Urinary retention finding in elderly client

1. The nurse is caring for an 87 year-old client who complains of urinary retention.
Which finding should be reported immediately to the health care provider?
Infrequent voiding
Burning with urination Incorrect response
Fecal impaction This is the correct response
Stress incontinence 1. In planning care for a six month-old infant, what must the nurse provide to assist in the development of trust?
Security This is the correct response
Food
Comfort Incorrect response
Learning Objective: Lesson 3 Health Promotion and Maintenance
While the infant has many physical needs, it must be touched, loved, and stimulated to develop security and trust.
1. Which statement by the client during the initial assessment in the emergency department most strongly suggests suspected domestic violence?
"I have only been married for two months."
"I am determined to leave my house in a week."
"I have tried leaving home, but have always gone back." This is the correct response
"No one else in the family is as accident prone as I am." Incorrect response 1. A client has just returned to the medical-surgical unit postop for a segmental lung resection. After assessing the client, which is the first action a nurse should take?
Monitor oxygen saturation with the application of an oximeter
Suction excessive tracheobronchial secretions
This is the correct response
Assist the client to turn, deep breathe and cough Incorrect response
Administer the prn pain medication 1. While caring for a client, a nurse notes a pulsating mass in the client's periumbilical area. Which of these assessments is appropriate for the nurse to perform on the mass?
Palpate Incorrect response
Measure the length
Auscultate This is the correct response
Percuss 1. A nurse is caring for clients over the age of 70. The nurse is aware that when giving medications to older clients, it is best to use what approach?
Avoid drugs with side effects that impact cognition
Review the drug regimen yearly
Do not stop a medication entirely
Start low and go slow Correct response
1. Prior to a plaster cast application a nurse should include what point in the discussion with the client of what should happen?
The casted extremity will be placed on a cloth-covered surface
The cast material will be dipped several times into the tepid water
The wet cast should be handled with the palms of hands until fully dry Correct response
The cast should be covered with cotton material until it fully dries
After treating a 4 month-old infant in the Emergency Department for dehydration, the nurse finds the mother and infant were driven to the hospital by a neighbor. Upon discharge, the emergency nurse supplies the infant with a properly positioned car seat. Indicate where the car seat should be positioned in a car.
Use your cursor to select an area on the image below.
1. Which of these findings indicate early signs of toxicity for lithium carbonate?
Vomiting, diarrhea, and lethargy Correct response
Pruritus, rash, and photosensitivity
Electrolyte imbalance, tinnitus, and cardiac arrhythmias
Ataxia, agnosia, and course hand tremors
1. A nurse admits a client transferred from the emergency room (ER). The client, diagnosed with a myocardial infarction, is complaining of substernal chest pain, diaphoresis and nausea. What should be the first action taken by the nurse?
Administer morphine sulfate as ordered This is the correct response
Give a PRN sublingual nitroglycerine Incorrect response
Obtain the vital signs
Get the PRN 12 lead EKG taken 1. The nurse manager identifies that time spent by staff in charting is excessive, with the requirement of overtime for completion of tasks. The nurse manager states that "staff will form a task force to investigate and develop potential solutions to the problem, and report on this at the next staff meeting." The nurse manager's leadership style is best described as
Participative Correct response
Laissez-faire
Group
Autocratic 1. The nurse receives a telephone order from the health care provider for acetaminophen (Tylenol) 1000 mg for a client's headache. What should the nurse add to the following order when documenting it in the chart? (Write the answer using lower case letters.) Acetaminophen (Tylenol) 1000 mg for headache, one time dose. Dr. Smith 10/1/2010 at 2:30 pm (1430) by N. Nurse, RN.
telephone or
CORRECT
Correct response: telephone order, Telephone order, TELEPHONE ORDER, Telephone Order
1. A nurse is working with one licensed practical nurse (PN), a student nurse and an unlicensed assistive personnel (UAP). Which newly admitted clients would be appropriate to assign to the UAP?
An adolescent diagnosed with dehydration and anorexia
A middle-aged client diagnosed with an obsessive compulsive disorder This is the correct response
A young adult who reports to be a heroin addict and states "I am in withdrawal and seeing spiders"
A 76-year-old client diagnosed with severe depression
1. During a teaching session by a nurse to a client about the patient controlled analgesia (PCA) planned for post-operative care, which statement by the client is incorrect and indicates that further teaching is needed?
"I will receive a continuous dose of medication."
"The machine will prevent an overdose of the medication."
"I should call the nurse before I take additional doses." Correct response
"I will call for assistance if my pain is not relieved." 1. A nurse provides instructions to a new mother on the proper techniques for breast feeding her infant. Which statement by the mother is incorrect and indicates a need for additional instruction?
" I can switch to a bottle if I need to take a break from breast feeding." Correct response
"The baby should latch onto the nipple and areola areas."
"There may be times that I will need to manually express milk."
"I should position my baby completely facing me with my baby's mouth in front of my nipple." 1. Which of these actions is the most effective nursing intervention to prevent atelectasis from developing in a postoperative client who had a laparotomy?
Assist the client to slowly deep breathe and cough Correct response
Maintain adequate hydration
Splint the incision
Ambulate client within 12 hours postop 1. The nurse is caring for the following clients. Which client is at the highest risk for falling?
The 59 year-old who had hip replacement surgery 4 days ago and is going to physical therapy
The 67 year-old who is diabetic and has a draining ulcer on the right leg
The 79 year-old who has arthritis and walks with the aid of a walker
The 81 year-old who fell at home last week and is confused Correct response
CORRECT
1. A client has been admitted with complaints of lower abdominal pain, difficulty swallowing, nausea, dizziness, headache and fatigue. The client is agitated, fearful, tachycardic and complains of being "too sick to return to work." The client is diagnosed with somatoform disorder. In formulating a plan of care, the nurse must consider that the client's behavior
is controlled by the subconscious mind This is the correct response
would respond to psychoeducational strategies Incorrect response
is manipulative to avoid work responsibilities
could be modified through reality therapy
1. A nurse is caring for a client with a myocardial infarction. Which finding requires the nurse's immediate action?
Periorbital edema
Dizzy spells This is the correct response
Lethargy
Shortness of breath Incorrect response 1. A nurse is talking by telephone with a parent of a four year-old child who has chickenpox. Which approach demonstrates appropriate teaching by the nurse?
The illness is only contagious prior to lesion eruption
Chewable aspirin is the preferred analgesic
Papules, vesicles, and crusts will be present at one time Correct response
Topical cortisone ointment relieves itching 1. How should a nurse instruct the client who is prescribed an inhaler, to breathe in the medication?
Until hearing whistling by the spacer
As quickly as possible
As slowly as possible
Deeply for three to four seconds Correct response 1. Which of these approaches would be the best strategy for a nurse to use when teaching insulin injection techniques to a newly diagnosed client with diabetes mellitus?
Observe a return demonstration Correct response
Allow another diabetic to assist
Give written pre and post tests
Ask questions during practice 1. A client with chronic heart failure should be instructed to contact a home health nurse if which finding occurs?
Urinating four to five times each day
Appearance of non-pitting ankle edema
A significant decrease in appetite
Weight gain of two pounds or more in a 48 hour period Correct response 1. A newly admitted adult client has a diagnosis of hepatitis A. The charge nurse should reinforce to the staff members that the priority routine infection control strategy, in addition to handwashing, is which of these approaches?
Use a mask with a shield if there is a risk of fluid splash
Place appropriate precaution signs outside and inside the room
Wear a gown to change soiled linens from incontinence
Have gloves on while handling bedpans with feces
Correct response 1. A client who lives an assisted living facility tells a nurse I am so depressed. Life isn't worth living anymore. What is the best response by the nurse to this statement?
"Did you tell any of this to your family?"
"Have you thought about hurting yourself?" Correct response
"Come on, it is not that bad."
"Think of the many positive things in life today." 1. A nurse is caring for a client who is receiving procainamide (Pronestyl) intravenously. It is important for the nurse to monitor which of these parameters?
Hourly urinary output
Continuous EKG readings Correct response
Neurological signs
Serum potassium levels Procainamide (Pronestyl) is used to suppress cardiac arrhythmias. When administered intravenously, it must be accompanied by continuous cardiac monitoring. 1. A newly promoted nurse manager is responsible for interviewing applicants for a staff nurse position. Which interview strategy would be the best approach?
Vary the interview style for each candidate to learn different techniques
Use simple questions requiring "yes" and "no" answers to gain definitive information
Ask personal information of each applicant to assure he/she can meet job demands
Obtain an interview guide from human resources (HR) for consistency in interviewing each candidate Correct response 1. A client with a new diagnosis of diabetes mellitus is referred for home care. A family member present expresses concern that the client seems depressed. The nurse should initially focus further assessment by use of which approach?
Inquire about use of alcohol or other nonprescribed substances
Observe the clients affect and behavior during the visit
Correct response
Obtain a family health history, including emotional problems or mental illness
Administer a standardized tool that measures depression Although it is important to begin an assessment for depression immediately, the assessment should not be aggressively intrusive. A direct assessment should be conducted to confirm the observations and concerns of the family member. 1. The health care provider has just finished writing the admission orders for a client diagnosed with pneumonia and sepsis, who has a history of type 1 diabetes. Prioritize how the nurse should complete the orders listed below (with 1 being the top priority).
3
IV normal saline at 100mL/hr

