A nurse is caring for a client who reports a pain level of 5 on a scale from o to. Question
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A nurse is caring for a client who reports a pain level of 5 on a scale from o to 10. The client informs the nurse that pain medications are not an option for managing pain. Which of the following is an appropriate response by the nurse?
a)”Why do you think pain medication is not going to help you
b) I’m sure it will work if you just give it a chance.”
c) “Would you like me to give you a back massage?”
d) “You may take any herbal remedies you bring from home.”
2) A nurse is providingteaching about preventing back strain to the caregiverof a client who is immobile and requires assistance to reposition in bed. Which of the following statements by the caregiver indicates an understanding of the teaching?
“I will keep my legs straight to provide more power in the lift.”
“I will place the bed in the lowest position.”
“I will twist at the waist while pulling the draw sheet.”
“I will tighten my abdominal muscles prior to moving.”
3). A nurse is planning to provide discharge instructions to a client who does not speak the same language as the nurse. Which of the following actions should the nurse take?
Ask a family member of the client to translatefor the nurse.
Find an assistive personnel who speaks the client’slanguage.
Speak to the client while indicating printed instructions in the client’s language. Arrange for a videoconference with an interpreter who speaks the client’s language.
4) A nurse is planning to provide discharge instructions to a client who does not speak the same language as the nurse. Which of the following actions should the nurse take?
Ask a family member of the client to translatefor the nurse.
Find an assistive personnel who speaks the client’slanguage.
Speak to the client while indicating printed instructions in the client’s language.
Arrange for a videoconference with an interpreter who speaks the client’s language.
5). A nurse is monitoring a client who is receiving continuous IV fluid therapy via a peripheral vein in the left forearm. Which of the following findings indicates that the client has developed phlebitis at the IV site?
Pallor of the client’s left forearm
Pitting edema at the insertion site
Coolness of the client’s left forearm
Erythema along the path of the vein
6.) A nurse enters a client’s room and discovers a smoldering fire in the drapes. After moving clients to a safe location, which of the following actions should the nurse take next?
Close the doors to client rooms
.Pull the fire alarm.
Use an extinguisher to put out the fire.
Turn off any electrical equipment in the room.
7.) A nurse hangs a bag of dextrose 5% in water 1,000 mL at 0800 to run at 125 mL/hr. At 1200, the nurse notices that the client’s IV bag is empty. Which of the following interventions should the nurse take first?
Notify the primary care provider.
Complete an incident report.
Assess the client’svital signs.
Calculate the infused volume.
8)
A nurse at a long-term care facility is providing change-of-shift report to an oncoming nurse about a client who has shingles. Which of the following information should the nurse include in the report?
The times for routine vital sign measurements
The client’s background health history
The number of visitors the client had during the shift
The type of transmission-based precautions in place
9) A nurse on à medical-surgical unit is caring for a client who reports difficulty sleeping at night. Which of the following findings should indicate to the nurse that the client has sleep deprivation?
Decreased judgment Increased
auditory alertness
Decreased activity
Increased reflexes
10). A nurse is caring for an older adult client who tells the nurse, “I have smoked one pack of cigarettes every day for the last 60 years.” Which of the following actions should the nurse take next?
Suggest that the client use nicotinegum to facilitate quitting.
Ask what the client knows about the effects of smoking
Work with the client to establish à quit date.
Refer the client to a local smokingcessation program.
11). A nurse is preparing to bathe a client who has dementia. Which of the following actions should the nurse take?
Complete the bath even if the clientis in distress.
Allow the client to select the temperature of the bath water.
Give detailed instructions for the clientto follow.
Use distractions when bathing the client.
12). A nurse is caringfor a client who is immunocompromised. Which of the following actions should the nurse take?
Use sterile glovesto provide perinealcare.
Cleanse hands with an alcohol-based hand rub before client contact.
Have the client apply a mask when children are visiting.
Place the client in a semi-private room.
13.) A nurse is caring for a client who is agitated and threatening to harm others. The nurse places the client in restraints but does not notify the provider or obtain a prescription for the restraints. This situation represents which of the following torts?
Assault
Invasion of privacy
Negligence
False imprisonment
14.) A nurse is caring for a group of clients whose primary languages are different from the nurse’s. For which of the following clients should the nurse provide written materials in the client’s primary language?
A client who requires administration of a prescribed pain medication
A client who is watching a video about the meal services at the facility in their primary language
A client who requires teaching prior to discharge
A client who is learning to use an incentive spirometer and has an interpreter present
15) A nurse is preparing to palpate a client’s systolic blood pressure using the brachial artery.After applying the blood pressure cuff to the client’s arm, identifythesequence of steps the nurse should follow. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)
Palpate the brachial pulse site.
Discontinue palpation of the brachial pulse.
Inflate the blood pressurecuff to 30 mm Hg beyond where the brachial pulse was last felt.
Deflate the blood pressure cuff slowly until the brachial pulse is detected.
