A) I will have to check on hospital regulations and policies.
B) These procedures have to be carried out by our staff.
C) Is there anything you need from me to perform the ritual bath?
D) A ritual bath will have to wait until after post-mortem care
Your response was" A".
The correct answer is C: Is there anything you need from me to perform the ritual bath?
Rationale: In some religious traditions, a ritual bath is performed by a family member or a ritual burial society. Nurses
A) Spray the oropharynx with saline
B) Ask the client to drink a warm liquid
C) Force fluids for the next 8 hours
D) Raise the head of the bed to at least 45 degrees
Your response was" A".
The correct answer is D: Raise the head of the bed to at least 45 degrees
Placing the client in semi or high fowler\u2019s position will promote lung expansion and effective coughing. While drinking
A client has just returned from the Post-Anesthesia Care Unit (PACU) to the surgical unit after a cholecystectomy. When
initial vital signs are taken the nurse notes a temperature of 94.8 degrees Fahrenheit. Whichfirst nursing action is
A) Continue to monitor the vital signs as indicated
B) Apply a warm blanket and check the temperature in 10 minutes
C) Ask the PACU nurse more details of what happened in PACU
D) Call the health care provider and obtain further orders for warming
A client\u2019s post-operative temperature should be at least 95 degrees. If the temperature does not increase, the nurse should call the provider for orders for an electric warming blanket or other measures. It is not sufficient to continue monitoring without taking action.
The client with amyotrophic lateral sclerosis is scheduled for 160 ml of enteral feeding as a bolus every 4 hours. Before
flushing with water the nurse aspirates the feeding tube contents and gets back 180 ml of feeding. What is the next
appropriate nursing action?
A) Administer the feeding as ordered
B) Hold the next feeding
C) Flush with sterile water
D) Discard the undigested feeding
If residual is greater than 150 ml, then the next feeding should be held. Administering water or the next feeding does not
help with the digestion of this feeding. Discarding the feeding that was aspirated depletes the body of enzymes and
electrolytes that have been mixed with the feeding
A) the procedure be done prior to the bath
B) family members should be taught the procedure
C) cardiac dysrhythmias can result during the process
D) increased dietary fiber can minimize such problems
A) take the BP again in 2 minutes in the same arm
B) retake the BP again immediately in the same arm
C) use an electronic BP cuff on the other arm
D) check to see if the stethoscope is plugged
A) "In order to measure your oxygen level, please remove the polish from at least 2 nails."
B) "If you do not remove all your polish, I will request a needlestick to test oxygen levels."
C) "I am sorry. All your nail polish must go off."
D) "I will ask your provider if we must ruin those beautiful nails."
A) ask the client to hold a breath
B) offer sips of water
C) bring the code cart to the bedside
D) empty the tube of all drainage
A) The radiation from a mammography is equivalent to 1 hour of sun exposure.
B) You have nothing to worry about; it is less than tanning in the nude.
C) A chest x-ray gives you more radiation exposure.
D) Exposure to mammography every 2 years is not dangerous.
Your response was" A". The correct answer is A: The radiation from a mammography is equivalent to one hour of sun
exposure. The exposure of radiation from a mammography is equivalent to 1 hour of sun exposure; a client would have to
have several in a year\u2019s time to be at risk for cancer. This answer is concise and gives the client a point of reference.
Option 2 is judgmental and non-therapeutic. Option 3 is not accurate and can cause further concern about radiation
exposure. Option 4 does not clearly address the client\u2019s question.
A) Suggest the client rent an apartment with a sprinkler system
B) Provide a brochure on methods to promote relaxation.
C) Determine available community and personal resources
D) Explore the feelings of grief associated with the loss
The client has experienced a sudden event that has resulted in disequilibrium. The most important initial intervention
focuses on identifying resources and obtaining assistance for housing and other immediate needs. Information on home
safety, relaxation exercises, and grief counseling are of value after meeting initial needs for shelter.
A) there is no urine present in the bladder
B) the catheter is in the vagina
C) the catheter is not inserted in far enough
D) the bladder is over distended
The urinary catheter is inserted about 2 to 3 inches in the urinary meatus until the urine flow is visualized. If urine does not
flow, the catheter is rotated gently and carefully inserted another inch farther. A catheter inserted 4 to 5 inches with no
urine return is probably in the vagina
The nurse is caring for a 16 year-old client with femur fracture14 hours after surgery. Assessment findings include
tachycardia, increased shortness of breath, a temperature of 100.2 degrees Fahrenheit, complaints of feeling anxious,
and oxygen saturation level of 88%. In immediately notifying the provider of these findings, the nurse recognizes the client
is at risk for
This action might not be possible to undo. Are you sure you want to continue?