A nurse is caring for a client who requires a 24-hr urine collection. Which of the
following statements by the client indicates an understanding of the teaching? -
ANSWERS -"I flushed what I urinated at 7:00 a.m. and have saved all urine since."
A nurse is assessing a client who has been on bed rest for the past month. Which of the
following findings should the nurse identify as an indication that the client has developed
thrombophlebitis? - ANSWERS- Calf swelling
A nurse manager is overseeing the care on a unit. Which of the following situations
,should the nurse manager identify as a violation of HIPAA guidelines? - ANSWERS-A
nurse asks a nurse from another unit to assist with her documentation .
A nurse is caring for a client who requires bed rest and has a prescription for antiembolic
stockings. Which of the following actions should the nurse take? - ANSWERS-Remove the
stockings at least once per shift.
A nurse is administering IV fluid to an older adult client. The nurse should perform which
priority assessment to monitor for adverse effects? - ANSWERS- Auscultate lung
sounds
A nurse is assessing a client's readiness to learn about insulin administration. Which of
the following statements should the nurse identify as an indication that the client is
ready to learn? - ANSWERS -"I can concentrate best in the morning."
A nurse is performing a Romberg's test during the physical assessment of a client. Which of the
following techniques should the nurse use? - ANSWERS-Have the client stand with her arms at
her side and her feet together.
A nurse is planning an deduction session for an older adult client who has just learned that she
has type 2 diabetes mellitus. Which of the following strategies should the nurse plan to use with
this client? - ANSWERS-Allow extra time for the client to respond to questions
, A nurse is teaching an older client who is at risk for osteoporosis about beginning a
program of regular physical activity. Which of the following types of activity should the nurse
recommend? - ANSWERS-Walking briskly
A nurse is assessing an adult client who has been immobile for the past 3 weeks. The
nurse should identify that which of the following findings requires further intervention?
ANSWERS- Erythema on pressure points
-
A nurse is preparing to administer 0.5 mL of oral single-dose liquid medication to a client.
Which of the following actions should the nurse take? - ANSWERS-Gently shake the container
of medication prior to administration.
A nurse is responding to a call light and finds a client lying on the bathroom floor. Which
of the following actions should the nurse take first? - ANSWERS- Check the client for
injuries
A nurse is caring for a client who is expressing anger over his diagnosis of colorectal cancer.
Which of the following actions should the nurse take? - ANSWERS-Reassure the client that this
is an expected response to grief.
A nurse in a clinic is caring for a middle adult client who states, "The doctor says that,
since I am at an average risk for colon cancer, I should have routine screening. What
does that involve?" Which of the following responses should the nurse make? -
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