The best position for the nurse to position the client in order to auscultate the apical site, if a low-pitched murmur is suspected during prior assessment, is: 1. Sitting up 2. Standing 3. Lying on the left side 4. Dorsal recumbent ANSWER ANS: 3 Extra heart sounds or heart murmurs are heard more easily […]
Date: September 21st, 2020
While discussing a client’s medication history, the client tells the nurse that she thinks she is al-lergic to a particular type of medication. Which of the following nursing actions has priority in this situation? 1. Note the allergy on the client’s Kardex. 2. Inform the provider of the client’s possible allergy. 3. Review the client’s […]
Date: September 21st, 2020
The nurse is in the process of conducting an admission interview with the client. At one point in the discussion, the client has provided information that the nurse would like to clarify. The nurse employs the technique of clarification as indicated by the response: 1. “I’m not sure that I understand what you mean by […]
Date: September 21st, 2020
A mother of a young child enters the kitchen and finds the child on the floor. There is a bottle of cleanser next to the child and particles of the substance around the child’s mouth. The parent’s first action should be to: 1. Call the Poison Control unit 2. Provide ipecac syrup 3. Check the […]
Date: September 21st, 2020
In goal setting, the nurse is aware that the factor that is associated with available client resources and motivation is: 1. Realistic 2. Observable 3. Measurable 4. Client-centered ANSWER ANS: 1 The nurse sets realistic goals that can be achieved. This increases the client’s motivation. The nurse also takes available resources into consideration in […]
Date: September 21st, 2020
A client who has experienced massive soft tissue trauma is handling both the physical and emo-tional stressors via the generalized adaptation syndrome (GAS). The major benefit of this defense mechanism is through the: 1. Identification of foreign antigens on invading bacteria 2. Production of endorphins that decrease awareness of pain 3. Increased epinephrine, resulting in […]
Date: September 21st, 2020
A client is unable to independently perform colostomy care due to arthritis. The nurse should first: 1. Offer to assist the client to learn to manage the care 2. Arrange for home care services to care for the colostomy 3. Inquire as to family members who may be able to assist with the care 4. […]
Date: September 21st, 2020
While participating in a community auditory screening, the nurse is alert to the population that has the greatest prevalence of problems. The nurse is aware that hearing impairment is more common for: 1. Whites 2. Asian Americans 3. African Americans 4. Native Americans ANSWER ANS: 1 Whites have more hearing impairment problems than African […]
Date: September 21st, 2020
Which of the following responses by an older-adult client is most reflective of a need for further education by the nurse regarding the physiological changes associated with the older adult? 1. “I call a cab if I want to go out after dark.” 2. “I can’t help worrying about becoming forgetful.” 3. “I have my […]
Date: September 21st, 2020
Which of the following statements made by a nurse reflects a lack of understanding regarding a DNR (do not resuscitate) order? 1. “All family members need to agree before a DNR order can be written.” 2. “All terminally ill clients are ultimately required to be declared a DNR status.” 3. “The DNR order on the […]
Date: September 21st, 2020
