Comprehensive practice B 2020 Graded A+

A nurse at a long-term care facility is caring for a client who requires oral suctioning. Which of the following supplies should the nurse plan to use for this task? Ans- yankeurs catheter Rationale: A Yankauer cath ...

A nurse at a long-term care facility is caring for a client who requires oral suctioning. Which of the following supplies should the nurse plan to use for this task? Ans- yankeurs catheter Rationale: A Yankauer catheter is a clean suction catheter used when performing oral and oropharyngeal suctioning to remove secretions from the client's mouth to facilitate breathing or obtain a sample for diagnostic evaluation. A nurse in a long-term care facility is serving on the ethics committee, which is addressing a client care dilemma. Which of the following strategies will facilitate resolving the dilemma? (Select all that apply.) Ans- [1] determine the facts related to the dilemma. [2] identify possible solution [3]consider the client wishes A nurse is talking with a client whose son died in a motor-vehicle crash 2 weeks ago. The client states, "l really thought I'd be back to my usual routines by now, but I can't think of anything else except that my son is gone." Which Of the following responses should the nurse make? Ans- Grieving for your son is hard work. it will take as much time as you need to come to terms with your loss. A nurse is reinforcing teaching with a client about cancer prevention. The nurse should include that frequent consumption of which of the following foods increases the risk for developing cancer? AnsLamb Rationale: including tuna fish reduces risk of developing cancer. including poultry reduces risk, A nurse notices an assistive personnel (AP) taking a nap in the break room during meal time. The nurse also notes that the AP is drowsy while performing routine tasks. Which of the following actions should the nurse take? Ans- Report the observation about the AP to the Unit nurse manager Rationale: The nurse should report their observations to the unit's nurse manager because they have a duty to report any behavior that poses a risk to client safety. A nurse on a pediatric unit is collecting data from four newly admitted clients. Which of the following clients should the nurse identify as being at risk for urinary retention? Ans- A school age child who has allergic rhinitis and is taking diphenhydramine. A nurse is caring for a client following a bronchoscopy. Which of the following actions should the nurse take first? Ans- check for gag reflex Rationale: The greatest risk to this client is injury from aspiration. Therefore, the first action the nurse should take is to check for a gag reflex. A nurse is assisting with the admission of a client who has a latex allergy. The nurse should identify that which of the following supplies has the potential to contain latex? Ans- Indwelling urinary catheter A nurse is performing postmortem care for a client prior to the arrival Of the client's family for viewing Of the body. Which Of the following actions should the nurse take? Ans- Gently close the client's eyelids A nurse is reinforcing teaching with a client who has dumping syndrome about measures to reduce manifestations. Which of the following instructions should the nurse include in the teaching? Ans- avoid foods high in sugar content. Rationale: The nurse should instruct the client to avoid sweet foods, which often increase the manifestations of dumping syndrome. These manifestations include nausea, sweating, abdominal pain, diarrhea, and weakness. A nurse is collecting data from a client who is experiencing a situational crisis following the loss of a job. The client states, "l don't think I can go through this again." Which of the following actions is the nurse's priority? Ans- Determine if the client is experiencing psychotic thinking. A nurse is contributing to the plan of care for a client following a transurethral resection of the prostate (TURP). Which of the following interventions should the nurse include? Ans- Irrigate the bladder using sterile technique Rationale: The nurse should irrigate the bladder using strict sterile technique and maintain the closed catheter drainage system to minimize the risk of infection. A nurse is caring for an infant who is receiving IV fluids for dehydration. Which of the following should the nurse recognize as a positive response to the therapy? Ans- Moist mucus membranes. Rationale: The condition of mucous membranes is an indicator of hydration status. Moist mucous membranes indicate adequate hydration and a positive response to IV fluid therapy. A nurse is assisting with the admission of a client who is experiencing alcohol withdrawal. Which of the following medications should the nurse expect the provider to prescribe for the client? AnsChlordiazepoxide Rationale: The nurse should expect to administer chlordiazepoxide to decrease anxiety and the risk for seizures associated with alcohol withdrawal. A nurse is caring for a client who is scheduled for surgery in the morning. The nurse learns that the client has decided not to have surgery even though they have already signed the informed consent form. Which of the following actions should the nurse take? Ans- report the situation to the provider who obtained informed consent. A nurse is collecting data from a client who is in