2
Blood and sputum cultures

1
Oxygen 2 liters nasal canula

5
Finger stick before each meal and at bedtime

4
Ceftriaxone (Rocephin) 1Gram every 12 hours
CORRECT.
For establishing priorities, first look at the ABCs. Oxygen administration is the first priority (and the clients oxygen saturation is probably low given the patient has pneumonia). The next priority would be to have the lab come and draw blood for the cultures; this must be done prior to starting the antibiotics. Then an IV must be started (since the antibiotic is ordered IV). Even though the patient is diabetic and it is dinner time, a finger stick is the last thing on the list to complete. 1. A 10 year-old child is recovering from a splenectomy after a traumatic injury. The childs laboratory results show a hemoglobin of 8.8 g/dL and a hematocrit of 26 percent. What is a priority approach that the nurse should include in the plan of care for the child?
Promote a diet rich in iron and lean red meats
Encourage bed activities and games for the next five days
Restrict the consumption of carbonated beverages
Plan for regularly scheduled rest periods Correct response
CORRECT
The initial priority for this client is rest due to the lack of sufficient red blood cells to carry oxygen. The normal hemoglobin is between 10.0 and 15.0 g/dL for this age of child. Note that all of the options are correct actions that may be used for various reasons. 1. To prevent drug resistance from developing, a nurse should be aware that which of these items is a characteristic of the typical treatment plan to eliminate the tuberculosis bacilli?
High doses of B complex vitamins
Administering two anti-tuberculosis drugs Correct response
An anti-inflammatory agent
Aminoglycoside antibiotic Resistance of the tubercle bacilli often occurs to a single antimicrobial agent. Therefore, therapy with multiple drugs over a long period of time helps to ensure eradication of the organism. 1. During a 12-hour shift, a client who underwent a transurethral resection of the prostate (TURP), had an IV intake of 1200 mL, oral intake of 400 mL, continuous bladder irrigation of 2400 mL, 2 syringe flushes of 50 mL each, and Foley catheter output of 3000 mL. What is the end of shift fluid intake? (Write the answer using a whole number.)
4100
mL.
CORRECT
Correct response: 4100

