C28 retake Flashcards
The nurse is caring for a client with dysphagia who coughs vigorously after drinking water to swallow an oral medication. Which of the following nursing interventions are appropriate? SATA
a. Avoid providing thin liquids
b. Collaborate with the speech therapist
c. Eliminate the use of straws
d. Instruct the client to tilt the head back when swallowing
e. Raise the HOB to 90 degrees during meals
a. Avoid providing thin liquids
b. Collaborate with the speech therapist
c. Eliminate the use of straws
e. Raise the HOB to 90 degrees during meals
The nurse is caring for an actively dying client receiving hospice care. On assessment, the nurse finds that the client has rapid respirations with noisy expiratory sounds and appears to be short of breath. Which of the following actions are appropriate for the nurse to take? SATA
a. Administer IV morphine sulfate for comfort
b. Begin performing nasotracheal suctioning hourly
c. Check the client’s mouth for retained secretions
d. Elevate the head of the client’s bed
e. Initiate PRN supplemental O2 via nasal cannula
a. Administer IV morphine sulfate for comfort
c. Check the client’s mouth for retained secretions
e. Initiate PRN supplemental O2 via nasal cannula
The nurse is teaching a client how to ambulate using crutches. Which of the following actions by the client requires the nurse to intervene?
A. The client adjusts the crutch handles to maintain a 30-degree bend in the elbows during ambulation.
B. The client maintains a 3-finger-width space between the axillae and should pads when ambulating
C. The client shifts and supports the body weight on the handgrips when preparing to ambulate
D. The client’s body weight is supported with the crutch pads under the axillae when resting
D. The client’s body weight is supported with the crutch pads under the axillae when resting
The nurse is admitting an adult client to the medical-surgical unit. Which situation is most concerning to the nurse?
a. Client reports easy bruising after accidentally bumping into furniture
b.Client reports frequent bladder spasms and occasional urinary incontinence
c. Client reports the need for all medications to be crushed and placed in applesauce
d. Client’s blood pressure is 140/82 mmHg, and heart rate is 61/min prior to evening medications
c. Client reports the need for all medications to be crushed and placed in applesauce
A client with a sacral stage 2 pressure injury is being prepared for a dressing change. Which action should the nurse perform first?
a. Administer the prescribed analgesic medication
b. Don clean gloves and remove the existing dressing
c. Place the client in a lateral position with back support
d. Prepare normal saline solution to cleanse the wound
a. Administer the prescribed analgesic medication
The clinic nurse is teaching methods to improve sleep hygiene to a client who has been diagnosed with insomnia. Which statement by the client indicates that the teaching has been effective?
a. “I can try having a small glass of wine each night before bedtime.”
b. “I need to get out of bed to read books at bedtime.”
c. “I should take a short, brisk walk right before I get ready for bed.”
d. “I will avoid snacking before bed, even if I am hungry.”
b. “I need to get out of bed to read books at bedtime.”
The clinic nurse is assessing a client with chronic lower back pain during a follow-up appointment. Which question by the nurse is most appropriate for evaluating the effectiveness of this client’s pain management?
a. “Have you noticed any mood swings or feelings of depression or anxiety levels?”
b. “How often are you needing to use your breakthrough pain medication?”
c. “On a scale of 0 to 10, how would you rate your current pain level?”
d. “What changes, if any, have you noticed in your ability to perform daily routines?”
d. “What changes, if any, have you noticed in your ability to perform daily routines?”
The nurse is caring for a client with chronic venous insufficiency who is prescribed graduated compression stockings for the legs. Which of the following actions by the nurse are appropriate? SATA
a. Assess for skin breakdown at least once per shift
b. Elevate the legs prior to applying the stockings
c. Fold down excess material at the top of the stockings
d. Remove the stockings if pallor in the toes develops
e. Smooth out creases or wrinkles along the stockings
a. Assess for skin breakdown at least once per shift
b. Elevate the legs prior to applying the stockings
d. Remove the stockings if pallor in the toes develops
e. Smooth out creases or wrinkles along the stockings
A nurse admits a 3-year-old who weighs 28.7 lb (13kg) and has sustained partial-thickness burns covering approximately 12% of the body. Using the Parkland formula, what hourly infusion rate in milliliters per hour (mL/hr) should the nurse program into the infusion pump during the first 8 hours of fluid resuscitation? Click the exhibit button for additional information. Record your answer using a whole number.
