1. A nurse is reaching a client and his family how to care for the client’s tracheostomy at home. Which of the following should the nurse include in the teaching?
a. Use tracheostomy covers when outdoors
2. A home heal
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1. A nurse is reaching a client and his family how to care for the client’s tracheostomy at home. Which of the following should the nurse include in the teaching?
a. Use tracheostomy covers when outdoors
2. A home health nurse is performing a follow-up visit for a client who has a gastrostomy tube through which they receive intermittent feedings and medications. The client has recently developed diarrhea. Which of the following findings should the nurse identify as a possible cause of the diarrhea?
a. The client’s care giver washed out the feeding bag once every 24 hours with warm water
3. A nurse is talking with an older adult client who is contemplating retirement. The client states, “I keep thinking about how much I enjoy my job. I’m not sure I want to retire.” Which of the following responses should the nurse make?
a. Let’s talk about how the change in your job status will affect you.
4. A nurse is assessing a client who reports increased pain following pt. Which of the following questions should the nurse ask When assessing the quality of the client’s pain?
a. Sharp & dull
5. A nurse is caring for a client who is expressing anger about his diagnosis of colorectal cancer. Which of the following actions should the nurse take?
a. Reassure the client that this is an expected response to grief.
6. A nurse on a medical-surgical unit is caring for a client who has a new prescription for wrist restraints. Which of the following actions should the nurse take?
a. Pad the client’s wrist before applying the restraints
7. A nurse is performing a home safety assessment for a client who is receiving supplemental oxygen. Which of the following observations should the nurse identify as proper safety protocol?
a. The client uses no acetone nail polish remover.
8. Nurse caring for a client who has a respiratory infection. What technique should she use when preforming nasotracheal suctioning?
a. Apply intermittent suction when withdrawing the catheter.
9. Nurse is preparing for change of shift. Which document or tools should the nurse use to communicate?
a. SBAR
10. Nurse is planning care for a client who had a stroke. What should be assigned to the assistive personal? (SATA)
a. -Assist the client with a partial bed bath.
b. -Measure the client’s BP after the nurse administers antihypertensive meds.
c. -Use a communication board to ask what the client wants for lunch.
11. Nurse caring for a client who has dementia. What interventions should be taken to minimize risk for injury?
a. Use bed exit alarm system
12. Nurse performing a skin assessment for a client who expresses concern about skin cancer. What findings should the nurse identify as a potential indication of a skin malignancy?
a. A mole with an asymmetrical appearance
13. Nurse is administering optic ear medication on an adult client. Which action should be done to ensure the medication reached the inner ear?
a. Press gently on the tragus of the client’s ear.
14. Nurse is planning strategies to manage time effectively for client care. What should the nurse implement?
a. Use the planning step of the nursing process to prioritize client care delivery.
15. Nurse caring for a client who has a sodium level of 125. What findings should the nurse expect?
a. Abdominal cramping
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