Prep U Q&A NU 331
Question 1 See full question Which instruction should a nurse give to a client who's 26 weeks pregnant and complains of constipation? You Selected: Encourage her to increase her intake of roughage and to drink at least six glasses of water per day. Correct response: Encourage her to increase her intake of roughage and to drink at least six glasses of water per day. Explanation: Question 2 See full question A pregnant client with diabetes mellitus is at risk for having a large-for-gestational-age neonate because: You Selected: insulin acts as a growth hormone on the fetus. Correct response: insulin acts as a growth hormone on the fetus. Explanation: Question 3 See full question A pregnant client complains of nausea every morning and again before meals. As a result of the nausea, she's been unable to eat enough and has lost weight. Which nonpharmacologic intervention should the nurse recommend? You Selected: Drinking water with every meal Correct response: Keeping crackers at the bedside to eat before getting out of bed Explanation: Question 4 See full question For the client who is receiving intravenous magnesium sulfate for severe preeclampsia, which assessment findings would alert the nurse to suspect hypermagnesemia? You Selected: decreased deep tendon reflexes Correct response: decreased deep tendon reflexes Explanation: Question 5 See full question A primigravid client with class II heart disease who is visiting the clinic at 8 weeks' gestation tells the nurse that she has been maintaining a low-sodium, 1,800-calorie diet. Which instruction should the nurse give the client? You Selected: Severely restrict sodium intake throughout the pregnancy. Correct response: Increase caloric intake to 2,200 calories daily to promote fetal growth. Explanation: Question 6 See full question A 20-year-old primigravid client tells the nurse that her mother had a friend who died from hemorrhage about 10 years ago during a vaginal birth. Which response would be most helpful? You Selected: "What is it that concerns you about pregnancy, labor, and childbirth?" Correct response: "What is it that concerns you about pregnancy, labor, and childbirth?" Explanation: Question 7 See full question During a routine clinic visit, a 25-year-old multigravid client who initiated prenatal care at 10 weeks' gestation and is now in her third trimester states, "I've been having strange dreams about the baby. Last week I dreamed he was covered with hair." The nurse should tell the mother: You Selected: "It is not uncommon to have dreams about the baby, particularly in the third trimester." Correct response: "It is not uncommon to have dreams about the baby, particularly in the third trimester." Explanation: Question 8 See full question A client who tells the nurse that she would like to use the basal body temperature method for family planning receives instructions about the method. Which client statement indicates to the nurse that the teaching has been successful? You Selected: "It is important to take my temperature at about the same time every morning before arising." Correct response: "It is important to take my temperature at about the same time every morning before arising." Explanation: Question 9 See full question After the nurse instructs a pregnant client about swimming and bathing during pregnancy, which client statement indicates the need for additional teaching? You Selected: "I can relax in a hot tub for about 20 minutes." Correct response: "I can relax in a hot tub for about 20 minutes." Explanation: Question 10 See full question A client at 37 weeks gestation is at a prenatal visit and states that she sometimes feels dizzy when lying directly on her back. Which of the following is the nurse's best response? You Selected: "This may be due to the uterus putting pressure on a blood vessel." Correct response: "This may be due to the uterus putting pressure on a blood vessel." Explanation: Question 1 See full question A nurse measures a client's apical pulse rate and compares it with his radial pulse rate. The differential between these two pulses is called: You Selected: the pulse deficit. Correct response: the pulse deficit. Explanation: Question 2 See full question A nurse determines that a client has 20/40 vision. Which statement about this client's vision is true? You Selected: The client can read from a distance of 20′ (6 m) what a person with normal vision can read at a distance of 40′. Correct response: The client can read from a distance of 20′ (6 m) what a person with normal vision can read at a distance of 40′. Explanation: Question 3 See full question To assess the effectiveness of cardiac compressions during adult cardiopulmonary resuscitation (CPR), a nurse should palpate which pulse site? You Selected: Carotid Correct response: Carotid Explanation: Question 4 See full question The nurse is caring for a client who has just had an upper GI endoscopy. The client's vital signs must be taken every 30 minutes for 2 hours after the procedure. The nurse assigns an unlicensed assistive personnel (UAP) to take the vital signs. One hour later, the UAP reports the client, who was previously afebrile, has developed a temperature of 101.8° F (38.8° C). The nurse should: You Selected: promptly assess the client for potential perforation. Correct response: promptly assess the client for potential perforation. Explanation: Question 5 See full question A client who had an exploratory laparotomy 3 days ago has a white blood cell (WBC) differential with a shift to the left. The nurse instructs unlicensed assistive personnel (UAP) to report which clinical manifestation of this laboratory report? You Selected: elevated temperature Correct response: elevated temperature Explanation: Question 6 See full question A client is on complete bed rest. The nurse should initiate measures to prevent which complication of bed rest? You Selected: thrombophlebitis Correct response: thrombophlebitis Explanation: Question 7 See full question Upon repositioning an immobile client, the nurse notes redness with blanching over a bony prominence. What is the most probable cause? You Selected: Abnormal reactive hyperemia Correct response: The reactive hyperemia is likely transient. Explanation: Question 8 See full question A nurse is assessing a client with a urinary tract infection who takes an antihypertensive drug. The nurse reviews the client's urinalysis results (see chart). The nurse should: You Selected: encourage the client to increase fluid intake. Correct response: encourage the client to increase fluid intake. Explanation: Question 9 See full question The nurse is conducting an admission interview with a client and is assessing for risk factors related to the client's safety. The nurse should include which targeted assessments? Select all that apply. You Selected: recent use of substances of abuse suicide or self-harm ideation allergic reactions or adverse drug reactions Correct response: suicide or self-harm ideation recent use of substances of abuse allergic reactions or adverse drug reactions Explanation: Question 10 See full question The most appropriate way for the nurse to assess a client's ability to perform activities of daily living is to: You Selected: observe client performing varied activities of daily living. Correct response: observe client performing varied activities of daily living. Explanation: Question 1 See full question When percussing a client's chest, the nurse should expect to hear: You Selected: resonance. Correct response: resonance. Explanation: Question 2 See full question When assessing an elderly client, the nurse expects to find various aging-related physiologic changes. These changes include: You Selected: delayed gastric emptying. Correct response: delayed gastric emptying. Explanation: Question 3 See full question A client was brought to the emergency department following a motor vehicle accident and has phrenic nerve involvement. The nurse should assess the client for: You Selected: ineffective breathing pattern. Correct response: ineffective breathing pattern. Explanation: Question 4 See full question The client has returned to the surgery unit from the postanesthesia care unit (PACU). The client's respirations are rapid and shallow, the pulse is 120 bpm, and the blood pressure is 88/52 mm Hg. The client's level of consciousness is declining. The nurse should first: You Selected: call the rapid response team (RRT)/medical emergency team. Correct response: call the rapid response team (RRT)/medical emergency team. Explanation: Question 5 See full question A nurse is assessing a client who has a rash on the chest and upper arms. Which questions would the nurse ask in order to gain further information about the client's rash? Select all that apply. You Selected: "When did the rash start?" "Are you allergic to any medications, foods, or pollen?" "Have you recently traveled outside the country?" "What have you been using to treat the rash?" Correct response: "When did the rash start?" "Are you allergic to any medications, foods, or pollen?" "What have you been using to treat the rash?" "Have you recently traveled outside the country?" Explanation: Question 6 See full question Before a transesophageal echocardiogram, a nurse gives a client an oral topical anesthetic spray. When the client returns from the procedure, the nurse observes that he has no active gag reflex. In response, the nurse should: You Selected: withhold food and fluids. Correct response: withhold food and fluids. Explanation: Question 7 See full question A nurse is caring for a client who is exhibiting signs and symptoms characteristic of a myocardial infarction (MI). Which statement describes priorities the nurse should establish while performing the physical assessment? You Selected: Assess the client's level of pain, and administer prescribed analgesics. Correct response: Assess the client's level of pain, and administer prescribed analgesics. Explanation: Question 8 See full question The nurse is performing a nutrition assessment of a client from the Middle East. What may the nurse expect as a traditional breakfast