RNSG 2341 Prep U Quiz 3 Questions & Answers Correctly Answered

RNSG 2341 Prep U Quiz 3 Questions & Answers Question 1 See full question 2s Report this Question For a child with hemophilia, what is the most important nursing goal? You Selected: • Controlling pain Correct response: • Preventing bleeding episodes Explanation: Remediation: Add a Note Question 2 See full question 2s Report this Question A mental health nurse receives the following phone messages. Which client with the nurse call back first? You Selected: • A client with a history of illicit drug use who stated, “My family would be happier if I was not around.” Correct response: • A client with a history of illicit drug use who stated, “My family would be happier if I was not around.” Explanation: Remediation: Add a Note Question 3 See full question 2s Report this Question A client who is 28 weeks pregnant is admitted for testing. After reading the nursing notes, which rationale best explains why a pregnant client should lie on her left side when resting or sleeping in the later stages of pregnancy? You Selected: • to prevent development of fetal anomalies Correct response: • to prevent compression of the vena cava Explanation: Add a Note Question 4 See full question 2s Report this Question The laboratory comes to draw an Hgb AIc. The client asks the nurse what this test represents. Which statement would be correct? You Selected: • "This blood test is done to measure hyperglycemia in your system for 3 to 4 days after you were diagnosed with diabetic ketoacidosis (DKA).” Correct response: • “This test reflects the average blood glucose over a period of approximately 2-3 months.” Explanation: Remediation: Add a Note Question 5 See full question 2s Report this Question The client in the early stage of Alzheimer’s disease and his adult son attend an appointment at the community mental health center. While conversing with the nurse, the son states, “I’m tired of hearing about how things were 30 years ago. Why does Dad always talk about the past?” What should the nurse tell the son? You Selected: • "Reminding your dad that you have heard that story will help him stop." Correct response: • "Your dad lost his short-term memory, but he still has his long-term memory." Explanation: Remediation: Add a Note Question 6 See full question 2s Report this Question The nurse instructs a client prescribed digoxin about the signs and symptoms of toxicity. Which client statement indicates that teaching was effective? You Selected: • "I can expect my ability to taste and smell to change because of the medication." Correct response: • "I should contact the healthcare provider if I notice a change in my vision such as flashing lights or different colors." Explanation: Remediation: Add a Note Question 7 See full question 2s Report this Question A 4-year-old child is brought into the emergency room for abdominal pain. While in the emergency department, the client's condition deteriorates and the child dies. After the physician pronounces the time of death, the child’s parent punches a hole in the wall of the exam room. Which stage of grief is the parent experiencing? You Selected: • Depression Correct response: • Anger Explanation: Add a Note Question 8 See full question 2s Report this Question The nurse is caring for a client from Southeast Asia who has HIV-AIDS. The client does not speak or comprehend the English language. What should the nurse do? You Selected: • Do an internet search for the Joint United Nations Programme on HIV/AIDS. Correct response: • Utilize language-appropriate interpreters. Explanation: Remediation: Add a Note Question 9 See full question 1s Report this Question When planning to move a person with a possible spinal cord injury, the nurse should direct the team to move the client using which procedure? You Selected: • Limit movement of the arms by wrapping them next to the body. Correct response: • Immobilize the head and neck to prevent further injury. Explanation: Remediation: Add a Note Question 10 See full question 1s Report this Question The nurse is providing teaching to an expectant mother about breastfeeding. What statement made by the mother would require immediate follow-up by the nurse? You Selected: • "I was treated for gonorrhea 2 years ago." Correct response: • "I have been HIV positive for 4 years." Explanation: Remediation: Add a Note Question 11 See full question 1s Report this Question An older adult diagnosed with dementia wanders the halls of the locked nursing unit during the day. To ensure the client’s safety while walking in the halls, what should the nurse do? You Selected: • Assess the client's gait for steadiness. Correct response: • Assess the client's gait for steadiness. Explanation: Remediation: Add a Note Question 12 See full question 2s Report this Question The nurse has completed education for a client about an antibiotic prescribed by the healthcare provider. Which statement by the client indicates an understanding of the proper use of the medication? You Selected: • "I will take the medication until it is all gone." Correct response: • "I will take the medication until it is all gone." Explanation: Add a Note Question 13 See full question 1s Report this Question The nurse is awaiting medications from the pharmacy. For which medication does the nurse expect to provide a signature upon receipt? You Selected: • hydromorphone Correct response: • hydromorphone Explanation: Remediation: Add a Note Question 14 See full question 1s Report this Question When performing client education, the nurse knows that which client statement is a safe, cost-saving choice? You Selected: • "I do cost comparisons between different pharmacies and different manufacturers, and ask my health care provider to prescribe a different brand of medication to save money." Correct response: • "I do cost comparisons between different pharmacies and different manufacturers, and ask my health care provider to prescribe a different brand of medication to save money." Explanation: Add a Note Question 15 See full question 3s Report this Question A client who has been physically abused by her spouse agrees to meet with the nurse. What is most important for the nurse to do before the nurse terminates the meeting with the client? You Selected: • Tell the client not to do anything that could upset her husband. Correct response: • Give the client the telephone numbers of a shelter or a safe house and the crisis line. Explanation: Remediation: Add a Note Question 16 See full question 4s Report this Question A nursing supervisor notices that a previously effective nurse has been preoccupied and distant for several days and is having difficulty focusing on clients' needs. What statement will the supervisor use to explore the change in the nurse's behavior? You Selected: • "I have noticed you seem to be preoccupied. Would you like to talk?" Correct response: • "I have noticed you seem to be preoccupied. Would you like to talk?" Explanation: Remediation: Add a Note Question 17 See full question 2s Report this Question The nurse is to administer insulin to a client with diabetes mellitus. Which illustration indicates the appropriate syringe to use? You Selected: • Correct response: • Explanation: Remediation: Add a Note Question 18 See full question 2s Report this Question Which is an expected outcome when a client is receiving an IV administration of furosemide? You Selected: • decreased pain Correct response: • increased urine output Explanation: Remediation: Add a Note Question 19 See full question 2s Report this Question The nurse is gathering supplies in the medication room when another nurse asks to borrow the nurse's security code for the computerized automated dispensing cabinet (ADC) to obtain a dose of hydrocodone for a client. What is the best response by the nurse? You Selected: • "If I share my security code with you, I need you to make certain you don't allow anyone else to use it." Correct response: • "It is important to use your own security code because the law requires accurate documentation of all controlled substances." Explanation: Add a Note Question 20 See full question 1s Report this Question A client with gestational hypertension is experiencing abdominal pain and vaginal bleeding. Which assessment should the nurse perform first? You Selected: • strength of contractions Correct response: • fetal heart tones Explanation: Remediation: Add a Note Question 21 See full question 2s Report this Question The nurse is preparing to administer IM morphine sulfate to a client who is in pain. On checking the health care provider’s (HCP’s) prescription, the nurse notes that the prescription states, “morphine sulfate 60 mg IM every 4 hours as needed for pain.” The usual dose of morphine is 10 to 15 mg. What is the most appropriate action for the nurse to take? You Selected: • Administer 15 mg of the drug. Correct response: • Contact the HCP to verify the prescription. Explanation: Remediation: Add a Note Question 22 See full question 2s Report this Question A 25-year-old male client has just had a plaster cast applied to his right forearm following the reduction of a closed radius fracture due to an inline skating accident. What is the priority nursing assessment for this client? You Selected: • Whether the client is having any pain Correct response: • Sensation and movement of the fingers Explanation: Remediation: Add a Note Question 23 See full question 1s Report this Question A client is being discharged from same-day surgery. Which statement indicates that the client does not understand postoperative instructions about transportation to home? You Selected: • "I am taking a taxi home, and my daughter will meet me at home." Correct response: • "I can drive myself home after surgery." Explanation: Remediation: Add a Note Question 24 See full question 2s Report this Question A nurse is caring for a client with panic disorder who has difficulty sleeping. Which nursing intervention would best help the client achieve healthy long-term sleeping habits? You Selected: • suggesting that the client talk with other clients until ready to sleep Correct response: • encouraging the client use relaxation exercises Explanation: Remediation: Add a Note Question 25 See full question 2s Report this Question A school-age child is diagnosed with pediculosis. The parent is concerned about the spread of the lice to children who have been in contact with her child. What should the nurse instruct the parent to have her child avoid? You Selected: • sharing batting helmets Correct response: • sharing batting helmets Explanation: Remediation: Add a Note Question 26 See full question 1s Report this Question The client with first-time bacterial cystitis is being treated with an antibiotic to be taken for 7 days. What should the nurse instruct the client