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B260 D&D, Clinical Judgement, Final Review (1).
B260 D&D, Clinical Judgement, Final Review (1).
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B260 D&D, Clinical Judgement, FinalReview
airborne - ANS-A nurse is admitting a client who has tuberculosis and a productive
cough. which of the following types of isolation precautions should the nurse initiate for
the client?
a. contact
b. droplet
c. protective
d. airborne
denial - ANS-a nurse in a dialysis center is caring for a client who has a new diagnosis
of end-stage kidney disease. when he arrives for his first dialysis treatment, he tells the
nurse, I decided to come today, but I am not sure if I will need to come back again this
week. I am feeling much better since my discharge from the hospital and I think my
kidneys are working again. the nurse should identify that this client is demonstrating
which of the following Kubler-ross stages of grieving?
a. bargaining
b. denial
c. depression
d. anger
i just can't believe that this dialysis is going to ruin my whole life - ANS-a nurse is caring
for a client who has a new diagnosis of chronic kidney disease. which of the following
statements should the nurse identify as an indication of anticipatory grieving?
a. i know that i will get a kidney transplant. I am a good candidate.
b. i can now eat whatever I want. the dialysis will remove it from my system
c. i just can't believe that this dialysis is going to ruin my whole life
d. I know that kidney disease runs in my family, but I can prevent it.
performs active range of motion exercises of all extremities - ANS-a nurse is assessing
a client who has required strict bed rest for 1 week. which of the following findings
should the nurse identify as an indication that the client is ready to ambulate?
a. needs assistance raising her legs to put on socks
b. demonstrates mild dyspnea when eating breakfast
c. performs active range of motion exercises of all extremities
d. develops fatigue when assisting with morning hygiene care
, inject the medication at 90 degree angle. - ANS-a nurse is planning to administer an IM
injection into a client's deltoid muscle. which of the following actions should the nurse
take?
a. inject the medication at 90 degree angle.
b. inject a volume of less than 2 ml
c. inject the medication 12.7 com (5in) below the client's acromion process
d. use a 21-guage needle for the injection
the client's self-report of pain severity - ANS-a nurse is caring for a client who is
postoperative. the nurse should base her pain management interventions primarily on
which of the following methods of determining the intensity of the client's pain?
a. vital sign measurement
b. the client's self-report of pain severity
c. visual observations for nonverbal signs of pain
d. the nature and invasiveness of the surgical procedure
rub all surfaces of your hands with an alcohol rub for 20 to 30 seconds - ANS-a nurse is
teaching a new group of assistive personnel about the importance of hand hygiene.
which of the following statements should the nurse include?
an older adult client who is confused and has urinary frequency - ANS-a nurse on the
medical surgical unit is conducting a fall risk assessment for four clients. the nurse
should identify that which of the following clients is the greatest risk for a fall
the shoulders droop
the facial muscles relax
the pulse is within the
expected range - ANS-a nurse provides a back massage as a palliative care measure to
a client who is unconscious, grimacing, and restless. which of the following findings
should the nurse identify as indicating a therapeutic response.
Provide skin care with a moisture barrier is correct.
Administer artificial tears PRN is correct
Perform mouth care every hour is correct
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