WITH ACTUAL EXAM QUESTIONS
AND ANSWERS
A nurse is planning to administer medication to a client who has a Clostridium di
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fficile infection. Which of the following actions should the nurse plan to take to pr
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event the transmission of this infection to others?
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Clean hands with an alcohol-based hand rub immediately after removing gloves.
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Remove the cover gown in the client's room after providing care. Place the client
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in a room with negative-pressure airflow
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Wear a mask when administering oral medications to the client. - ANSWERS--
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Remove the cover gown in the client's room after providing care.
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A nurse is caring for a client who has a prescription for a high-protein diet to
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promote wound healing following surgery. The client's religion prohibits eating
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meat on particular days. Which of the following actions should the nurse take?
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a. encourage the client to eat meat during this time to promote healing
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b. advise the client to eat everything on the tray except the meat
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c. suggest the client receive high-protein enteral feedings
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d. ask the dietitian to recommend alternative food choices for the client -
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ANSWERS--
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ask the dietitian to recommend alternative food choices for the client
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A nurse is caring for a client who has prescription for a high-
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protein diet to promote wound healing following surgery. The client's religion proh
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ibits eating meat on particular days. Which of the following actions should the nu
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rse take? SZ SZ
Encourage the client to eat meat during this time to promote healing
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Advise the client to eat everything on the tray except the meat
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Suggest the client receive high-protein enteral feedings
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Ask the dietitian to recommend alternative food choices for the clie -
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ANSWERS--
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Ask the dietitian to recommend alternative food choices for the client
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A nurse is collecting data from a client who is 2 days postoperative following a
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colostomy. Which of the following findings should the nurse report to the
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provider?
a purple-colored stoma
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protrusion of the stoma SZ SZ SZ
a small amount of bleeding from the stoma
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intestinal gas in the pouch - ANSWERS--a purple-colored stoma
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A nurse is reinforcing teaching with a client about self-administration of
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, ophthalmic drops. Which of the following instructions should the nurse include?
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"You will need to look to the side when you put the drops in your eye."
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"You should put the drops directly in the center of your eyeball."
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"You should cleanse your eye from the inner to the outer edge prior to putting in
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the drops." SZ
"You should avoid pressing on your tear duct after putting the drops in your eye.
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" - SZ
ANSWERS--"You should cleanse your eye from the inner to the outer edge prio
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r to putting in
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the drops." SZ
A nurse is reinforcing teaching about carbohydrate counting with a client who ha
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s
a new diagnosis of diabetes mellitus. Which of the following actions should the
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nurse take first? SZ SZ
a. use pictures of different food groups to help the client plan a daily menu
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b. ask the client what he already knows about meal planning
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c. give the client a brochure with sample menus for all meals
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d. involve the family in the discussion of the client's meal plan - ANSWERS--
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ask the client what he already knows about meal planning
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A nurse is assisting with the admission of an adult client to a medical-
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surgical unit. Which of the following findings should the nurse identify as an indic
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ation that the client is malnourished?
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heart rate 89/min SZ SZ
pink mucous membranes
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pale, scaly skin SZ SZ
body mass index 23 - ANSWERS--pale, scaly skin
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A nurse is reinforcing teaching about advance directives with a client who has e
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nd-
stage renal disease. Which of the following client statements indicates an
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understanding of the teaching? SZ SZ SZ
a. "I know that i can change my advance directives if I need to in the future."
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b. "My health care proxy will make my health care decisions as soon as I have
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signed the power of attorney."SZ SZ SZ SZ
c. "My family can overrule the decisions made by my health care proxy."
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d. "Advance directives from one state are valid in any other state." -
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ANSWERS--"I know that i can change my advance directives if I need to in the
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future."
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A nurse is preparing a client for a Romberg test. Which of the following stateme
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nts should the nurse make?
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"Stand with your feet together and your arms at your sides."
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"After I place the tuning fork, tell me when you no longer hear the sound"
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"I'm going to stroke the lateral side of the bottom of your foot."
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