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A nurse in a long-term care facility is caring for a client who has dementia. Which
of the following actions should the nurse take?
Give detailed directions when addressing the
client. Provide finger food at mealtime.
Use written signs to redirect the client.
Seat the client at a large table for meals.
Provide finger food at mealtime.
The nurse should provide the client who has dementia with fingers foods.
Clients who have dementia can have difficulty sitting still and tend to
wander, which makes weight loss and malnutrition a concern. Therefore,
foods that the client can hold while
ambulating are ideal.
,A nurse is caring for a client immediately following intubation with an
endotracheal (ET) tube. Which of the following methods should the nurse
identify as the most reliable for verifying placement of the ET tube?
Feel for exhaled air emerging from the endotracheal
tube. Assess for bilateral breath sounds.
Observe for symmetric chest
movement. Check for end-tidal
carbon dioxide levels.
Check for end-tidal carbon dioxide levels.
According to evidence-based practice, the most reliable method for
verifying ET tube placement is checking for end-tidal carbon dioxide levels by
using capnometry. A chest x-ray is another reliable method for verifying
placement.
A nurse is providing teaching for a client who has neutropenia and is receiving
chemotherapy. Which of the following client statements indicates an
understanding of the teaching? (select all that apply)
"I will avoid crowds."
"I will wash my toothbrush weekly."
"I will change my cat's litter box twice
weekly." "I will take my temperature
daily."
"I will eat plenty of fresh fruits and vegetables."
"I will avoid crowds."
The client who is immunocompromised should avoid crowds while undergoing
chemotherapy to reduce the risk of infection.
"I will take my temperature daily."
The client who is immunocompromised should take daily temperature readings
and report an elevated temperature to the provider.
,A nurse is planning care for a. client who has a lump in their right breast. Which of
the following findings increases the client's risk of developing breast cancer?
Menarche started at age 15
First born child was at 20 years of age
History of a fibrocystic breasts
Menopausal obesity
Menopausal obesity
During menopause, increased fat tissue can lead to higher stores of estrogen.
Higher levels of estrogen in the body increase the risk for postmenopausal
breast cancer.
A nurse is teaching a client who is scheduled to receive radioactive iodine
therapy for treatment of hyperthyroidism. Which of the following instructions
should the nurse
include in the teaching?
Remain 0.3 m (1 ft) away from children.
Limit the time spent around women who are pregnant to 10
min daily. Use disposable utensils for meals.
Use an absorbent pad if incontinent.
Use disposable utensils for meals.
The client who receives radioactive iodine has radioactivity in the body fluids,
including saliva, for several weeks following treatment. The nurse should
instruct the client to use disposable utensils, plates, and cups during this time
period to decrease the risk for
radiation exposure to other members of the household.
, A nurse is providing discharge teaching to a client following a loop
electrosurgical excision procedure (LEEP) for the treatment of cervical cancer.
Which of the following statements by the client indicates an understanding of the
teaching?
"I can resume sexual intercourse in 48 hours."
"I can expect some heavy vaginal bleeding for 24
hours." "I can use tampons when my period comes
in a week."
"I may have mild cramping for several hours."
"I may have mild cramping for several hours."
The client should expect very little discomfort from the LEEP procedure, which
is performed in ambulatory care using a painless electrical current.
A nurse is providing teaching to a client who has a new prescription for
cephalexin oral suspension. Which of the following statements by the client
indicates an understanding of the teaching?
"I will increase my consumption of foods high in
potassium." "I will apply lotion to my skin if I feel any
itching."
"I will avoid sun exposure while taking this
medication." "I will keep the medication
refrigerated."
"I will keep the medication refrigerated."