(1200 mL + 400 mL + 2400 mL + 100 mL) = 4100 mL. The amount of irrigation fluid must be included in intake; only the urine collected from the Foley catheter is considered output
1. Which task could be safely delegated by a nurse to an unlicensed assistive personnel (UAP)?
Stay with a client during the self-administration of insulin
Remove and apply a new rectal pouch for a client Correct response
Cleanse and dress a small decubitus ulcer on the leg
Monitor a client's response to passive range of motion exercises The RN may delegate the application and care of rectal pouches to a UAP. This is an uncomplicated, routine task with an expected outcome. 1. A nurse is planning care for a client with increased intracranial pressure. What is the best position for this client?
Semi-Fowler's
Low Fowler's Correct response
Side-lying with head flat
Trendelenburg Maintaining the head of the bed at 15-20 degrees reduces cerebral venous congestion. Low Fowler's is this degree of elevation and semi-Fowler's is 35 to 45 degree head of bed elevation. 1. A staff nurse complains to a nurse manager that an unlicensed assistive personnel (UAP) consistently leaves the work area untidy and does not restock supplies. The initial response by the nurse manager should be which of these statements?
I will add this concern to the agenda for the next unit meeting so we can discuss it
"I will arrange for a conference with you and the UAP within the next week"
"I can assure you that I will look into the matter in due time"
"I would like for you to approach the UAP about the problem the next time it occurs" Correct response Part of the manager's role is to help the staff manage conflict among themselves. It is appropriate to urge the nurse to confront the other staff member to work out problems without a manager's intervention when possible. This is an approach at the first level of management. If the two staff members cannot resolve the issue then the manager would have a conference with the two staff to facilitate a negotiation for a win-win result.
1. While explaining an illness to a 10 year-old, what should a nurse keep in mind about the cognitive development at this age?
Conclusions are based on previous experiences
Interpretation of events originate from their own perspective
Children of this age are able to make simple association of ideas
They are able to think logically in the organization of facts
Children in the concrete operations stage, according to Piaget, are capable of mature thought when they are allowed to mentally or physically manipulate and organize objects.
1. Which statement by a client who will undergo a myelogram indicates a contraindication for this test?
"I can lie still for thirty minutes."
"I suffer from claustrophobia."
"I had a severe headache after a prior spinal tap."
"I am allergic to shrimp." Correct response
A client undergoing myelography should be questioned carefully about allergies to iodine and iodine-containing substances such as seafood. An allergy to iodine or seafood may indicate sensitivity to the radiopaque contrast agent used in the test. A headache after a spinal tap is often from a lack forcing fluids after the procedure. 1. The nurse is caring for a client diagnosed with a venous stasis ulcers on one leg. Which nursing intervention would be most effective in the promotion of healing?
Initiate limb compression therapy for the leg
Improve the client's nutritional status Correct response
Begin proteolytic debridement within 24 hours
Apply dressings with the use of sterile technique The goal of clinical management in a client diagnosed with venous stasis ulcers is to promote healing. This only can be accomplished with proper nutrition. The other interventions are appropriate, but without proper nutrition, they would be of little help. Venous ulcers take a long time to heal so nutritional therapy needs to be maintained. 1. During the care of a client with Legionnaire's disease, which finding would require a nurse's immediate attention?
Dry mucus membranes in the mouth
A decrease in respiratory rate from 34 to 24
Decrease in chest wall expansion This is the correct response
Pleuritic pain on inspiration Incorrect response The respiratory status of a client with this acute bacterial pneumonia known as Legionnaires' disease is critical. Note that all of these findings would be of concern -- the task is to select the priority. Chest wall expansion reflects a possible decrease in the depth and effort of respirations. Further findings of restlessness may indicate hypoxemia. If these occurred the client may then need mechanical ventilation. 1. During the discharge teaching about exercises for an affected extremity of a client with a long leg cast , the nurse should recommend which of these exercises?
Range of motion
Aerobic
Isometric Correct response
Isotonic A nurse should instruct the client on isometric exercises for the muscles of the casted extremity. This means the client should be instructed to alternately contract and relax muscles without moving the affected part. The client should also be instructed to do active range of motion exercises for every joint that is not immobilized at regular and frequent intervals of at least every four hours.
1. The nurse is caring for two children who have had surgical repair of congenital heart defects. For which defect is it a priority to assess for findings of heart conduction disturbance?
Aortic stenosis Incorrect response
Atrial septal defect
Ventricular septal defect This is the correct response
Patent ductus arteriosus While assessments for conduction disturbance should be included following repair of any defect, it is a priority for this condition. A ventricular septal defect is an abnormal opening between the right and left ventricles. The atrioventricular bundle (bundle of His), is a part of the electrical conduction system of the heart. It extends from the atrioventricular node along each side of the interventricular septum and then divides into right and left bundle branches. Surgical repair of a ventricular septal defect consists of a purse-string approach or a patch sewn over the opening. Either method involves manipulation of the ventricular septum, thereby increasing risk of interrupting the conduction pathway. Consequently, postoperative complications include conduction disturbances. 1. A novice nurse on the unit notes that a nurse manager seems to be highly respected by the nursing staff. The novice nurse is surprised when one of the nurses states: "The manager makes all decisions and rarely asks for our input." What is the best description of the nurse manager's management style?
Participative or democratic
Autocratic or authoritarian Correct response
Laissez faire or permissive
Ultraliberal or communicative Autocratic leadership style is suggested in this situation. It is appropriate for groups with little education and experience who need strong direction. A participative or democratic style is usually more successful on nursing units with a mix of staff experience. 1. A nurse notes an abrupt onset of confusion in an older adult client. Which recently ordered medication would have most likely contributed to this change?
Liquid antacid
Anticoagulant
Antihistamine This is the correct response
Cardiac glycoside Incorrect response
Older adults are more susceptible to the side effect of anticholinergic drugs, such as antihistamines. Antihistamines often cause confusion in the older adult, especially at higher doses.
1. A client exhibiting confusion has been placed in physical restraints by an order of the health care provider. Which task could be assigned to an unlicensed assistive personnel (UAP)?
Monitor the client's physical safety
Evaluate for basic comfort needs
Document mental status and muscle strength
Assist the client with activities of daily living Correct response 1. A nurse is teaching a school-aged child and family about the use of inhalers prescribed for asthma. What is the best way to evaluate effectiveness of the treatments?
Monitor pulse rate
Rely on child's self-report
Observe use of peak-flow meter
This is the correct response
Note skin color changes Incorrect response 1. The parents of a 15 month-old child ask a nurse to explain their child's lab results and how the results show the child has iron deficiency anemia. The nurse's response should include which statement?
"The blood cells that carry nutrients to the cells are too large and indicate a lack of iron rich food."
"Although the results are here, your health care provider needs to talk with you about the details."
"There are not enough total blood cells in your child's circulation from a not eating enough foods with iron."
"Your child has fewer red blood cells that carry oxygen and this is called anemia." Correct response The results of a complete red blood cell count in clients with iron deficiency anemia will show decreased red blood cell numbers, a low hemoglobin and microcytic, hypochromic red blood cells. This is a simple and clear explanation. There is no reason to defer answering the question to the health care provider. The last option is not the best since the focus is the total blood cells which would include more than just the red blood cells.
1. A client receiving chemotherapy has developed sores in the mouth. The client asks a nurse why this has happened. How should the nurse respond?
"The cells in the mouth are sensitive to the chemotherapy." Correct response
"It is a sign that the medication is working."
"This always happens with chemotherapy."
"You need to have better oral hygiene The epithelial cells in the mouth are very sensitive to chemotherapy due to their high rate of cell turnover 1. Which task for a client diagnosed with anemia and confusion could the nurse delegate to the unlicensed assistive personnel (UAP)?
