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,Which of these instructions should a nurse include in the
teaching plan for a client who had removal of a cataract in the
left eye?
a. "Forcefully cough and take deep breaths every two hours to
keep your airway clear."
b. "Perform the prescribed eye exercises each day to
strengthen your eye muscles."
c. "Rinse your eyes with saline each morning to prevent
postoperative infection."
d. "Take the prescribed stool softener to avoid increasing
intraocular pressure." - Answer: d
A client vomits during a continuous nasogastric tube feeding. A
nurse should stop the feeding and take which of these actions?
a. Suction the nasogastric tube.
b. Flush the tube with 30 mL of sterile water.
c. Remove the nasogastric tube.
d. Check the residual volume. - Answer: D
,Which of these actions best demonstrates cultural sensitivity by
a nurse?
a. The nurse talks in a slow-paced speech.
b. The nurse asks clients about their beliefs and practices
toward pregnancy.
c. The nurse uses charts and diagrams when teaching pregnant
clients.
d. The nurse can speak several different languages. - Answer: B
Which of these manifestations should a nurse expect to
observe in a 3-month-old infant who is diagnosed with
dehydration?
a. Hyperreflexia.
b. Tachycardia.
c. Bradypnea.
d. Agitation. - Answer: B
When assessing a client's risk of developing nosocomial
infection, a nurse plans to determine potential entry portals,
which include:
, a. the urinary meatus.
b. vomitus.
c. contaminated water.
d. sexual intercourse. - Answer: A
A client who is on the inpatient psychiatric unit has a history of
violence. Which of these actions should a nurse take if the
client is agitated?
a. Encourage the client to verbalize feelings.
b. Lock the client in a secluded room.
c. Ask the other clients to give feedback regarding the client's
behavior.
d. Ignore the client's inappropriate behavior. - Answer: A
Which of these measures should a nurse include when planning
care for a school-aged child during a sickle cell crisis episode?
a. Monitoring for signs of bleeding.
b. Providing pain relief.