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Questions, Answers & Rationales
A nurse at a long-term care facility is caring for a client who requires oral
suctioning. Which of the following supplies should the nurse plan to use for this
task?
ANSWER yankeurs catheter
rationale: A Yankauer catheter is a clean suction catheter used when performing oral
and oropharyngeal suctioning to remove secretions from the client's mouth to
facilitate breathing or obtain a sample for diagnostic evaluation.
A nurse in a long-term care facility is serving on the ethics committee, which is
addressing a client care dilemma. Which of the following strategies will facilitate
resolving the dilemma? (Select all that apply.) - ANSWER [1] determine the facts
related to the dilemma.
[2]identify possible
solution [3]consider the
client wishes
A nurse is talking with a client whose son died in a motor-vehicle crash 2 weeks
ago. The client states, "l really thought I'd be back to my usual routines by now, but
I can't think of anything else except that my son is gone." Which Of the following
responses should the nurse make? - ANSWER Grieving for your son is hard work. it
will take as much time as you need to come to terms with your loss.
,A nurse is reinforcing teaching with a client about cancer prevention. The nurse
should include that frequent consumption of which of the following foods increases
the risk for
,developing cancer? - ANSWER Lamb
rationale: including tuna fish reduces risk of developing cancer. including
poultry reduces risk,
A nurse notices an assistive personnel (AP) taking a nap in the break room during
meal time. The nurse also notes that the AP is drowsy while performing routine tasks.
Which of the following actions should the nurse take? - ANSWER Report the
observation about the AP to the Unit nurse manager
A nurse on a pediatric unit is collecting data from four newly admitted clients.
Which of the following clients should the nurse identify as being at risk for urinary
retention? - ANSWER A school age child who has allergic rhinitis and is taking
diphenhydramine.
A nurse is caring for a client following a bronchoscopy. Which of the following
actions should the nurse take first? - ANSWER check for gag reflex
A nurse is assisting with the admission of a client who has a latex allergy. The nurse
should identify that which of the following supplies has the potential to contain latex?
- ANSWER Indwelling urinary catheter
A nurse is performing postmortem care for a client prior to the arrival Of the client's
family for viewing Of the body. Which Of the following actions should the nurse take?
- ANSWER Gently close the client's eyelids
A nurse is reinforcing teaching with a client who has dumping syndrome about
measures to reduce manifestations. Which of the following instructions should the
nurse include in the teaching? - ANSWER avoid foods high in sugar content.
, rationale: The nurse should instruct the client to avoid sweet foods, which often increase
the manifestations of dumping syndrome. These manifestations include nausea, sweating,