consumed by a client from the Middle East? You Selected: Cheese and olives. Correct response: Cheese and olives. Explanation: Question 9 See full question For which of the following clients is the nursing assessment of pain most likely to result in undertreatment? You Selected: Older adult who grimaces and states there is no pain after a gastrostomy tube placement Correct response: Older adult who grimaces and states there is no pain after a gastrostomy tube placement Explanation: Question 10 See full question A client arrives at a public health clinic worried that she has breast cancer after finding a lump in her breast. When assessing the breast, which assessment finding provides an indication that the lump is more typical of fibrocystic breast disease? You Selected: The lump is round and movable. Correct response: The lump is round and movable. Explanation: uestion 1 See full question A client has been receiving an I.V. solution. What is an appropriate expected outcome for this client? You Selected: "The client remains free of signs and symptoms of phlebitis." Correct response: "The client remains free of signs and symptoms of phlebitis." Explanation: Question 2 See full question The following statement appears on a client's care plan: "Client will ambulate in the hall without assistance within 4 days." This statement is an example of: You Selected: a client outcome. Correct response: a client outcome. Explanation: Question 3 See full question An elderly client is admitted to the facility after fainting while gardening on a hot summer day. Which nursing diagnosis takes highest priority for this client? You Selected: Hyperthermia Correct response: Hyperthermia Explanation: Question 4 See full question After a stroke, a client develops aphasia. The nurse expects to see which assessment finding? You Selected: Inability to speak clearly Correct response: Inability to speak clearly Explanation: Question 5 See full question Each morning, a nurse-manager assigns clients and additional tasks for the staff nurses to complete that day. During the shift, a crisis develops and one staff nurse doesn't complete the additional tasks. The next day, the nurse-manager reprimands this nurse. When the nurse tries to explain, the nurse-manager interrupts, saying that the nurse should have completed the tasks no matter what happened. Which leadership style is the nurse-manager exhibiting? You Selected: Autocratic Correct response: Autocratic Explanation: Question 6 See full question When documenting information in a client's medical record, the nurse should: You Selected: end each entry with her signature and title. Correct response: end each entry with her signature and title. Explanation: Question 7 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: pH Correct response: pH Explanation: Question 8 See full question A client complains of severe abdominal pain. To elicit as much information as possible about the pain, the nurse should ask: You Selected: "Can you describe the pain?" Correct response: "Can you describe the pain?" Explanation: Question 9 See full question A nurse is caring for a client with a diagnosis of Impaired gas exchange. Based upon this nursing diagnosis, which outcome is most appropriate? You Selected: The client has normal breath sounds in all lung fields. Correct response: The client has normal breath sounds in all lung fields. Explanation: Question 10 See full question When developing a care plan for an older adult, a nurse should consider which challenges that clients in this age-group face? You Selected: Adjusting to retirement, deaths of family members, and decreased physical strength Correct response: Adjusting to retirement, deaths of family members, and decreased physical strength Explanation: Question 11 See full question Which finding is an example of a variance in the critical pathway of a client 3 days after an above-the-knee amputation? You Selected: Temperature of 102° F (38.9°C) Correct response: Temperature of 102° F (38.9°C) Explanation: Question 12 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 at 32 weeks' gestation who is preeclamptic with +3 proteinuria Correct response: a woman at 32 weeks' gestation who is preeclamptic with +3 proteinuria Explanation: Question 13 See full question Which information is appropriate to include in an incident report? You Selected: the extenuating circumstances involved in the situation Correct response: what the nurse saw and did Explanation: Question 14 See full question Which strategy is the most effective for a nurse to use to reduce the number of children involved in automobile accidents who were not wearing seat belts? You Selected: Attend a school board meeting to advocate for classes teaching children seat belt safety. Correct response: Attend a school board meeting to advocate for classes teaching children seat belt safety. Explanation: Question 15 See full question A 57-year-old woman with breast cancer who does not speak English is admitted for a lumpectomy. Her daughter, who speaks English, accompanies her. In order