The nurse determines that unlicensed assistive personnel (UAP) are not to be delegated client blood pressure measurements. What did the nurse observe to make this clinical decision? 1. The valve on the bulb was closed. 2. The client was sitting with the legs crossed. 3. The arm was below the level of the heart. 4. […]
While assisting the client with a bath, the nurse encourages full range of motion in all the client’s joints. Which activity would best support range of motion in the hand and arm? 1. Give the client a washcloth to wash the face. 2. Move the wash basin farther toward the foot of the bed so […]
Which of the following may improve the sleep of an older adult client? 1. Drinking an alcoholic beverage before bedtime 2. Using an over-the-counter sleeping agent 3. Eliminating naps during the day 4. Going to bed at a consistent time even if not feeling sleepy ANSWER ANS: 3 To promote sleep, daytime naps should […]
The nurse is aware that application of cold is indicated for the client with: 1. Menstrual cramping 2. An infected wound 3. A fractured ankle 4. Degenerative joint disease ANSWER ANS: 3 Direct trauma such as fractures or sprains may be treated with cold. The application of cold can initially diminish swelling and pain. […]
A client is prescribed 0.45% sodium chloride, which is a hypotonic solution. The nurse recognizes the primary goal of such intravenous therapy is to: 1. Expand the volume of fluid in the vascular system 2. Pull fluid from the cells 3. Keep protein levels normal 4. Move fluid into the cells ANSWER ANS: 4 […]
As the RN is suctioning a client, the pulse oximetry reading drops to 83%. What should the nurse do? 1. Allow the client to take some extra deep breaths. 2. Continue to suction but only intermittently. 3. Keep the catheter in place and wait a few minutes. 4. Stop suctioning and give supplemental oxygen. […]
Which one of the following statements by the parent of a child indicates that further teaching by the nurse is required? 1. “Now that my child is 2 years old, I can let her sit in the front seat of the car with me.” 2. “I make sure that my child wears a helmet when […]
A client is being transferred from an acute care facility to a long-term care facility. What information should the nurse provide to the long-term care facility about the client’s medications? 1. Nothing, as the medications all need to be reordered at the long-term care facility. 2. Have the client’s medication prescriptions filled before going to […]
The nurse is caring for a 23-year-old male client who is in the ICU with second and third degree burns over 40 percent of his body. One of the first symptoms that the client is having organ fail-ure is that the urine output is less than: 1. 30 mL/hour 2. 40 mL/hour 3. 50 mL/hour […]
The sounds heard over the trachea during the auscultation of the thorax, are expected to be: 1. Soft, low-pitched, and breezy 2. Loud, high-pitched, and hollow 3. Moist, crackling, and bubbling 4. High-pitched and musical ANSWER ANS: 2 Sounds heard during auscultation over the trachea should be loud, high-pitched and hollow. Soft, low-pitched, and […]