Test stool for occult blood and urine for glucose with a report of the results This is the correct response
Assess with documention of skin turgor and skin color changes
Suggest foods that are high in iron and those easily consumed
Report mental status changes and the degree of mental clarity Incorrect response
The UAP can do routine, standard, and unchanging procedures which have known expected outcomes. These tasks do not require judgments or decision making. 1. Several clients are admitted to an adult medical unit. For which client condition(s) would the nurse institute airborne precautions?
A tentative diagnosis of viral pneumonia with productive brown sputum
Autoimmune deficiency syndrome (AIDS) with cytomegalovirus (CMV)
A positive purified protein derivative (PPD) test with an abnormal chest x-ray Correct response
Advanced carcinoma of the lung with hemoptysis mixed with a yellow tinge The client who must be placed in airborne precautions is the client with these findings that suggest a suspicious tuberculin lesion. A sputum smear for acid fast bacillus would be done next. CMV usually causes no signs or symptoms in children and adults with healthy immune systems. Good handwashing is recommended for CMV. When findings do occur, they are often similar to those of mononucleosis, including sore throat, fever, muscle aches and fatigue. 1. An ambulatory client reports edema during the day in the feet and ankles that disappears while the client sleeps during the night. What is the most appropriate follow-up question for a nurse to ask?
"Do you become short of breath during your normal daily activities?" Correct response
"How many pillows do you use at night to sleep comfortably?"
"Have you had a recent heart attack?"
"Do you smoke daily or every other day?
CORRECT
These are the findings of right-sided heart failure, which causes increased pressure in the systemic venous system. To equalize this pressure, the fluid shifts into the interstitial spaces causing edema. Because of gravity, the lower extremities are first affected in an ambulatory client. This question would elicit information to confirm the nursing diagnosis of activity intolerance and fluid volume excess, both associated with right-sided heart failure. 1. A nurse is assigned to a newly hospitalized adolescent. What should be the major threat experienced by this hospitalized adolescent?
Pain management
Altered body image This is the correct response
Separation from family
Incorrect response
Restricted physical activity 1. The hospitalized adolescent may see each of these as a threat. However, the major threat felt when hospitalized for this age group is the fear of an altered body image. There is great emphasis on physical appearance during this developmental stage. 2. The mother of a two month-old baby calls a pediatricians nurse two days after the first DTaP, inactivated polio vaccine (IPV), Hepatitis B and Haemophilus influenzae type B (HIB) immunizations. She reports that the baby feels very warm, cries inconsolably for as long as three hours, and has had several shaking spells. In addition to referring the mother to the emergency room, the nurse should document the reaction on the baby's record and expect which immunization to be most associated with the findings that were reported to be displayed by the infant?
HIB
DTaP This is the correct response
IPV
Hepatitis B Incorrect response DTaP immunization is a vaccine that protects against diptheria, tetanus, and pertussis (whooping cough). The majority of reactions occur with the administration of the DTaP vaccination. Contradictions to giving repeat DTaP immunizations include the occurrence of severe side effects after a previous dose as well as signs of encephalopathy within seven days of the immunization.
1. What is the priority information a nurse should teach a client after an extracorporeal shock-wave lithotripsy (ESWL) procedure?
"Restrict milk and dairy products for one to two months."
"Increase intake of citrus fruits to three servings per day for two months."
"Limit fluid intake to 1,000 mL each day for two months."
"Drink 3,000 to 4,000 mL of fluid each day for one month." Correct response 1. Drinking three to four quarts (3,000 to 4,000 mL) of fluid each day will aid passage of fragments of the broken up renal calculi and help prevent formation of new calculi. 2. The mother of a three month-old infant tells the nurse that "I want to change from formula to whole milk and add cereal and meats to my infant's diet." What should be emphasized as the nurse teaches about infant nutrition?
Solid foods should be introduced at three to four months
Fluoridated tap water should be used to dilute milk
Supplemental apple juice can be used between feedings
Whole milk is difficult for a infants to digest
Correct response
CORRECT
1. Cow's milk is not given to infants younger than 1 year because the tough, hard curd that develops in the digestive tract is difficult to digest. In addition, it contains little iron and creates a high renal solute load. If infants drink milk with a minimal introduction to solid food they will have a tendency to develop anemia. 2. A nurse is caring for a client on mechanical ventilation. When performing endotracheal suctioning, the nurse will avoid hypoxia by which action?
Insertion of a fenestrated catheter with a whistle tip without suction
Complete a suction pass in 30 seconds with a pressure of 150 mm Hg
Hyperoxygenation with 100% O2 for one to two minutes before and after each suction pass Correct response
Minimize a suction pass to 60 seconds while slowly rotating the lubricated catheter 1. A nurse in the emergency department suspects domestic violence as the cause of a client's injuries. What action should the nurse take first ?
Ask client if there are any old injuries also present
Gain client's trust by not being hurried during the intake process
Interview the client privately without the persons who came with the client This is the correct response
Photograph the specific injuries in question for documentation on the chart Incorrect response It is critical to separate the client from anyone who came in with the client whether it be a partner or friend. With the use of the nursing process the nurses first action when a client is unstable or has potential problems is further assessment of the situation. The correct answer is the oneᙦmost focused on gathering more information. During the private intake assessment the nurse would possibly institute the other actionsᙦin the remaining options.
Safety 1. A client from a developing country arrived in the US one week ago. The client is now seeking health care in the emergency department and reports unintended weight loss, drug abuse, and night sweats. The client is admitted to a medical surgical unit with a preliminary diagnosis of HIV/AIDS. The nurse should assign the client to share a room with a client with which of the diagnoses listed below?
Acute tuberculosis with a productive cough of discolored sputum for over three months
Pseudomembranous colitis and C. difficile
Exacerbation of migrating polyarthritis with severe pain Correct response
Lupus and vesicles on one side of the middle trunk from the back to the abdomen
CORRECT
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Learning Objective: Lesson 2 Safety and Infection Control
It is most appropriate to place clients with similar diagnoses in the same room. Since this option does not exist, the nurse would understand that a client with HIV/AIDS would be immunocompromised and should not be placed in a room with any client with an active infection. Of the available options, the client with arthritis
would be the best roommate for the client with HIV/AIDS. Typically, standard precautions would be used for a person diagnosed with HIV/AIDS (unless the person presents with cough/fever/pulmonary infiltrate, in which case the person would be placed in a private room and airborne plus contact precautions would be implemented). 1. Which of these clients would a nurse recommend to keep in a hospital during an internal disaster at the facility?
A middle-aged client known to have had an uncomplicated myocardial infarction four days ago
An older adult client admitted two days ago with an acute exacerbation of ulcerative colitis
An adolescent diagnosed with sepsis seven days ago and whose vital signs are maintained within low normal limits. Incorrect response
A young adult in the second day of treatment for an overdose of acetometaphen (Tylenol) This is the correct response
INCORRECT
An overdose of acetometaphen (Tylenol) requires close observation for three to four days as well as Mucomyst by mouth during that time. A strong risk for liver failure exists after an overdose of Tylenol. 1. A RN is assigned to work at the Poison Control Center telephone hotline. In which of these cases of childhood poisoning should the nurse suggest that parents have the child drink orange juice?
A 14 month-old who chewed two leaves of a philodendron plant Incorrect response
An 18 month-old who ate an undetermined amount of crystal drain cleaner This is the correct response
A 20 month-old who is found sitting on the bathroom floor beside an empty bottle of diazepam (Valium)
A 30 month-old who has swallowed a mouthful of charcoal lighter fluid
INCORRECT
Drain cleaner is very alkaline. Orange juice is acidic and will help to neutralize this substance as well as dilute it. 1. A nurse is reviewing with a client how to collect a clean catch urine specimen. What is the appropriate sequence to teach the client?
Void continuously and catch some of the urine midstream