16.) A nurse is caringfor a client who is postoperative and asks the nurse, “When will I get to go home? I’m not sure what happens next.” Which of the following actions should the nurse take?
Tell the client that the provider will discharge him when she feels he is ready to leave.
Explain that the client should trust the provider because she has an excellent reputation.
Assure the client that the provider will come to talk to him when she gets the chance.
Inform the provider that the client is requesting information about his treatment plan.
17.) A nurse is assessing an older adult client. Which of the following findings should the nurse expect?
Increased nighttime sleeping
Nighttime urinary incontinence
Decreased sense of balanceHeightened
sense of pain
18.) A nurse is preparing to administer a controlled substance to a client for pain management. Which of the following actions should the nurse take?
Report any discrepancy in the count total of the controlled substance after administration.
Ask a second nurse to record her signature when wasting any unused portionof the controlled substance.
Place the wasted portion of the controlled substance in the sharps container.
Verify the count total of the controlled substance after removing the amount needed.
19.) A nurse is caring for a client who has right-sided paralysis following a cerebrovascular accident. Which of the following prescriptions should the nurse anticipate to prevent a plantar flexioncontracture of the affected extremity?
Abduction splint
Continuous passive motion machine
Sequential compression device
Ankle-foot orthotic
20). A nurse is caring for a client who has a chest tube following thoracic surgery. Which of the following tasks should the nurse delegate to an assistive personnel?
Evaluate the client’s response to pain medication.
Assist the client to select food choices from the menu.
Teach deep breathing and coughing to the client.
Monitor the characteristics of the client’s chest tube drainage
21). A nurse at an assisted living facility is preparing an in-service for residents about electrical safety. Which of the following instructions should the nurse include?
Cover exposed wires with tape before use.
Clean electrical equipment prior to disconnecting.
Avoid taping electrical cords to the floor.
Disconnect electrical equipment by grasping the plug.
22.) A nurse is preparing to apply a condom catheter for a client who is uncircumcised. Which of the following actions should the nurse plan to take?
Allow 2.5 to 5 cm (1 to 2 in) between the end of the catheter and the tip of the penis.
Place adhesive tape directly on the penis.
Keep foreskin in a retracted position after application of the catheter.
Change the condom catheter every 3 days.
23). A nurse is speaking with the partner of a client who is unconscious and has a do-not-resuscitate (DNR) order in place.
The partner requests thatCPRbeperformedif necessary. Which of the following responses should the nurse make?
“It must be very difficult for you to accept your partner’s wishes.”
“You should call your partner’s provider to change the DR order.
“Let’s discuss other areas of your partner’s care.”
“I understand how you feel because I recently lost a family member myself.”
24). A nurse is completing a dressing change on a client who has a surgical wound drain. Which of the following actions should the nurse take?
Use a separate, sterile swab for each stroke when cleaning the wound.
Don clean gloves before cleaning the wound.
Cut a 4 X4 piece of gauze to place around the drain site.
First, clean the drain site and then clean the incision.
25). A nurse is preparing to administer a medication to a client. Which of the following should the nurse use as a client identifier?
Age
Photograph
Bed number
Room number
26) A nurse is caring for a client who has a new diagnosis of terminal cancer. Which of the following interventions is the priority?
Develop a list of goals with the client.
Teach the client to use progressive relaxation techniques.
Discuss the client’s prior coping mechanisms.
Help the client to find a local support group.
27). A nurse is preparing a sterile field to assist with suturing a client’s laceration. Which of the following actions should the nurse plan to take?
Apply sterile gloves before opening the bottle of sterile solution.
Pour the sterile solution with the bottle held 20 cm (8 in) above the sterile bowl.
Place the lid of the sterile solution bottle face down on the sterile drape.
Hold the bottle of sterile solution so that the label is facing the palm of the hand.
28) A nurse is preparing to administer several medications to a client. Which of the following data should the nurse plan to use to confirm the client’s identity?
The client’s admitting diagnosis
The name of the client’s next of kin
The client’s room number
The client’s telephone number
29) A nurse is assessing a client who is receiving a blood transfusion. The nurse notes lung crackles, hypoxia, and distended neck veins. Which of the following actions should the nurse take? (Selectall that apply.)
Administer oxygen to the client.
Stop the transfusion.
Administer epinephrine to the client.
Place the client in high-Fowler’s position.
Obtain à prescription for a diuretic.
30) A nurse is providing teaching to a client who is to self-administer an ophthalmic solution. Which of the following statements by the client indicates an understanding of the teaching?
“I will raise my eyelid up while looking down to insert the drops.”
“I will insert the drops in the center of each eye.”
“I will keep my eyes closed for 5 minutes after inserting the drops.”
” Willpress the innerIngrner of my eye after linsertthe drops.
SCIENCE
HEALTH SCIENCE
NURSING
A nurse is caring for a client who reports a pain level of 5 on a scale from o to
