The nurse is identifying goals for a client experiencing diarrhea. What goal should the nurse select for this client? 1. Client will defecate regularly. 2. Client will increase the amount of sugar in the diet. 3. Client will limit fluid intake. 4. Client will regain normal stool consistency. ANSWER Correct Answer: 4 Rationale 1: […]
A nurse has been assigned a new client who cannot speak English. In order that the client receives accurate information, the nurse should: 1. Have a member of the housekeeping staff who speaks the same language translate. 2. Use the translation services supplied by the hospital. 3. Make sure a family member who does speak […]
The nurse is preparing to present an educational program to residences of an assisted-living facil-ity. Which teaching strategies would be most appropriate for the learning needs of this age-group? (Select all that apply.) 1. Speak in a slow but well-articulated manner. 2. Present a variety of ideas so as to have broad appeal. 3. Speak […]
A client is instructed on the care of an indwelling urinary catheter. Which returned demonstration by the client indicates that teaching has been effective? 1. The client empties the drainage bag once a day. 2. The client hangs the drainage bag on the towel rod. 3. The client refuses drinks one to two 8-ounce glasses […]
A client with a nasotracheal tube in place has been restless and pulling at the tube. How should the nurse assess if the tube is still in place? 1. Count the client’s respirations. 2. Assess the depth of the client’s respirations. 3. Auscultate for bilateral breath sounds. 4. Deflate the cuff and listen for minimal […]
The nurse is preparing to perform an eye assessment. What equipment should the nurse have available to complete this assessment? 1. Penlight 2. Snellen’s chart 3. Sterile gloves 4. Gauze square 5. Millimeter ruler ANSWER Correct Answer: 1, 2, 4, 5 Rationale 1: When performing an eye examination, the nurse will need a penlight. […]
An individual contacts the emergency department of the local hospital to ask what to do for a skiing partner who appears to be suffering from hypothermia. The victim is alert and able to re-spond to questions. The nurse instructs the individual who has called to have the victim: 1. Take sips of brandy 2. Drink […]
While undergoing a soapsuds enema, the client complains of abdominal cramping. The nurse should: 1. Immediately stop the infusion 2. Lower the height of the enema container 3. Advance the enema tubing 2 to 3 inches 4. Clamp the tubing ANSWER ANS: 2 The nurse should lower the container if the client complains of […]
Nurses working with clients in pain need to recognize and avoid common misconceptions and myths about pain. In regard to the pain experience, which of the following is correct? 1. The client is the best authority on the pain experience. 2. Chronic pain is mostly psychological in nature. 3. Regular use of analgesics leads to […]
Which of the following statements made by an older adult reflects the best understanding of the role of fiber regarding good bowel health? 1. “Fiber is very effective at cleaning out the bowels.” 2. “A high-fiber diet results in softer bowel movements.” 3. “Passing hard, dry stool is more uncomfortable and harder on the bowels.” […]