Void a little, clean the meatus, then collect specimen Incorrect response
Clean the meatus, begin voiding, then catch urine stream This is the correct response
Clean the meatus, then urinate into the container
INCORRECT
A clean catch urine is difficult to obtain and requires clear directions. Instructing the client to carefully clean the meatus, then void naturally with a steady stream prevents surface bacteria from contaminating the urine specimen. As starting and stopping flow can be difficult, once the client begins voiding it's best to just slip the container into the stream. Other responses do not reflect correct techniques. 1. Which of these clients would the triage nurse request that the provider examine immediately?
A middle-aged man with second degree burns over the right hand
A toddler with singed ends of long hair that extends down to the waist
A five month-old infant who has audible wheezing and grunting This is the correct response
An adolescent who has soot over the face and shirt Incorrect response
INCORRECT
The age and the findings suggest this client is at immediate risk for respiratory complications. The other clients are at a lesser risk for respiratory problems 1. A nurse is performing the routine daily cleaning of a tracheostomy. During the procedure, the client coughs and displaces the tracheostomy tube out of the stoma. This negative outcome could have avoided by which action?
Fasten the clean tracheostomy ties before removal of the old ties Correct response
Placement of an obturator at the clients bedside
Place the client in a flat, supine position
Have another nurse assist with the procedure
CORRECT
Fastening clean tracheostomy ties before removal of the old ones will ensure that the tracheostomy is secured during the entire cleaning procedure. The obturator is useful to keep the airway open only after the tracheostomy outer tube is coughed out. However, the question asks how to prevent the situation. A second nurse is not needed during the procedure. A change in the position of the client does not prevent a dislodged tracheostomy.
1. A nurse is to administer meperidine hydrochloride (Demerol) 100 mg, atropine sulfate (Atropisol) 0.4 mg, and promethazine hydrochloride (Phenergan) 50 mg IM to a preoperative client. Which action should the nurse take first ?
Place the call bell within the client's reach Incorrect response
Instruct the client to remain in the bed
Have the client empty his/her bladder This is the correct response
Raise the side rails on the bed at the top
INCORRECT
The first step in the process is to have the client void prior to administration of the preoperative medication. The other actions would follow this initial step in this sequence: instruct to remain in bed, place call light and then raise the side rails.
1. A client with hepatitis A (HAV) is newly admitted to the unit. Which action would be the priority to include in this clients plan of care within the initial 24 hours?
Wear gown and gloves during client contact Correct response
Provide soft easily digested food with frequent snacks
Use disposable utensils and plates for meals
Wear masks with shields if there is potential for fluid splash
CORRECT
HAV is usually transmitted via the fecal-oral route, i.e., someone with the virus handles food without washing his or her hands after using the bathroom. The virus can also be contracted by drinking contaminated water, eating raw shellfish from water polluted with sewage or by being in close contact with a person who's infected even if that person has no findings. In fact, the disease is most contagious before findings ever appear. The nurse should recognize the importance of isolation precautions from the initial contact with the client on admission until the noncontagious convalescence period. 1. A nurse is teaching parents about accidental poisoning in children. Which point should be emphasized to be done initially ?
Keep the child as quiet as possible if a toxic substance was inhaled
Empty the child's mouth in any case of a possible poisoning This is the correct response
Do not induce vomiting if the poison is a hydrocarbon Incorrect response
Call the Poison Control Center once the situation is identified
INCORRECT
Emptying the mouth of poison prevents further ingestion and should be done first to limit damage from the substance. Note that all of the actions are correct, but emptying the mouth is the priority. 1. The nurse is having difficulty reading the health care provider's written order that was left just before the shift change. What action should the nurse take?
Call the provider for clarification of the order Correct response
Leave the order for the oncoming staff to follow-up on
Contact the charge nurse for an interpretation
Ask the pharmacy for assistance in the interpretation
CORRECT
Relying on anyone else's interpretation is very risky. When in doubt, check it out with the health care provider who wrote the difficult-to-read order. Order entry systems help to minimize these types of problems. 1. Which of these nursing diagnoses that are appropriate for older adult clients, would indicate a client is at greatest risk for falls?
Alteration in mobility related to fatigue
Sensory perceptual alterations related to decreased vision Incorrect response
Altered patterns of urinary elimination related to nocturia This is the correct response
Impaired gas exchange related to retained secretions
INCORRECT
Nocturia is especially problematic because many older adults fall when they rush to reach the bathroom during the night. They may be confused or not fully alert because of having been asleep. Inadequate lighting can increase their chances of stumbling, and then they may fall over furniture or carpets. Note that the question asks for the greatest risk, so that all of the options are correct and associated with falls. However, altered patterns of elimination are the most common risk for falls. 1. A newborn has hyperbilirubinemia and is undergoing phototherapy with a fiberoptic blanket. Which safety measure is indicated during this process?
Provide water feedings at least every two hours This is the correct response
Withhold feedings while the newborn is under the phototherapy
Protect the eyes of neonate from the phototherapy lights Incorrect response
Regulate the neonates temperature using a radiant heater
INCORRECT
Frequent water or feedings are given to help with the excretion of the bilirubin in the stool. Protecting the eyes of the neonates is a priority when under the ultraviolet lights to prevent damage. Since a fiberoptic blanket is used, extra protection of the eyes is unnecessary. The neonates skin is exposed to the light and the temperature is monitored continuously and a heater is not often necessary. There is no reason to withhold feedings for phototherapy 1. Which of these actions is the primary nursing intervention designed to limit transmission of a clients Salmonella infection?
Wear gloves when disposing of contaminated linens
Wash hands thoroughly before and after client contact
Correct response
Wear gloves when in contact with body secretions
Double glove when in contact with feces or vomitus
CORRECT
Gram-negative bacilli cause Salmonella infection, and lack of sanitation is the primary means of contamination. Two million new cases appear each year. Thorough handwashing can prevent the spread of salmonella. Note that all of the options are appropriate activities, and the question asks about primary, which is handwashing. 1. The nurse is offering safety instructions to a parent with a four monthold infant and a four year-old child. Which statement by the parent indicates a correct understanding of the appropriate precautions to take with the children?
"I have the four year-old hold and help feed the four month-old a bottle in the kitchen while I make supper." This is the correct response
"I place my infant in the middle of the living room floor on a blanket to play with my four year-old while I make supper in the kitchen."
Incorrect response
"My sleeping baby lies so cute in the crib with the little buttocks stuck up in the air while the four year-old naps on the sofa."
"I strap the infant car seat on the front seat to face backwards."
INCORRECT
The infant seat should be placed on the rear seat. Small children and infants are not to be left unsupervised. Infants are to be placed on their "back when they go back" to sleep or are lying in a crib. A four year-old could assist with the care of an infant such as feeding with proper direct supervision. This enhances bonding with the infant and the developmental needs of the preschooler to "help" and not feel left out. 1. A nurse accidentally sticks a used hypodermic needle in one hand. What immediate action should the nurse take?
Look up the policy on needle sticks
Contact employee health services
Immediately wash the hands with vigor Correct response
Notify the supervisor and risk management
CORRECT
The immediate action of vigorously washing will help remove possible contamination. Then the sequence would be to notify the supervisor and risk management, look up the policy and then contact employee health services. 1. A parent calls the hospital hot line and is connected to the triage nurse. The caller proclaims: I found my child with odd stuff coming from the mouth and an unmarked bottle nearby. Which of these comments would be the best tool for the nurse to determine if the child has swallowed a corrosive substance?
"Take the childs pulse at the wrist and see if the child is has trouble breathing lying flat." Incorrect response
"Has the child had vomiting, diarrhea or stomach cramps?"
"What color is the childs lips and nails and has the child voided today?"