severe pain. Which of the following questions should the nurse ask first? Ans- where is your pain located A nurse in a provider's office is reinforcing teaching with a client who has a new prescription for ferrous sulfate elixir. Which of the following statements by the client should indicate to the nurse an understanding of the teaching? Ans- i will rinse my mouth after taking this medication Rationale: Iron preparations can stain the teeth. The nurse should instruct the client to use a straw to drink the medication and rinse the mouth immediately after taking the medication. A nurse is contributing to the plan of care for a client who is postoperative following a rhinoplasty. Which of the following interventions should the nurse recommend? Ans- instruct the client to avoid the Valsalva maneuver. Rationale: The nurse should instruct the client to avoid the Valsalva maneuver and other activities that increase pressure at the operative site, resulting in an increased risk for bleeding. A nurse is collecting data from a postpartum client who had a vaginal birth 2 days ago. Which Of the following findings is the nurse's priority to report to the provider? Ans- client reports burning with urination. Rationale: When using the urgent vs. non-urgent approach to client care, the nurse should determine that dysuria is a manifestation of a urinary tract infection. Therefore, the nurse should identify this as the priority finding to report to the provider. A nurse is preparing to administer digoxin to a client who has heart failure. Which Of the following findings should indicate to the nurse that the medication has been effective? Ans- cardiac workload decreases A nurse is reinforcing teaching about stress management techniques with a client who has moderate anxiety disorder. Which of the following responses by the client indicates an understanding of the teaching? Ans- i will imagine myself in a calm place when i cant concentrate A nurse is reinforcing teaching with a client about taking warfarin to treat atrial fibrillation. Which of the following statements by the client indicates an understanding of the teaching? Ans- if i forget to take a dose i can take it later on the same day. A charge nurse in a long-term care facility notices an assistive personnel's (AP) repeated failure to provide oral care for clients. Which of the following actions should the charge nurse take? Ans- Discuss this behavior with the AP while reinforcing expectations. Rationale: The charge nurse should discuss this behavior with the AP and reinforce expectations moving forward. Evaluation of the AP's performance is a part of the nurse's delegation process. Teaching and counseling the AP about behaviors and expectations is an important component of leadership. A nurse in a long-term care facility is observing a newly licensed nurse who is providing tracheostomy care for a client. The nurse identifies proper performance of the procedure when the newly licensed nurse selects which of the following solutions to clean the inner cannula? Ans- Hydrogen peroxide Rationale: The nurse should identify that sterile hydrogen peroxide solution is used to loosen secretions from the inner cannula during cleansing. If the client's skin becomes irritated, the nurse should choose 9% sodium chloride solution. A nurse is caring for a client who took an overdose of acetaminophen. Which of the following medications should the nurse plan to administer to the client? Ans- acetylcysteine A nurse is caring for a client who is in Buck's traction. Which of the following actions should the nurse take? Ans- allow the weight to hang freely A nurse is preparing to administer metoclopramide 10 mg IM. Available is metoclopramide 5 mg/mL How many mL should the nurse administer? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.) Ans- 2 ml A nurse is reinforcing discharge instructions with the parent of an infant who has rotavirus. Which of the following statements by the parent indicates an understanding of the teaching? Ans- i will apply diaper cream to my baby skin during each diaper change rationale: The nurse should reinforce to the parent that applying a skin barrier, such as zinc oxide, during diaper changes will minimize skin irritation from frequent stools. A charge nurse is observing a newly licensed nurse apply sterile gloves. Which of the following actions by the newly licensed nurse demonstrates sterile technique? Ans- putting a glove on their dominant hand first. Rationale: The nurse is demonstrating sterile technique when they put a glove on their dominant hand first. Using the dominant hand to apply the second glove helps prevent contamination because the nurse's dominant hand is more likely to have better dexterity than their nondominant hand. A nurse is reviewing laboratory reports for a client who has an Escherichia coli infection and is receiving gentamicin. Which of the following results should the nurse report to the provider before administering the next dose? Ans- creatinine 2.5mg/dl A nurse is reinforcing teaching with a client regarding prescribed asthma medications. The nurse should instruct the client to use which of the following medications for treatment of an acute asthma attack? Ans- albuterol Rationale: The nurse should instruct the client to use albuterol, a bronchodilator, to relieve the bronchospasms of an acute asthma attac