to obtain admission information from the client, what should the nurse do? You Selected: Obtain a trained medical interpreter. Correct response: Obtain a trained medical interpreter. Explanation: Question 16 See full question The hospital is responding to a mass casualty disaster with adult and pediatric victims. After reallocating staff, the charge nurse on the pediatric floor should: You Selected: review the census for clients that are candidates for early discharge. Correct response: review the census for clients that are candidates for early discharge. Explanation: Question 17 See full question The charge nurse on the pediatric floor has assigned a 6-year-old girl with newly diagnosed type 1 diabetes and an 8-year-old girl recovering from ketoacidosis to the same semi-private room. The 6-year-old's mother is upset because the parent staying with the other child is male and believes the arrangement is violates her social norms. The nurse should: You Selected: reassign the children to different rooms. Correct response: reassign the children to different rooms. Explanation: Question 18 See full question An airplane crash results in mass casualties. The nurse is directing personnel to tag all victims. Which information should be placed on the tag? Select all that apply. You Selected: triage priority identifying information when possible (such as name, age, and address) medications and treatments administered Correct response: triage priority identifying information when possible (such as name, age, and address) medications and treatments administered Explanation: Question 19 See full question An alert and oriented elderly client is admitted to the hospital for treatment of cellulitis of the left shoulder after an arthroscopy. Which fall prevention strategy is most appropriate for this client? You Selected: Use a nightlight in the bathroom. Correct response: Use a nightlight in the bathroom. Explanation: Question 20 See full question The nurse manager on the orthopedic unit is reviewing a report that indicates that in the last month five clients were diagnosed with pressure ulcers. The nurse manager should: You Selected: institute a quality improvement plan that identifies contributing factors, proposes solutions, and sets improvement outcomes. Correct response: institute a quality improvement plan that identifies contributing factors, proposes solutions, and sets improvement outcomes. Explanation: Question 21 See full question Which type of surgery is most likely to cause the client to experience postoperative nausea and vomiting? You Selected: abdominal hysterectomy Correct response: abdominal hysterectomy Explanation: Question 22 See full question When changing a wet-to-dry dressing covering a surgical wound, what should the nurse do? You Selected: Cover the wet packing with a dry sterile dressing. Correct response: Cover the wet packing with a dry sterile dressing. Explanation: Question 23 See full question A nurse is caring for a client who is receiving hospice care at home. The client's neighbors have been calling the nurse to inquire about the client's condition. The nurse should tell the callers: You Selected: "Please call the client's sister" Correct response: "Please call the client's sister" Explanation: Question 24 See full question A nurse on the gynecologic surgery unit observes a respiratory therapist (RT) take a medication cup with pills that was sitting in the medication room. What course of action should the nurse take? You Selected: Report the situation to the nursing supervisor. Correct response: Report the situation to the nursing supervisor. Explanation: Question 25 See full question A client with type 1 diabetes is admitted to the emergency department with dehydration following the flu. The client has a blood glucose level of 325 mg/dL (18 mmol/L) and a serum potassium level of 3.5 mEq (3.5 mmol/L). The health care provider (HCP) has prescribed 1,000 mL 5% dextrose in water to be infused every 8 hours. Prior to implementing the HCP's prescriptions, the nurse should contact the HCP, explain the situation, provide background information, report the current assessment of the client, and: You Selected: verify the prescription for 5% dextrose in water. Correct response: verify the prescription for 5% dextrose in water. Explanation: Question 26 See full question When planning care for a client with ulcerative colitis who is experiencing an exacerbation of symptoms, which client care activities can the nurse appropriately delegate to an unlicensed assistive personnel (UAP)? Select all that apply. You Selected: obtaining the client's weight providing skin care following bowel movements maintaining intake and output records Correct response: providing skin care following bowel movements maintaining intake and output records obtaining the client's weight Explanation: Question 27 See full question A nurse is obtaining consent for a bone marrow aspiration. Which actions should the nurse take? Select all that apply. You Selected: Verify that the client is signing the consent form of his or