To provide comfort for the client, while preparing to assist the client in the end stage of her life in response to anticipated symptom development, the nurse plans to: 1. Decrease the client’s fluid intake 2. Limit the use of over-the-counter analgesics 3. Provide larger meals with more appealing seasoning 4. Determine valued activities and […]
The nurse has provided an otic medication to a client. What should the nurse document about this medication’s administration? 1. Name of the drug 2. The strength 3. The appetite of the client 4. The number of drops 5. The response of the client ANSWER Correct Answer: 1, 2, 4, 5 Rationale: When documenting […]
The son of a client diagnosed with moderately advanced Alzheimer’s disease shows concern over the care his mother will receive after making the decision to institutionalize her. Which of the following statements made by the admitting nurse is most therapeutic in addressing the son’s concerns? 1. “We care deeply for all our clients and take […]
The nurse is caring for a postpartum client receiving pain medication through an epidural catheter. Which assessment finding should the nurse report immediately to the physician? 1. Pulse rate: 80 2. Respiratory rate: 8 3. Blood pressure: 120/80 4. Pain rating of 4 on scale of 1 to 10 ANSWER Correct Answer: 2 Rationale […]
When observing an older client’s response upon learning of the death of a close family friend, the nurse realizes that the significance of the loss to the client is dependent upon which factors 1. Importance of the person to the client 2. Amount of changes that will occur because of the loss 3. The client’s […]
Which goals should the nurse identify as appropriate for a client with the nursing diagnosis Urinary Pattern Alteration related to an enlarged prostate? 1. The client will avoid bladder distention. 2. The client will maintain fluid imbalance. 3. The client will remain free of skin breakdown. 4. The client will voice increased discomfort. ANSWER […]
The nurse is assessing a client’s blood pressure. What should the nurse hear during phase 2 of Korotkoff’s sounds? 1. A muffled, whooshing, or swishing sound 2. Disappearance of sound 3. Faint, clear tapping sound 4. Increased intensity of sound ANSWER Correct Answer: 1 Rationale 1: Phase 2 produces a muffled, whooshing, or swishing […]
The client states, “Heart disease runs in our family. My blood pressure has always been high.” The nurse determines that this is an example of the client’s: 1. Risk factors 2. Active strategy 3. Health beliefs 4. Negative health behavior ANSWER ANS: 1 Risk factors are anything that increases the vulnerability of an individual […]
A disabled client requiring restorative care should be referred to a(n): 1. Nursing home 2. Subacute care unit 3. Home health care agency 4. Ambulatory health center ANSWER ANS: 3 A home health care agency provides health services to individuals and families in their home to promote, maintain, or restore health, or to maximize […]
The best example of an appropriate nursing assumption is: 1. Clients will make their needs and wants known to the staff 2. Clients require a quiet, darkened environment in which to sleep 3. Prompt administration of pain medication is an expectation of a postoperative client 4. A client recently diagnosed with cancer will want family […]
