A client who underwent an uncomplicated gastric bypass surgery has difficulty with diet
management. What dietary instruction is most important for the nurse to explain to the
client?
a. Chew food slowly and thoroughly before attempting to swallow
b. Plan volume-controlled evenly-spaced meals throughout the day
c. Sip fluid slowly with each meal and between meals
d. Eliminate or reduce intake of fatty and gas-forming food - ✔️✔️b. Plan volume-
controlled evenly-spaced meals throughout the day
The nurse is assessing the feet of a client with type 1 diabetes mellitus. Which finding
requires immediate intervention by the nurse?
a. Decreased response to pain discrimination on the dorsal surface of the foot.
b. Erythema and edema at the base of the left great toe.
c. Hard, painless nodule over the metatarsophalangeal joint of the first toe.
d. Painful corns and calluses over hammer toes on both feet. - ✔️✔️a. Decreased
response to pain discrimination on the dorsal surface of the foot.
The nurse is planning to assess the client's oxygen saturation to determine if additional
oxygen is needed via nasal cannula. The client has bilateral below the-knee
amputations and radial pulses that are weak and thready. What action should the nurse
take?
a. Document that an accurate oxygen saturation reading cannot be obtained. b. Elevate
the client's hands for five minutes prior to obtaining a reading from the finger.
c. Increase the oxygen based on the client's breathing patterns and lung sounds.
d. Place the oximeter clip on the earlobe to obtain the oxygen saturation reading. -
✔️✔️d. Place the oximeter clip on the earlobe to obtain the oxygen saturation reading
the nurse observes a client prepare a meal in the kitchen of a rehabilitation facility prior
to discharge. which behaviors indicate the client understands how to maintain balance
safely?
a. brings a heavy can close to body before lifting
b. locks knees while preparing food on the counter
c. widens stance while working near the sink
d. bends from the waist to pick trash off the floor
e. leans forward to pull a pan from a high shelf - ✔️✔️a. brings a heavy can close to
body before lifting
c. widens stance while working near the sink
,The RN is assigned to care for four surgical clients. After receiving the report, which
client should the nurse see first?
a. Two days postoperative bladder surgery with continuous bladder irrigation infusing.
b. One-day postoperative laparoscopic cholecystectomy requesting pain medication.
c. Three days postoperative colon resection receiving a transfusion of packed RBCs.
d. Preoperative, in buck's traction, and scheduled for hip arthroplasty within the next 12
hours - ✔️✔️c. Three days postoperative colon resection receiving a transfusion of
packed RBCs. .
A client is receiving a continuous infusion of the anticoagulant, heparin, for treatment of
a deep vein thrombosis of the right calf. Which goal should the nurse include in this
client's plan of care?
a. No further thrombus will form.
b. The client's INR (international normalized ratio) will be 2.
c. The existing thrombosis will dissolve. d. The circumference of the client's right calf will
decrease. - ✔️✔️a. No further thrombus will form.
Which information is more important for the nurse to obtain when determining a client's
risk for (OSAS)?
a. Body mass index
b. Level of consciousness
c. Self-description of pain
d. Breath sounds - ✔️✔️a. Body mass index
A client with a prescription for "do not resuscitate" (DNR) begins to manifest signs of
impending death. After notifying the family of the client's status, what priority action
should the nurse implement?
a. The impending signs of death should be documented
b. The client's status should be conveyed to the chaplain
c. The client's need for pain medication should be determined
d. The nurse manager should be updated on the client's status - ✔️✔️c. The client's
need for pain medication should be determined
Which information is more important for the nurse to obtain when determining a client's
risk for (OSAS)?
a. Body mass index
b. Level of consciousness
c. Self-description of pain
d. Breath sounds - ✔️✔️Body mass index.
, The nurse is preparing to obtain a rapid COVID-19 test for a client who was exposed to
the virus eight days ago. The client is experiencing fever, cough, and shortness of
breath. Which action is the most important for the nurse to take?
a. Counsel family members to monitor for illness symptoms for 2 weeks after last
contact with patient
b. Assist the client to recall everyone possibly exposed since onset of symptoms
c. Start an intravenous infusion for antiviral drug to be administered for positive COVID-
19 test results.
d. Move the client to a private room, keep the door closed, and initiate droplet
precautions. - ✔️✔️d. Move the client to a private room, keep the door closed, and
initiate droplet precautions.
The nurse is preparing an adult with Addison's disease for self-management. Which
information should the nurse include in the client's instructions?
a. events requiring steroid dose adjustments
b. need to check temperature daily
c. importance of recording daily weights
d. adherence to a high fiber, low fat diet - ✔️✔️a. events requiring steroid dose
adjustments
The nurse is performing preoperative care of a client for an open reduction and internal
fixation (ORIF) of a fractured right tibia before the procedure, which action should the
nurse prioritize? - ✔️✔️Verify clients signed consent.
A client receives a prescription for acetaminophen 1,000 mg by mouth every 8 hours as
needed for pain. The bottle is labeled "Acetaminophen for Oral Suspension, USP 500
mg per 15 mL." How many tablespoons should the nurse instruct the client to take with
each dose? (Enter numerical value only.) - ✔️✔️2
The family of an older adult client who received a lung transplant asks if the 2-year-old
grandchild can visit. Which response should the nurse offer?
a. "Yes, grandchildren offer emotional support and positive diversion."
b. "No, protective precautions are required after a lung transplant."
c. "No, small children are often carriers of infectious organisms."
d. "Yes, if the child is not ill or has not recently received a live vaccine." - ✔️✔️d. "Yes,
if the child is not ill or has not recently received a live vaccine."
The nurse is using a straight urinary catheter kit to collect a sterile urine specimen from
a female client. After positioning and prepping the client, rank the actions in the
sequence they should be implemented. (place the first action at the top, and last action
at the bottom)