her own free will. Witness the client signing the consent form. Explain the risks of the procedure to the client. Evaluate that the client understands the procedure. Correct response: Witness the client signing the consent form. Evaluate that the client understands the procedure. Verify that the client is signing the consent form of his or her own free will. Determine that the client understands postprocedure care. Explanation: Question 28 See full question The charge nurse on a hematology/oncology unit is reviewing the policy for using abbreviations with the staff. The charge nurse should emphasize which information about why dangerous abbreviations need to be eliminated? Select all that apply. You Selected: to ensure client safety to prevent medication errors to make it easier for clients to understand the medication prescription to make data entry into a computerized health record easier to ensure efficient and accurate communication Correct response: to ensure efficient and accurate communication to prevent medication errors to ensure client safety Explanation: Question 29 See full question A client with chronic renal failure is admitted with a heart rate of 122 beats/minute, a respiratory rate of 32 breaths/minute, a blood pressure of 190/110 mm Hg, jugular vein distention, and bibasilar crackles. Which nursing diagnosis takes highest priority for this client? You Selected: Excess fluid volume Correct response: Excess fluid volume Explanation: Question 30 See full question A client has a history of macular degeneration. While in the hospital, the priority nursing goal will be to: You Selected: promote a safe, effective care environment. Correct response: promote a safe, effective care environment. Explanation: Question 31 See full question The nurse has been assigned to provide care for four clients at the beginning of the day shift. In what order should the nurse assess these clients? All options must be used. You Selected: a client with peptic ulcer disease experiencing a sudden onset of acute stomach pain a client who is requesting pain medication 2 days after surgery to repair a fractured jaw a client with suspected gastric cancer who is on nothing-by-mouth (NPO) status for tests a client awaiting surgery for a hiatal hernia repair at 1100 Correct response: a client with peptic ulcer disease experiencing a sudden onset of acute stomach pain a client who is requesting pain medication 2 days after surgery to repair a fractured jaw a client with suspected gastric cancer who is on nothing-by-mouth (NPO) status for tests a client awaiting surgery for a hiatal hernia repair at 1100 Explanation: Question 32 See full question A nurse is documenting a variance that has occurred during the shift, and this report will be used for quality improvement to identify high-risk patterns and potentially initiate in-service programs. This is an example of which type of report? You Selected: Incident report. Correct response: Incident report. Explanation: Question 33 See full question When documenting the care of a client, the nurse is aware of the need to use abbreviations conscientiously and safely. This includes: You Selected: Limiting abbreviations to those approved for use by the institution. Correct response: Limiting abbreviations to those approved for use by the institution. Explanation: Question 34 See full question A client's diagnosis of pneumonia requires treatment with antibiotics. The corresponding order in the client's chart should be written as: You Selected: Moxifloxacin 400 mg daily. Correct response: Moxifloxacin 400 mg daily. Explanation: Question 35 See full question A nurse on a night shift entered an elderly client's room during a scheduled check and discovered the client on the floor beside her bed after falling when trying to ambulate to the washroom. After assessing and assisting the client back to bed, the nurse has completed an incident report. What is the primary purpose of this particular type of documentation? You Selected: Identifying risks and ensuring future safety for clients. Correct response: Identifying risks and ensuring future safety for clients. Explanation: Question 36 See full question A client reports to the primary health care facility for routine physical examination after cardiac rehabilitation that followed myocardial infarction. Keeping in mind that the client speaks English as a second language, how should the nurse conduct the interview? You Selected: The nurse should avoid using complex medical terminology. Correct response: The nurse should avoid using complex medical terminology. Explanation: Question 37 See full question A nurse who works on a palliative care unit has participated in several clinical scenarios that have required the application of ethics. Ethics is best defined as: You Selected: The principles that determine whether an act is right or wrong. Correct response: The principles that determine whether an act is right or wrong. Explanation: Question 38 See full question A mentally incapacitated client is scheduled for surgery. Considering the