four clients. Which of the following situations requires the nurse to complete an incident report?
The additional 250 mL of IV fluid because it needs to be reported if an IV infusion pump malfunctions
