Which of the following clients has the greatest risk for friction-induced skin breakdown? 1. A client who is obese and is frequently incontinent of both urine and feces 2. A client who insists she is comfortable only when positioned on her left side 3. A client who is cognitively impaired and comforts herself by wringing […]
The spouse of a dying client is sitting quietly in the client’s room, looking at the floor. What can the nurse do to help the client and spouse during this time? 1. Encourage the spouse to move closer to the client, if desired. 2. Permit the spouse to sit alone. 3. Leave the spouse and […]
A client was given the wrong dose of medication and died. The case is being tried in court and similar cases are used by the court in comparison to arrive at a decision. What doctrine is being applied here? 1. Common law 2. Public law 3. Administrative law 4. Stare decisis ANSWER Correct Answer: […]
A client on diuretic therapy has a serum potassium level of 3.4 mg/dL. Which food should the nurse encourage this client to choose from the dinner menu? 1. Baked chicken 2. Green beans 3. Cantaloupe 4. Iced tea ANSWER Correct Answer: 3 Rationale: A potassium level of 3.4 is low, so the client should […]
The nurse is preparing to apply sequential compression devices to a client. In which order should the nurse apply these devices? 1. Place in the dorsal recumbent or semi-Fowler’s position. 2. Place a sleeve under each leg with the opening at the knee. 3. Wrap the sleeve securely around the leg, securing the Velcro tabs. […]
The nurse is caring for a terminally ill client who frequently engages in prayer with her family. The most therapeutic nursing intervention for this client regarding this practice would be to: 1. Move the family into the unit’s sunroom for the ritual 2. Ask the client and her family to be allowed to pray with […]
The nurse is evaluating the client in the hospital’s postanesthesia care unit (PACU) and deter-mines that the Aldrete score is 8. Based on this assessment, the nurse anticipates that the client will: 1. Be sent to the intensive care unit 2. Be discharged back to his or her room on the nursing unit 3. Remain […]
A visiting nurse completes an assessment of the ambulatory client in the home and determines the nursing diagnosis of risk for injury related to decreased vision. Based on this assessment, the cli-ent will benefit the most from: 1. Installing fluorescent lighting throughout the house 2. Becoming oriented to the position of the furniture and stairways […]
A client who is scheduled for surgery is found to have thrombocytopenia. A specific postopera-tive concern for the nurse for this client is: 1. Hemorrhage 2. Wound infection 3. Fluid imbalance 4. Respiratory depression ANSWER ANS: 1 A client with thrombocytopenia is at risk for hemorrhaging during and after surgery. Clients with immunological disorders […]
Which assessment technique will the nurse use first when examining a client with a fecal elimination problem? 1. Auscultation 2. Inspection 3. Palpation 4. Percussion ANSWER Correct Answer: 2 Rationale 1: After inspection, the nurse should then auscultate for bowel sounds. Rationale 2: The nurse will first inspect the client’s abdominal region. Rationale 3: […]