principle of autonomy, who should give the consent for surgery? You Selected: Surrogate decision maker. Correct response: Surrogate decision maker. Explanation: Question 39 See full question A nurse is caring for a client who is well known in society. A person inquires about the medical details of the client, saying that he is a family member. The nurse reveals the requested information. Later, the nurse comes to know that the inquirer was not a family member. Which of the following ethical rules of professional-client relationships has the nurse violated? You Selected: Confidentiality. Correct response: Confidentiality. Explanation: Question 40 See full question Which of the following measures should a home healthcare nurse implement to minimize the potential for lawsuits? You Selected: Perform thorough, accurate, and timely documentation. Correct response: Perform thorough, accurate, and timely documentation. Explanation: Question 41 See full question A client has a complex medical history involving consequences of type 1 diabetes. As a result of diabetic nephropathy, the client now is involved in the local hospital's dialysis program and has been referred to an ophthalmologist by his primary care physician following vision problems. In addition, he receives home care nursing for treatment of a foot ulcer that is slow to heal. This client's situation characterizes which of the following phenomena? You Selected: Fragmentation of care. Correct response: Fragmentation of care. Explanation: Question 42 See full question The nurse is providing care for a client with a tracheotomy whose pulse oximeter has recently alarmed, showing the oxygen saturation to be 77%. The nurse has repositioned the client and applied supplemental oxygen, interventions that have raised the oxygen levels to 80% and somewhat decreased work of breathing. The client is not in immediate distress, and level of consciousness remains high. The nurse should page which of the following practitioners? You Selected: Respiratory therapist. Correct response: Respiratory therapist. Explanation: Question 43 See full question The nurse is reflecting on the evaluation step of the nursing process. Which documentation would indicate nursing actions were effective in reducing breathing problems for a client? Select all that apply. You Selected: Lung sounds clear bilaterally with non-labored respirations noted Anxiety decreased, oxygen saturation levels at 94%, nonproductive cough, respirations at 22 breaths/min Correct response: Anxiety decreased, oxygen saturation levels at 94%, nonproductive cough, respirations at 22 breaths/min Lung sounds clear bilaterally with non-labored respirations noted Explanation: Question 44 See full question A nurse working in the operating room is assigned to the suite where therapeutic abortions are to be performed throughout the day. The nurse feels that participation in these procedures conflicts with personal religious beliefs. What should the nurse do after notifying the operating room supervisor? You Selected: Remain in the operating room suite until another nurse arrives to take that assignment. Correct response: Remain in the operating room suite until another nurse arrives to take that assignment. Explanation: Question 45 See full question Following the discharge of a client from the day clinic, the nurse cannot find the client's health record (chart). Which of the following steps taken by the nurse would be most appropriate? You Selected: Notify the client that the record is missing. Correct response: Notify the client that the record is missing. Explanation: Question 46 See full question Following notification of two client falls on the unit, a nurse manager decides a formal investigation is necessary and informs the staff. Which of the following statements indicates the primary reason for the nurse manager to perform an investigation to determine the causes of the two falls? You Selected: "I would like to establish the causes and trends related to client falls." Correct response: "I would like to establish the causes and trends related to client falls." Explanation: Question 47 See full question A nurse is caring for a client who speaks only French. The client's granddaughter is bilingual and assists with translating, but the nurse needs to provide the client with discharge instructions. Which of the following would be the best option for the nurse and the client? You Selected: Ask the manager to find an interpreter who is able to provide the discharge instructions. Correct response: Ask the manager to find an interpreter who is able to provide the discharge instructions. Explanation: Question 48 See full question A client is placed on a low-sodium (1500 mg/day) diet. Which client statement indicates that the nurse's nutrition teaching plan has been effective? You Selected: "I chose broiled chicken with a baked potato for dinner." Correct response: "I chose broiled chicken with a baked potato for dinner." Explanation: Question 49 See full question The nurse assists the client to the operating room table