"Ask the child if the mouth is burning or throat pain is present." This is the correct response
INCORRECT
Local irritation of tissues indicates a corrosive poisoning. The other comments may be helpful in determining the childs overall condition. However, the question concerns evaluation for ingestion of a caustic substance. 1. A client is scheduled to receive an oral solution of radioactive iodine (131I). In order to reduce hazards, the priority information for a nurse to include in client teaching is which of these statements?
Your family can use the same bathroom that you use without any special precautions.
"Drink plenty of water and empty your bladder often during the initial three days of therapy."
"In the initial 48 hours, avoid contact with children and pregnant women, and flush the commode twice after urination or defecation." Correct response
"Use disposable utensils for two days and if vomiting occurs within 10 hours of the dose, do so in the toilet and flush it twice."
CORRECT
The client's urine and saliva are radioactive for 24 hours after ingestion, and vomitus is radioactive for six to eight hours. The client should drink three to four liters of fluid a day for the initial 48 hours to help remove the (131I) from the body. To minimize exposure to radiation, nursing staff should plan to give care in the shortest time possible (less time equals less exposure), working as far away from the radiation source as possible. Each nurse should also wear a personal film badge or pocket dosimeter 1. A nurse is planning discharge for a 90 year-old client diagnosed with musculoskeletal weakness. Which intervention should be included in the plan that would be most effective for the prevention of falls?
Place nightlights in the bedroom This is the correct response
Wear eyeglasses at all times
Install grab bars in the bathroom Incorrect response
Teach muscle strengthening exercises
INCORRECT
Because more falls occur in the bedroom than any other location, preventative actions should begin at this location. However, work in partnership with the client and family so they are willing to move furniture, lamp cords, and storage areas, add lighting, remove throw rugs, and eliminate other environmental hazards. To wear eye glasses at all times is unrealistic. To have grab bars in the bathroom or to do muscle strengthening exercises might be used to prevent falls. However, they are not thought to be the most effective of actions. 1. A nurse is reinforcing teaching with a client about compromised host precautions. The client is receiving filgrastim (Neupogen) for neutropenia. Which lunch selection suggests the client has learned about the necessary dietary changes?
Grilled chicken sandwich and skim milk
Peanut butter sandwich, banana, and iced tea
Roast beef, mashed potatoes, and sauteed green beans Correct response
Barbecue beef, baked beans, and coleslaw
CORRECT
The client has correctly selected an appropriate lunch and appears to know the dietary restrictions. Low granulocyte counts and susceptibility to infection are expected. Compromised host precautions require that foods are either cooked or canned. The other choices do not demonstrate learning since raw fruits, vegetables, and any types of milk should be avoided. 1. Which approach is the best way to prevent infections when providing care to clients in the home setting?
Using a barrier between the client's furniture and the nurse's bag
Handwashing before and after examination of clients Correct response
Wearing a mask with a shield during any eye/mouth/nose examination
Wearing nonpowdered latex-free gloves to examine the client
CORRECT
Handwashing remains the most effective way to avoid spreading infection. However, too often nurses do not practice good handwashing techniques and do not teach families to do so. Nurses need to wash their hands before and after touching the client and before entering the nursing bag. All of the options are correct, and the sequence of priorities would be to wash hands in stated manner, use of a barrier for the nurse's bag, wear gloves, and wear a mask during head examinations. Lesson 1 1. During an interview of a prospective employee who just completed the agency application, which approach should a nurse manager use to assess skills' competence of this potential employee?
"Let's talk about your comfort zones for working independently."
"What degree of supervision for basic care do you think you need?"
"What types of complex client care tasks or assignments do you prefer?"
"Lets review your skills check-list for type and level of skill for tasks." Correct response
CORRECT
Learning Objective: Lesson 1 Management of Care
The nurse needs to know that the potential employee has competence in certain tasks that are common on the unit. One way to do this is to do mutual review of the agency list of skills. The other questions might be asked during the skills checklist review. 1. As the RN responsible for a client in isolation, which task can be delegated to a practical nurse (PN)?
Observation of the client's total environment for risks of harm
Reinforcement of isolation precautions with visitors Correct response
Evaluation of staff compliance with infection control measures
Assessment of the client's attitude about infection control
CORRECT
PNs and UAPs can reinforce information that was originally given by the RN. The other options are responsibilites of the RN and cannot be delegated. 1. The hospital is planning to downsize and eliminate a number of staff positions as a cost-saving measure. To assist staff in this change process, the nurse manager is preparing for the "unfreezing" phase of change. With this approach the nurse manager should take what action?
assist the staff for an acceptance of the new changes
clarify what the changes mean to the community and hospital
explain to the unit staff why change is necessary Correct response
discuss with the staff how to deal with any defensive behavior
CORRECT
The first phase of change, unfreezing, begins with awareness of the need for change. This can be facilitated by the manager who clearly understands the need and stands behind it and explains this to the staff. The phase is completed when the staff comprehend the need for change. 1. At a nursing staff meeting, there is discussion of perceived inequities in weekend staff assignments. As a follow-up, the nurse manager should initially take which action?
Clarify reasons for current assignments
Help staff see the complexity of issues
Allow the staff to change assignments Incorrect response
Facilitate creative thinking on staffing This is the correct response
INCORRECT
The manager, as a change agent, can facilitate the staff's solving the problem. Referred to as the "moving phase" Lewin's change theory, the problem is first viewed from a different perspective and a variety of solutions are examined and decided upon; a new approach for weekend assignments can then be tried out. 1. When caring for a client with an intravenous (IV) infusion for pain control, a nurse should ask an unlicensed assistive personnel (UAP) to do which action?
Check the IV site for drainage and loose tape when in the room
Assist the client with ambulation after supervising a gown change Correct response
Readjust the set rate on the pump by two mL/minute
Monitor the client for the degree of pain relief
CORRECT
When giving assignments to a UAP, the nurse should communicate clearly and specifically what the task is, what should be reported to the nurse, and when it should be reported. Implementation of routine tasks with expected outcomes should be delegated to UAPs. The other options are actions that PNs or RNs could do. 1. During seizure activity which observation is a priority to enhance further direction of any treatment?
Identify the pattern of breathing Incorrect response
Determine if loss of bowel or bladder control occurs
Note the time from beginning to end
Observe the sequence or types of movement This is the correct response
INCORRECT
It is a priority to note, and then record, what movements are seen during a seizure because the diagnosis and subsequent treatment often rest solely on the seizure description. The clue is that the question is asking for a priority so ALL of the options are going to be correct. 1. A nurse who is assigned for five days to a client who has exhibited manipulative behaviors becomes aware of the nurse's own feelings of reluctance to interact with the client. The nurse should take what action next?
Develop a behavior modification plan for the client that will promote more functional behavior within the next week Incorrect response
Discuss the feelings of reluctance with an objective peer or supervisor within the next 24 hours This is the correct response
Talk with the client about the negative effects of manipulative behaviors on other clients and staff within the next few days
Limit contacts with the client to avoid reinforcement of the manipulative behavior during the work times
INCORRECT
The nurse who experiences stress in a therapeutic relationship can gain objectivity through discussion with other professionals. The nurse may wish to have a peer observe the nurse-client interactions with this client for a shift and then have a debriefing of positive and negative actions. The nurse must attempt to discover attitudes and feelings in the self that influence the nurse-client relationship in positive and negative manners. 1. The nurse manager informs the nursing staff at morning report that the clinical nurse specialist will be conducting a research study on staff attitudes toward client care. All staff are invited to participate in the study if they wish. This affirms which ethical principle?