312 mL/hr
The registered nurse is educating a graduate nurse (GN) about prevention of IV extravasation. Which of the following statements by the GN indicates a need for further education?
a. “I should flush the IV catheter with sterile normal saline before starting the infusion
b. “I should use antecubital IV sites, if possible, when giving vesicant medications.”
c. “I will make sure the dressing and stabilization device are intact before each use.”
d. “I will teach my clients to immediately report pain, burning, and tingling during the infusion.”
b. “I should use antecubital IV sites, if possible, when giving vesicant medications.”
The nurse is caring for a client with an indwelling urinary catheter. Which of the following actions by the nurse are appropriate? SATA
a. Checks for kinks in the catheter tubing after repositioning the client
b. Empties the urine collection bag frequently to prevent overfilling
c. Places the urine collection bag in the client’s bed prior to transport
d. Stabilizes the catheter tubing near the urinary meats while cleaning the tubing
e. Uses the sampling port on the drainage tubing to obtain a urine specimen.
a. Checks for kinks in the catheter tubing after repositioning the client
b. Empties the urine collection bag frequently to prevent overfilling
d. Stabilizes the catheter tubing near the urinary meats while cleaning the tubing
e. Uses the sampling port on the drainage tubing to obtain a urine specimen.
The nurse preceptor is reviewing basic life support protocols with the graduate nurse (GN) and asks which actions the GN would take if an infant client becomes unresponsive. Which statement by the GN indicates a need for further teaching?
a. “I would ask my preceptor or another nurse to activate the emergency response system.”
b. “I would attempt to stimulate the infant by patting the chest and tapping the feet.”
c. “I would palpate for a femoral pulse while assessing for the presence of respirations.”
d. “I would place two fingers on the chest to begin compressions if the client has no pulse.”
c. “I would palpate for a femoral pulse while assessing for the presence of respirations.”
The nurse is reviewing the procedure for administration of a rectal suppository with a student nurse who is preparing to administer a promethazine suppository to an adult. Which of the following statements by the student nurse indicate a correct understanding of the procedure? Select all that apply.
a. “I will assess for hemorrhoids before administering the suppository.”
b. “I will assist the client into the Sims position and drape for privacy.”
C. “I will insert the suppository past the anal sphincter and into the rectum.”
D. “I will instruct the client to bear down while the suppository is inserted.”
E. “I will lubricate the tapered end of the suppository before inserting it.”
a. “I will assess for hemorrhoids before administering the suppository.”
b. “I will assist the client into the Sims position and drape for privacy.”
C. “I will insert the suppository past the anal sphincter and into the rectum.”
E. “I will lubricate the tapered end of the suppository before inserting it.”
The graduate nurse (GN) is performing closed (in-line) suctioning on a client with an established tracheostomy who is mechanically ventilated. Which action by the GN would cause the supervising nurse to intervene?
a. Applies suction while inserting the catheter
B. Dons clean gloves to perform the procedure
C. Increases fraction of inspired oxygen to 100% before the procedure
D. Limits each suction pass to 10 seconds
Mutes ventilator alarm while client rests (← answer from the first test)
a. Applies suction while inserting the catheter
A nurse is caring for a client who requires instruction on the use of an incentive spirometer following a recent open cholecystectomy. Place the instructions in the correct order. All options must be used.
A. “Inhale as slowly and deeply as possible through your mouth.”
B. “Exhale normally and then close your lips tightly around the mouthpiece.”
C.“Sit as upright as possible and brace your abdomen with a pillow.”
D. “Remove your lips from the mouthpiece and exhale slowly.”
E. “Hold your breath for at least 2-3 secs.”
C. “Sit as upright as possible and brace your abdomen with a pillow.”
B. “Exhale normally and then close your lips tightly around the mouthpiece.”
A. “Inhale as slowly and deeply as possible through your mouth.”
E. “Hold your breath for at least 2-3 secs.”
D. “Remove your lips from the mouthpiece and exhale slowly.”
A nurse is preparing to teach a client to perform wound care for a painful venous leg ulcer. For teaching to be effective, which nursing intervention is most important?
