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A nurse provides a back massage as a palliative care measure to a client who is
unconscious, grimacing, and restless. Which of the following findings should the
nurse identify as indicating a therapeutic response? (Select all that apply.)
The shoulders droop.
The facial muscles
relax.
The respiratory rate increases.
The pulse is within the expected range.
The client draws his legs up into a fetal position.
The shoulders droop.
The facial muscles
relax.
The pulse is within the expected range.
A nurse is assessing a client who is postoperative and has anemia due to excess
blood loss following surgery. Which of the following findings should the
nurse expect?
A. Fatigue
B. Hypertension
C. Bradycardia
D. Diarrhea
A. Fatigue
,A nurse is reviewing the arterial blood gas (ABG) results of a client who the
provider suspects has metabolic acidosis. Which of the following results should
the nurse expect to see?
A. pH below 7.35
B. HCO3 above 26 mEq/L
C. PaO2 below 70 mmHg
D. PaCO2 above 45 mmHg
A. pH below 7.35
A hospice nurse is reviewing the prescriptions for a client who is receiving
palliative care. Which of the following prescriptions should the nurse expect?
(Select all that apply.)
Provide skin care with a moisture barrier
cream. Administer artificial tear PRN.
Obtain vital signs every 2 hr.
Perform mouth care every
hour.
Administer oxygen 2L/min via nasal cannula.
Provide skin care with a moisture barrier
cream. Administer artificial tear PRN.
Perform mouth care every hour.
Administer oxygen 2L/min via nasal cannula.
,A nurse is planning care for a client who is postoperative and at risk of paralytic
ileus. Which of the following interventions should the nurse plan to take to
promote peristalsis?
A. Increase ambulation.
B. Decrease fluid intake.
C. Increase protein intake.
D. Offer the client the bedpan every 2 hr.
A. Increase ambulation.
A nurse has completed care procedures for a client who requires airborne
precautions. Which of the following items of personal protective equipment
(PPE) should the nurse remove last?
A. Mask
B. Gloves
C. Gown
D. Goggles
A. Mask
, A nurse is providing teaching to an assistive personnel (AP) about caring for
clients with restraints. Which of the following statements by the AP indicates an
understanding of the teaching?
A. "I will tie restraints in double knots."
B. "I will tie a restraint to the portion of the bed that moves when the head of the
bed is moved."
C. "I will ensure that restraints fit tightly against the client."
D. "I will put four side rails up if a client is confused."
B. "I will tie a restraint to the portion of the bed that moves when the head of the
bed is moved."
A nurse is teaching a new group of assistive personnel (AP) about the
importance of hand hygiene. Which of the following statements should the
nurse include?
A. "If you wear gloves, you do not have to wash your hands."
B. "Rub all surfaces of your hands with an alcohol rub for 20 to 30 seconds."
C. "Use an alcohol rub when your hands are visibly soiled."
D. "If you don't have an infection, your hands won't infect others."
B. "Rub all surfaces of your hands with an alcohol rub for 20 to 30 seconds."