The nurse assesses a 2-year-old who is admitted for dehydration and finds that the
peripheral IV rate by gravity has slowed, even though the venous access site is healthy.
What should the nurse do next?
A) Apply a warm compress proximal to the site.
B) Check for kinks in the tubing and raise the IV pole.
C) Adjust the tape that stabilizes the needle.
D) Flush with normal saline and recount the drop rate.
B) Check for kinks in the tubing and raise the IV pole.
During the initial morning assessment, a male client denies dysuria but reports that his
urine appears dark amber. Which intervention should the nurse implement?
,A) Provide additional coffee on the client's breakfast tray.
B) Exchange the client's grape juice for cranberry juice.
C) Bring the client additional fruit at mid-morning.
D) Encourage additional oral intake of juices and water.
D) Encourage additional oral intake of juices and water.
Dark amber urine is characteristic of fluid volume deficit, and the client should
be encouraged to increase fluid intake (D). Caffeine, however, is a diuretic (A),
and may worsen the fluid volume deficit. Any type of juice will be beneficial
(B), since the client is not dysuric, a sign of an urinary tract infection. The client
needs to restore fluid volume more than solid foods (C).
Which indicates that performing passive range-of-motion (ROM) exercises on an
unconscious client has been successful?
A) Preservation of muscle mass.
B) Prevention of bone demineralization.
C) Increase in muscle tone.
D) Maintenance of joint mobility.
D) Maintenance of joint mobility.
The goal of performing passive ROM exercises is to maintain joint mobility.
Active exercise is needed to preserve bone and muscle mass. Passive ROM
movements do not prevent bone demineralization or have a positive effect on
the client's muscle tone.
,While caring for a child and mother from an Asian culture, which action should the nurse
implement to accommodate the clients' cultural needs?
A) Speak initially with the oldest family member to show respect.
B) Realize that Southeast Asians may not take Western medications.
C) Ask the husband to step out during the mother's pelvic examination.
D) Tell the family that planning health care is provided in private with the client.
Give this one a try later!
A) Speak initially with the oldest family member to show respect.
Members of the Asian culture have high respect for others, especially those in
positions of authority. Extended family members need to be included in the
nursing care plan. Southeast Asians do not necessarily refuse Western
medications. Asians also believe that touching strangers is not acceptable,
particularly health professionals whom they have not previously known.
The daughter of an older woman who became depressed following the death of her
husband asks, "My mother was always well-adjusted until my father died. Will she tend to
be sick from now on?" Which response is best for the nurse to provide?
A) "She is almost sure to be less able to adapt than before."
B) "It's highly likely that she will recover and return to her pre-illness state."
C) "If you can interest her in something besides religion, it will help her stay well."
D) "Cultural strains contribute to each woman's tendencies for recurrences of
depression."
Give this one a try later!
, B) "It's highly likely that she will recover and return to her pre-illness state."
Analysis of behavior patterns using Erikson's framework can identify age-
appropriate or arrested development of normal interpersonal skills. Erikson
describes the successful resolution of a developmental crisis in the later years
(older than 65 years) to include the achievement of a sense of integrity and
fulfillment, wisdom, and a willingness to face one's own mortality and accept
the death of others.
An elderly male client who is unresponsive following a cerebral vascular accident (CVA)
is receiving bolus enteral feedings though a gastrostomy tube. What is the best client
position for administration of the bolus tube feedings?
A) Prone.
B) Fowler's.
C) Sims'.
D) Supine.
Give this one a try later!
B) Fowler's
The client should be positioned in a semi-sitting (Fowler's) (B) position during
feeding to decrease the occurrence of aspiration. A gastrostomy tube, known
as a PEG tube, due to placement by a percutaneous endoscopic gastrostomy
procedure, is inserted directly into the stomach through an incision in the
abdomen for long-term administration of nutrition and hydration in the
debilitated client. In (A and/or C), the client is placed on the abdomen, an
unsafe position for feeding. Placing the client in (D) increases the risk of
aspiration.
peripheral IV rate by gravity has slowed, even though the venous access site is healthy.
