The nurse is preparing to assist a newly admitted client with personal hygiene measures. The client...the client’s gag reflex. Which action
should the nurse include?
A. Offer smalls sips of water through a straw
B. Pl
...
The nurse is preparing to assist a newly admitted client with personal hygiene measures. The client...the client’s gag reflex. Which action
should the nurse include?
A. Offer smalls sips of water through a straw
B. Place tongue blade on back half of tongue
C. Use a penlight to observe back of oral cavity
D. Auscultate breath sounds after client swallows
3. The nurse explains to an older adult male the procedure for collecting a 24-hour urine specimen for creatinine clearance.
A. Assess the client for confusion and reteach the procedure
B. Check the urine for color and texture
C. Empty the urinal contents into the 24-hour collection container
D. Discard the contents of the urinal
4. A 54-year-old male client and his wife were informed this morning that he has terminal cancer. Which nursing intervention is likely to be
most
A. Ask her how she would like to participate in the client’s care
B. Provide the wife with information about hospice
C. Encourage the wife to visit after painful treatments are completed
D. Refer her to support group for family members of those dying of cancer
5. A client who has a body mass index (BMI) of 30 is requesting information on the initial approach to a weight loss plan. Which action
should the nurse recommend?
A. Plan low carbohydrate and high protein meals
B. Engage in strenuous activity for an hour daily
C. Keep a record of food and drinks consumed daily
D. Participated in a group exercise class 3 times a week
6. The nurse assesses a client who has a nasal cannula delivering oxygen at 2 L/min. To assess for skin damage related to the cannula, which
areas should the nurse observe?
A. Tops of the ear
B. Bridge of the nose
C. Around the nostrils
D. Over the cheeks
E. Across the forehead
7. The nurse observes an unlicensed assistive personnel (UAP) who is providing a total bed bath for a confused and lethargic client. The
UAP is soaking the client’s foot in a basin of warm water placed on the bed. What action should the nurse take?
a. Remove the basin of water from the client’s bed immediately
b. Remind the UAP to dry between the client’s toes completely
c. Advise the UAP that this procedure is damaging to the skin
d. Add skin cream to the basin of water while the foot is soaking
8. The nurse in the emergency department observes a colleague viewing the electronic health record (EHR) of a client who holds an elected
position in the community. The client is not a part of the colleague’s assignment. Which action should the nurse implement?
a. Communicate the colleague’s actions to the unit charge nurse
b. Send an email to facility administration reporting the action
c. Write an anonymous complaint to a professional website
d. Post a comment about the action on a staff discussion board
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