and supervises the operating room technician preparing the sterile field. Which action, completed by the surgical technician, indicates to the nurse that a sterile field has been contaminated? You Selected: Wetness in the sterile cloth on top of the nonsterile table has been noted. Correct response: Wetness in the sterile cloth on top of the nonsterile table has been noted. Explanation: Question 50 See full question The nurse is providing preoperative instructions to a client who is deaf. Which strategy is mosteffective in assuring that the client understands the information? You Selected: Give the client written material to read, and follow up with time for questions. Correct response: Give the client written material to read, and follow up with time for questions. Explanation:
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Question 1 See full question A client has a nursing diagnosis of Risk for injury related to adverse effects of potassium-wasting diuretics. What is a correctly written client outcome for this nursing diagnosis? You Selected: "By discharge, the client correctly identifies three potassium-rich food sources." Correct response: "By discharge, the client correctly identifies three potassium-rich food sources." Explanation: Question 2 See full question When implementing the planned care of a client with pneumonia, a nurse achieves proper placement of a tympanic thermometer probe in an adult's ear canal by which method? You Selected: Pulling the ear pinna back, up, and out Correct response: Pulling the ear pinna back, up, and out Explanation: Question 3 See full question The nurse finds a client lying on the floor next to the bed. After returning the client to bed, assessing for injury, and notifying the health care provider (HCP), the nurse fills out an incident report. What should the nurse do next? You Selected: Place the incident report on the medical record. Correct response: Give the incident report to the nurse-manager. Explanation: Question 4 See full question An elderly client becomes confused and combative. The client's nurse receives an order for soft wrist restraints. When the client's family insists that he not be restrained, the nurse informs the family that the family must provide an around-the-clock attendant for the client to avoid use of restraints. The family spokesman replies, "You find the attendant; that is your responsibility." Which of the following would be the best response by the nurse? You Selected: "I recommend family members arrange to stay with the client." Correct response: "I recommend family members arrange to stay with the client." Explanation: Question 5 See full question A nurse observes a second nurse making social plans with a client and disclosing information of a personal nature, including financial situation. What should the first nurse do in this situation? You Selected: Discuss the observation directly with the nurse. Correct response: Discuss the observation directly with the nurse. Explanation:
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Question 1 See full question While caring for a client who's immobile, a nurse documents the following information in the client's chart: "Turned client from side to back every 2 hours." "Skin intact; no redness noted." "Client up in chair three times today." "Improved skin turgor noted." Which nursing diagnosis accurately reflects this information? You Selected: Risk for impaired skin integrity related to immobility Correct response: Risk for impaired skin integrity related to immobility Explanation: Question 2 See full question The charge nurse on the postpartum unit has received a report about a client who has just experienced a fetal demise and will be ready for transfer out of the labor unit in about 2 hours. The client has asked her primary nurse if she can stay on the obstetrical unit since she has found support from the nursing staff there. What action should the charge nurse on the postpartum unit take? You Selected: Talk to the mother first and decide on a location that is mutually agreeable. Correct response: Talk to the mother first and decide on a location that is mutually agreeable. Explanation: Question 3 See full question Thirty people are injured in a train derailment. Which client should be transported to the hospital first? You Selected: a 25-year-old with a sucking chest wound Correct response: a 25-year-old with a sucking chest wound Explanation: Question 4 See full question Using the nursing process to make ethical decisions involves following several steps. Which step is the nurse implementing when he or she reflects on the decision-making process and the role it will play in making future decisions? You Selected: Evaluating. Correct response: Evaluating. Explanation: Question 5 See full question A nurse discusses the HIV-positive status of a client with other colleagues. The client can sue the nurse for which of the following? You Selected: Invasion of privacy. Correct response: Invasion of privacy. Explanation:
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