The nurse is caring for a client who is receiving parenteral nutrition (PN). Which of the following is an appropriate nursing intervention when administering parenteral nutrition to a client? 1. Begin the infusion rates at 100 to 150 mL/hour. 2. Maintain a consistent infusion rate. 3. Change the infusion tubing once a week. 4. Monitor […]
The nurse enters the room of a client who has a history of heart disease. On looking at the client, the nurse feels that something is “not right” with the client and proceeds to take the vital signs. This is the nurse acting on: 1. Intuition 2. Reflection 3. Knowledge 4. Scientific methodology ANSWER […]
A nurse mistakenly gave a client who was NPO a morning breakfast tray. After realizing the mistake, the nurse notified the physician as well as the client; explained the consequences of this mistake, which included a delay in the client’s scheduled procedure; and documented the situation in the client’s medical record. This nurse demonstrates which […]
During an interview, the nurse needs to obtain specific information about the signs and symp-toms of the client’s health problem. To obtain these data most efficiently, the nurse should use: 1. Channeling 2. Open-ended questions 3. Closed-ended questions 4. Problem-seeking responses ANSWER ANS: 3 Using closed-ended questions helps the nurse to acquire specific information […]
The nurse uses olfaction in the client’s assessment. If a sweet, fruity smell is noticed in the oral cavity, the nurse suspects: 1. Diabetic acidosis 2. Gum disease 3. Stomatitis 4. Malabsorption syndrome ANSWER ANS: 1 A sweet, fruity smell noticed in the oral cavity is indicative of diabetic acidosis. Halitosis of the oral […]
A 21-year-old woman asks when she should perform a breast self-examination during the month. The nurse should inform the client: 1. “Any time you think of it.” 2. “At the same time each month.” 3. “On the first day of your menstrual period.” 4. “Two to three days after your menstrual period.” ANSWER ANS: […]
A client diagnosed with chronic bronchitis is awakened from sleep experiencing shortness of breath. The nurse suspects that he is experiencing orthopnea and suggests positioning him to minimize the dyspnea so he can sleep more peacefully. The nurse best describes this position to the client as: 1. “I’ll use pillows to take the pressure off […]
The nurse is caring for a client who has just had a lumbar puncture. What should the nurse document about this client’s procedure? 1. Date and time performed 2. The physician’s name 3. The client’s ability to void after the procedure 4. The color, character, and amount of cerebrospinal fluid withdrawn 5. The client’s status […]
A clinical nursing instructor recognizes that a nursing student understands the legal responsibilities she/he has to their clients when the student: 1. is prepared to discuss their client’s medical diagnosis in pre-conference. 2. is overheard stating, “My care is held to the same standards as that of the unit nurses.” 3. offers to stay with […]
Which of the following statements made by a nurse reflects a need for further instruction re-garding communicating with the older adult client? 1. “Children and the elderly have the same communication barriers.” 2. “If I tell him why he needs to know something, he’ll usually listen.” 3. “Hearing deficits can certainly make communication a challenge.” […]