a. Administer prescribed ibuprofen 30 minutes prior to dressing change
B. Encourage the client to touch and manipulate the supplies
C. Have the client perform a return demonstration of the dressing change
D. Provide uninterrupted time and attention to the client
a. Administer prescribed ibuprofen 30 minutes prior to dressing change
The precepting nurse observes a student nurse caring for a non catheterized female client with a prescription for a 24-hour urine collection. Which of the following actions by the student nurse is appropriate? SATA
a. Discards the client’s first voided urine and begins the 24-hour time frame
B. Obtains a sample of urine from the collection container for a prescribed urinalysis
C. Places the collection container on ice until the urine collection is complete
D. Reinforces the client and family members the importance of collecting all urine
E. Reminds the client to avoid placing toilet tissue in the urine hat during collection
a. Discards the client’s first voided urine and begins the 24-hour time frame
C. Places the collection container on ice until the urine collection is complete
D. Reinforces the client and family members the importance of collecting all urine
E. Reminds the client to avoid placing toilet tissue in the urine hat during collection
The nurse is reinforcing discharge instructions with a client who received a prescription for a 24-hour urine test for creatinine clearance. Which of the following instructions should the nurse provide? Select all that apply.
a. “Be careful not to spill any collected urine while pouring it into the collection container.”
B. “Discard the urine from your first void, and then mark the time to begin the collection.”
C. “Do not place toilet tissue in the urine collection container.”
D. “Place a collection device in the toilet to help you collect the urine.”
E. “The sample can only be accepted if an antiseptic wipe is used prior to every void.”
a. “Be careful not to spill any collected urine while pouring it into the collection container.”
B. “Discard the urine from your first void, and then mark the time to begin the collection.”
C. “Do not place toilet tissue in the urine collection container.”
D. “Place a collection device in the toilet to help you collect the urine.”
A client at a nursing home accidentally starts a small fire in a common area. The nurse escorts all the clients from the area while another employee obtains a fire extinguisher. Place the nurse’s action in the correct order. All options must be used
a. Sweeps the nozzle from side to side
b. Squeezes the handle of the extinguisher
c. Activates the nursing home fire alert syste
d. Points the nozzle at the base of the fire
e. Removes the safety pin of the extinguisher
c. Activates the nursing home fire alert system
e. Removes the safety pin of the extinguisher
d. Points the nozzle at the base of the fire
b. Squeezes the handle of the extinguisher
a. Sweeps the nozzle from side to side
The nurse is evaluating the client’s intake and output after breakfast. The intake record indicates that the client consumed 240 mL of coffee with 2 added tablespoons of liquid creamer, 120 mL of whole milk, 1 pancake, 2 scrambled eggs, and 4 oz of grape-flavored gelatin. How many milliliters (mL) of fluid intake should the nurse document? Record your answer using a whole number.
510 mL
The nurse is teaching a health promotion class about sleep hygiene strategies to several clients with insomnia. Which of the following statements by the nurse are appropriate to include? SATA
a. “Browsing on your cellphone when you first lie down may make you drowsy.”
B. “Drinking a glass of warm milk or a cup of chamomile tea may help you fall asleep.”
C. “Increasing physical activity promotes sleep, but avoids strenuous exercise near bedtime.”
D. “Maintaining a dark and slightly cool bedroom provides an optimal sleeping environment.”
E. “Using a fan or white noise machine may help with relaxation and mask distracting noises.”
B. “Drinking a glass of warm milk or a cup of chamomile tea may help you fall asleep.”
C. “Increasing physical activity promotes sleep, but avoids strenuous exercise near bedtime.”
D. “Maintaining a dark and slightly cool bedroom provides an optimal sleeping environment.”
The nurse is caring for a client who has bladder cancer and hematuria and who is prescribed continuous bladder irrigation with normal saline solution at 150 mL/hr via a triple-lumen indwelling urinary catheter. The nurse empties the urine drainage bag for a total of 2570 mL at the end of the 12-hour shift. How many milliliters (mL) of net urine output should the nurse document for the shift? Record your answer using a whole number.
770 mL
The nurse is caring for a client who requires suture removal after a knee replacement. Which of the following actions is appropriate as the nurse removes sutures from the incision? SATA
a. Avoid pulling the exposed portion of the suture through the incision
b. Cleanse the incision area by wiping toward the suture line
C. Count and document the total number of sutures removed
D. Cut the middle of each suture with scissors before removal
E. Use sterile suture scissors and forceps for the removal procedure
a. Avoid pulling the exposed portion of the suture through the incision
C. Count and document the total number of sutures removed
E. Use sterile suture scissors and forceps for the removal procedure
