A client comes to the emergency department with injuries to her upper shoulders and back area. When questioned about how the injuries occurred, the client becomes less talkative and states that she “fell.” The client has a history of frequent ED visits, always with believable excuses about how her injuries occurred. The nurse begins to […]
The nurse is concerned that a break occurred in a sterile field. Which action occurred that caused this break? 1. Grasping the edge of the outermost flap and opening it away from oneself 2. Keeping objects on the field 1 inch from the edge 3. Keeping the sterile field in eyesight 4. Transferring a sterile […]
Which of the following statements should the nurse use to instruct the nursing assistant caring for a client with an indwelling urinary catheter? 1. Empty the drainage bag at least every 8 hours. 2. Clean up the length of the catheter to the perineum. 3. Use clean technique to obtain a specimen for culture and […]
Which of the following clients is at greatest risk for serious complications when using the Valsalva maneuver to expel feces? 1. 25-year-old pregnant client 2. 66-year-old male with hypertrophied prostate disease 3. 44-year-old male client with glaucoma 4. 53-year-old female with stomach cancer ANSWER ANS: 3 Clients with cardiovascular disease, glaucoma, increased intracranial pressure, […]
The postoperative client is ambulating for the first time since surgery. The client has been able to tolerate sitting up on the side of the bed and has stood at the bedside without difficulty on two occasions. Which staff member should ambulate this client? 1. The UAP 2. A licensed practical (vocational) nurse 3. A […]
An assisted living facility has provided its clients with an educational program on safe admin-istration of prescribed medications. Which statement made by an older-adult client reflects the best understanding of safe self-administration of medications? 1. “I don’t seem to have problems with side effects, but I’ll let my doctor know if something happens.” 2. “I’m […]
The nurse is providing care to a client during the posttest phase of diagnostic testing. What will the nurse do during this phase? 1. Provide emotional and physical support to the client. 2. Compare the previous and current test results. 3. Prepare the client for the test. 4. Modify nursing interventions as necessary. 5. Report […]
A 6-year-old is hospitalized for asthma. Which of the following activities would be appropriate to help this child resolve the crisis of hospitalization? 1. Crayons and a coloring book 2. A 1000-piece puzzle to complete 3. A CD player with soothing CDs 4. A Nerf football to throw around the room ANSWER ANS: 1 […]
During the assessment phase of the nursing process, the nurse may uncover data that help to identify communication problems. An example of this information is: 1. Extreme dyspnea or shortness of breath 2. Urinary frequency and pain 3. Chronic stomach pain 4. Lack of appetite ANSWER ANS: 1 An extremely breathless person must use […]
Which of the following symptoms would the nurse expect with a client who is experiencing acute pain? 1. Bradycardia 2. Bradypnea 3. Diaphoresis 4. Decreased muscle tension ANSWER ANS: 3 An expected assessment finding of a client experiencing acute pain would be diaphoresis result-ing from sympathetic nerve stimulation. Additional assessment findings of a client […]