What should the nurse do next?
A) Apply a warm compress proximal to the site.
B) Check for kinks in the tubing and raise the IV pole.
C) Adjust the tape that stabilizes the needle.
D) Flush with normal saline and recount the drop rate.
B) Check for kinks in the tubing and raise the IV pole.
During the initial morning assessment, a male client denies dysuria but reports that his
urine appears dark amber. Which intervention should the nurse implement?
,A) Provide additional coffee on the client's breakfast tray.
B) Exchange the client's grape juice for cranberry juice.
C) Bring the client additional fruit at mid-morning.
D) Encourage additional oral intake of juices and water.
D) Encourage additional oral intake of juices and water.
Dark amber urine is characteristic of fluid volume deficit, and the client should
be encouraged to increase fluid intake (D). Caffeine, however, is a diuretic (A),
and may worsen the fluid volume deficit. Any type of juice will be beneficial
(B), since the client is not dysuric, a sign of an urinary tract infection. The client
needs to restore fluid volume more than solid foods (C).
Which indicates that performing passive range-of-motion (ROM) exercises on an
unconscious client has been successful?
A) Preservation of muscle mass.
B) Prevention of bone demineralization.
C) Increase in muscle tone.
D) Maintenance of joint mobility.
D) Maintenance of joint mobility.
The goal of performing passive ROM exercises is to maintain joint mobility.
Active exercise is needed to preserve bone and muscle mass. Passive ROM
movements do not prevent bone demineralization or have a positive effect on
the client's muscle tone.
,While caring for a child and mother from an Asian culture, which action should the nurse
implement to accommodate the clients' cultural needs?
A) Speak initially with the oldest family member to show respect.
B) Realize that Southeast Asians may not take Western medications.
C) Ask the husband to step out during the mother's pelvic examination.
D) Tell the family that planning health care is provided in private with the client.
Give this one a try later!
A) Speak initially with the oldest family member to show respect.
Members of the Asian culture have high respect for others, especially those in
positions of authority. Extended family members need to be included in the
nursing care plan. Southeast Asians do not necessarily refuse Western
medications. Asians also believe that touching strangers is not acceptable,
particularly health professionals whom they have not previously known.
The daughter of an older woman who became depressed following the death of her
husband asks, "My mother was always well-adjusted until my father died. Will she tend to
be sick from now on?" Which response is best for the nurse to provide?
A) "She is almost sure to be less able to adapt than before."
B) "It's highly likely that she will recover and return to her pre-illness state."
C) "If you can interest her in something besides religion, it will help her stay well."
D) "Cultural strains contribute to each woman's tendencies for recurrences of
depression."
Give this one a try later!
, B) "It's highly likely that she will recover and return to her pre-illness state."
Analysis of behavior patterns using Erikson's framework can identify age-
appropriate or arrested development of normal interpersonal skills. Erikson
describes the successful resolution of a developmental crisis in the later years
(older than 65 years) to include the achievement of a sense of integrity and
fulfillment, wisdom, and a willingness to face one's own mortality and accept
the death of others.
An elderly male client who is unresponsive following a cerebral vascular accident (CVA)
is receiving bolus enteral feedings though a gastrostomy tube. What is the best client
position for administration of the bolus tube feedings?
A) Prone.
B) Fowler's.
C) Sims'.
D) Supine.
Give this one a try later!
B) Fowler's
The client should be positioned in a semi-sitting (Fowler's) (B) position during
feeding to decrease the occurrence of aspiration. A gastrostomy tube, known
as a PEG tube, due to placement by a percutaneous endoscopic gastrostomy
procedure, is inserted directly into the stomach through an incision in the
abdomen for long-term administration of nutrition and hydration in the
debilitated client. In (A and/or C), the client is placed on the abdomen, an
unsafe position for feeding. Placing the client in (D) increases the risk of
aspiration.
