A 1-year-old child is scheduled to receive an IV line. The most appropriate type of restraint to use for this client to prevent removal of the IV line would be a(n): 1. Wrist restraint 2. Jacket restraint 3. Elbow restraint 4. Mummy restraint ANSWER ANS: 4 A mummy restraint is used short-term for a […]
Date: September 16th, 2020
The nurse is planning to conduct a spiritual self-assessment. What questions would the nurse include in this assessment? 1. “What makes me joyful?” 2. “What causes me to feel despair?” 3. “What possessions do I value the most?” 4. “What is my purpose in life?” 5. “What feeds my spirit?” ANSWER Correct Answer: 1, […]
Date: September 16th, 2020
The client has a history of gastrointestinal problems and has used herbal remedies in the past. The nurse expects that this client will be taking: 1. Chamomile 2. St. John’s wort 3. Echinacea 4. Ginkgo biloba ANSWER ANS: 1 Chamomile is used for inflammatory diseases of the gastrointestinal and upper respiratory tracts, and for […]
Date: September 16th, 2020
The nurse is identifying outcome criteria for a client with a nursing diagnosis of Disturbed Sensory Perception, Auditory. What would indicate that interventions to address this diagnosis have been successful? 1. Client places hearing aid on beside table when not in use. 2. Client does not respond appropriately to questions. 3. Client demonstrates use and […]
Date: September 16th, 2020
For a functionally illiterate client, the nurse particularly focuses on: 1. Using intricate analogies and examples 2. Avoiding lengthy return demonstrations 3. Incorporating familiar nonmedical terminology 4. Providing longer learning sessions with the client ANSWER ANS: 3 When teaching a functionally illiterate client, the nurse should use simple terminology, avoiding medical jargon. The nurse […]
Date: September 16th, 2020
A threshold of 90% is identified for an outcome indicator in the quality improvement program. Which of the following situations indicates a need for further review of the quality improvement plan? 1. The waiting time for clinic appointments has decreased 96%. 2. Clients with renal dialysis expressed a 95% satisfaction with their care. 3. In […]
Date: September 16th, 2020
The nurse suspects that a client is experiencing compromised gastrointestinal function. What assessment data did the nurse use to make this clinical decision? 1. Bowel sounds active in all four quadrants 2. Clay-colored stool 3. Increased appetite 4. Semisolid and moist stool ANSWER Correct Answer: 2 Rationale 1: Bowel sounds active in all four […]
Date: September 16th, 2020
An older client has an oral temperature reading of 97.2 degrees F. The nurse realizes that this client’s low temperature could be due to which observation? 1. The anxiety level of the client has increased. 2. Hormones have fluctuated in this client. 3. Muscle activity has increased during the client’s therapy session. 4. Loss of […]
Date: September 16th, 2020
The nurse understands that a pressure ulcer is an impairment of the skin as a result of prolonged ischemia. One of the easiest ways to prevent a pressure ulcer from occurring in an immobile client is to: 1. Keep the skin dry 2. Provide range of motion every shift 3. Use lift equipment when transferring […]
Date: September 16th, 2020
The home care nurse wants to ensure the safety of an older client who lives at home alone. Which intervention should the nurse identify as a way to prevent this client from falling? 1. Check vision every 5 years. 2. Exercise regularly. 3. Place socks on feet. 4. Turn the light on after getting out […]
Date: September 16th, 2020