Beneficence Incorrect response
Justice
Anonymity
Autonomy This is the correct response
INCORRECT
Individuals must be free to make independent decisions about participation in research without coercion from others. Anonymity means the persons identity is not revealed. Beneficence is the state or quality of being kind, charitable, beneficial or a charitable act. 1. The nurse receives a telephone call from a health care provider who wants to give a telephone order for a client in the post anesthesia care unit. Which of the following actions should the nurse take? ( Select all that apply )
Record the order word-for-word and sign the order Correct response
Request that the order is signed by the provider before implementation
Ask a second nurse listen on another extension while the order is being given
Begin the order with the abbreviation "P.O." to indicate that it was a "phone order" Incorrect response
Verify understanding by reading the order back to the provider before hanging up Correct response
INCORRECT
Reading the order back allows the provider to correct any misunderstanding and is a Joint Commission read-back requirement. The order should be immediately written and signed by the nurse. The order should clearly state "telephone order"; abbreviations can be misunderstood (P.O. could be interpreted as "by mouth"). Having a second person listen in on the conversation is not required unless the nurse cannot understand the health care provider. The order may be implemented right away, but it must be countersigned within the time limits set by the facility. 1. A client continuously calls out to the nursing staff when anyone passes the clients door and asks them to do something in the room. The approach by the charge nurse should be to take which action?
Reassure the client that a staff person will check frequently to see if the client needs anything Incorrect response
Keep the clients room door cracked to minimize the distractions of people passing by the room
Assign a nursing staff member to visit the client at regular intervals This is the correct response
Arrange for each staff member to go into the clients room to check on needs every hour on the hour
INCORRECT
Regular, frequent, planned contact by a designated staff member is the best approach to provide a continuity of care and communicate to the client that care will be available as needed. 1. The charge nurse has a health care team that consists of one practical nurse (PN), one unlicensed assistive personnel (UAP) and one PN nursing student. The charge nurse has made these assignments. Which assignment should be questioned by the nurse manager?
A client who was diagnosed with a major stroke six days ago - PN nursing student
An older adult client who had been diagnosed with a myocardial infarction one week ago - UAP
The admission at the change of shifts of a client diagnosed with atrial fibrillation and acute heart failure - PN
Correct response
A child diagnosed with 2nd degree burns over 30% of the body and has IV packed red cells running and an order for albumin IV - charge nurse
CORRECT
The care for a new admission with risk of instability should be performed by an RN. In addition, since the client was admitted at the change of shifts, the stability of the client would not have been established. The charge nurse should take this client. PNs should be delegated clients who are stable with minimal risk for instability, medication administration except for IV push, sterile procedures, reinforcement of teaching and other client care that does not require judgments and decisions. The nurse may delegate routine tasks and a stable client to UAPs. 1. The nurse manager has been using a block scheduling plan to staff the nursing unit. However, staff have asked for many changes and exceptions to the schedule over the past few months. To consider selfscheduling, the manager should know that this method will have what effect?
Improve the quality of care
Decrease staff turnover by 10%
Improve team morale throughout the unit
Correct response
Minimize the amount of overtime payouts
CORRECT
Nurses in direct care positions are more satisfied when opportunities exist for autonomy and control. The nurse manager becomes the facilitator rather than the decision-maker of the schedule for unit needs when self-scheduling exists. Peer pressure and team work are the driving forces during self-schedule approaches. 1. The triage nurse identifies that a 16 year-old teenager is legally married and has signed the consent form for treatment. What should be an appropriate action by the nurse?
Refer the teenager to a community pediatric hospital emergency department
Ask the teenager to wait until a parent or legal guardian can be contacted
Proceed with the triage process in the same manner as any adult client Correct response
Withhold treatment until telephone consent can be obtained from the partner
CORRECT
Minors may become known as an "emancipated minor" through marriage, pregnancy, high school graduation, independent living or service in the military. Therefore, this married client has the legal capacity of an adult. Otherwise, the age for legal signatures is 18 years of age. 1. With an alert of an internal disaster and the need for beds, a charge nurse is asked to list the clients who are potential discharges within the next hour. Which one of these clients should the charge nurse select?
An older adult client who has been diagnosed with type 2 diabetes mellitus for over 20 years, admitted with diabetic ketoacidosis 24 hours ago Correct response
A school-aged child who was admitted at the change of shifts with a diagnosis of suspected bacterial meningitis
A middle-aged client who was admitted yesterday with an internal automatic defibrillator and complaints of passing out at unknown times
An adolescent admitted the prior night with Tylenol intoxication
CORRECT
This client is the most stable and has a chronic condition. Tylenol intoxication requires at least three to four days of intensive observation for the risk of hepatic failure. The other clients should be considered unstable. 1. Decentralized scheduling is used on a nursing unit. What is the advantage of this management strategy?
frees the nurse manager to handle other priorities Incorrect response
allows requests for special privileges
conserves time spent on planning
considers client and staff needs This is the correct response
INCORRECT
Decentralized staffing takes into consideration specific client needs and staff abilities and interests. This means the staffing is decided on the lowest level which is at the unit level. 1. A newly admitted older adult client is diagnosed with severe dehydration. When planning care for this client, the nurse should assign which task to an unlicensed assistive personnel (UAP)?
Monitor client's ability for movement in the bed from side to side
Report hourly outputs of less than 30 mL/hr within 15 minutes of the check Correct response
Check skin turgor every four hours along with the need to change the adult diaper
Converse with the client to determine if the mucous membranes are impaired
CORRECT
When assigning a UAP, the nurse must communicate clearly about each delegated task with specific instructions on what must be reported and when. Because the RN is responsible for all care-related decisions, only routine tasks should be assigned to UAPs because they do not require judgments and decisions. 1. Which one of these tasks for a client who has a nasogastric tube after colon surgery can be safely delegated to an unlicensed assistive personnel (UAP)?
Monitor the client for nausea or other gastric complications
Perform nostril and mouth care on an every two hour schedule Correct response
Monitor the type and amount of nasogastric tube drainage
Irrigate the nasogastric tube with the ordered irrigant
CORRECT
Skin care around a nasogastric tube is a routine task with an expected outcome and is appropriate to assign to for UAPs. The other tasks would be appropriate for assignment to PNs since the skills are advanced and do not require major judgments or decisions. 1. During the evaluation phase for a client, the nurse should focus on which aspect?
The client's status, progress toward goal achievement, and ongoing reevaluation Correct response
Select interventions that are measurable and achievable within selected timeframes
Findings of physical and psychosocial stressors of the client and in the family
Setting short and long-term goals to insure continuity of care from hospital to home
CORRECT
The evaluation step of the nursing process focuses on the client's status, progress toward goal achievement and ongoing reevaluation of the plan of care. The other possible answers focus on some of the other steps of the nursing process. 1. client with a diagnosis of bipolar disorder has been referred to a local boarding home for placement consideration. The social worker telephoned the hospital unit to obtain information about the clients mental status and adjustment during hospitalization. The appropriate response of the nurse should be which of these statements?
"I can never give any information out by telephone. How do I know who you are?"
"Since this is a referral, I can give you a limited amount of information."
"I need to get the clients written consent before I release any information to you." This is the correct response
"I am sorry. Referral information can only be provided by the clients providers." Incorrect response
INCORRECT
In order to release information about a client there must be a signed consent form with designation of to whom information can be given, and what information can be shared. The other actions are incorrect approaches to this request.

Urinary retention finding in elderly client

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Urinary retention finding in elderly client

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1. The nurse is caring for an 87 year-old client who complains of urinary retention.

Which finding should be reported immediately to the health care provider?

Burning with urination Incorrect response

Fecal impaction This is the correct response

Security This is the correct response

Comfort Incorrect response

Learning Objective: Lesson 3 Health Promotion and Maintenance

"I have only been married for two months."

"I am determined to leave my house in a week."

Monitor oxygen saturation with the application of an oximeter

Suction excessive tracheobronchial secretions

This is the correct response

Palpate Incorrect response

Measure the length

Auscultate This is the correct response

Avoid drugs with side effects that impact cognition

Review the drug regimen yearly

Do not stop a medication entirely

Start low and go slow Correct response

The casted extremity will be placed on a cloth-covered surface

Vomiting, diarrhea, and lethargy Correct response

Pruritus, rash, and photosensitivity

Electrolyte imbalance, tinnitus, and cardiac arrhythmias

Ataxia, agnosia, and course hand tremors

Administer morphine sulfate as ordered This is the correct response

Give a PRN sublingual nitroglycerine Incorrect response

Obtain the vital signs

Participative Correct response

An adolescent diagnosed with dehydration and anorexia

A 76-year-old client diagnosed with severe depression

"I will receive a continuous dose of medication."

"The machine will prevent an overdose of the medication."

"There may be times that I will need to manually express milk."

Maintain adequate hydration

Splint the incision

is controlled by the subconscious mind This is the correct response

would respond to psychoeducational strategies Incorrect response

is manipulative to avoid work responsibilities

could be modified through reality therapy

Dizzy spells This is the correct response

The illness is only contagious prior to lesion eruption

Chewable aspirin is the preferred analgesic

Until hearing whistling by the spacer

Observe a return demonstration Correct response

Allow another diabetic to assist

Give written pre and post tests

Urinating four to five times each day

Appearance of non-pitting ankle edema

A significant decrease in appetite

Use a mask with a shield if there is a risk of fluid splash

Place appropriate precaution signs outside and inside the room

Wear a gown to change soiled linens from incontinence

Have gloves on while handling bedpans with feces

"Did you tell any of this to your family?"

"Have you thought about hurting yourself?" Correct response

"Come on, it is not that bad."

Hourly urinary output

Continuous EKG readings Correct response

Inquire about use of alcohol or other nonprescribed substances

Observe the clients affect and behavior during the visit

Obtain a family health history, including emotional problems or mental illness

IV normal saline at 100mL/hr

Blood and sputum cultures