to do? You Selected: • Notify the health care provider (HCP) when the urine is clear. Correct response: • Take the entire prescription as ordered. Explanation: Add a Note Question 27 See full question 1s Report this Question A pregnant client at about 29 weeks’ gestation asks the nurse “What can I do about this dark brown line running down my stomach?” When teaching the client about this brown line, what should the nurse tell the client? You Selected: • “This is a linea nigra that will fade after the baby is born.” Correct response: • “This is a linea nigra that will fade after the baby is born.” Explanation: Remediation: Add a Note Question 28 See full question 2s Report this Question After a myocardial infarction, the hospitalized client is taught to move the legs while resting in bed. What is the expected outcome of this exercise? You Selected: • Promote urinary and intestinal elimination. Correct response: • Prevent thrombophlebitis and blood clot formation. Explanation: Remediation: Add a Note Question 29 See full question 1s Report this Question A client is on isolation precautions for a hospital-acquired infection, and the client's visitors are not following the posted hand hygiene protocol. What is the nurse's best action? You Selected: • Post "do not enter" and "report to the nurse's desk" signs on the hospital door. Correct response: • Explain to visitors the importance to the client of consistent hand hygiene. Explanation: Remediation: Add a Note Question 30 See full question 1s Report this Question A client who likes energy drinks asks the nurse if consuming bread or milk will reverse the effect of excessive caffeine intake. What is the best response by the nurse? You Selected: • "Do an internet search on how to reduce caffeine." Correct response: • "Water is the safest way to keep the body hydrated." Explanation: Remediation: Add a Note Question 31 See full question 3s Report this Question A nurse is planning care for a client after a tracheostomy. One of the client's goals is to overcome verbal communication impairment. Which intervention should the nurse include in the care plan? You Selected: • Encourage the client's communication, allowing time to select or write words. Correct response: • Encourage the client's communication, allowing time to select or write words. Explanation: Remediation: Add a Note Question 32 See full question 2s Report this Question A high-risk adolescent is given a tuberculin intradermal skin test to detect tuberculosis infection. How long after the test is administered should the results be evaluated? You Selected: • immediately afterward Correct response: • in 48 to 72 hours Explanation: Remediation: Add a Note Question 33 See full question 1s Report this Question Health promotion activities to reduce the incidence of osteoporosis include: You Selected: • teaching women to maintain adequate calcium intake. Correct response: • teaching women to maintain adequate calcium intake. Explanation: Remediation: Add a Note Question 34 See full question 2s Report this Question The nurse on the adolescent unit delegates a task to the nursing assistant. After delegating the task, the nurse should: You Selected: • assume the nursing assistant has completed the task to the nurse's satisfaction. Correct response: • allow adequate time for the nursing assistant to complete the task, then follow-up with the nursing assistant. Explanation: Add a Note Question 35 See full question 1s Report this Question A pregnant client at 36 weeks gestation tells the nurse she has been to see her physician but doesn’t feel that the physician is taking her symptoms of lower extremity edema seriously. Which of the following is the most appropriate response from the nurse? You Selected: • “Have you thought of switching physicians?" Correct response: • “Tell me more about your experience with your physician.” Explanation: Add a Note Question 36 See full question 2s Report this Question When performing cardiopulmonary resuscitation (CPR), which finding indicates that external chest compressions are effective? You Selected: • cool, dry skin Correct response: • palpable pulse Explanation: Remediation: Add a Note Question 37 See full question 1s Report this Question An adolescent with type 1 diabetes is monitoring her blood glucose level at home. Which action indicates that the client understands appropriate care management strategies for a blood glucose level of 250 mg/dL (13.9 mmol/L)? You Selected: • taking insulin Correct response: • taking insulin Explanation: Remediation: Add a Note Question 38 See full question 2s Report this Question The nurse leaves an older adult client with confusion unattended with the bed in high position, and the client sustains a fall. What will the action of the nurse be considered? You Selected: • collective liability Correct response: • negligence Explanation: Remediation: Add a Note Question 39 See full question 1s Report this Question A nurse is assigned to care for a non-English-speaking client. Which is the most appropriate action by the nurse to provide effective nursing care? You Selected: • request help from a nurse colleague Correct response: • request a trained interpreter Explanation: Add a Note Question 40 See full question 1s Report this Question The healthcare provider prescribes aspirin 325 mg by mouth each day for a client diagnosed with a transient ischemic attack (TIA). During education, how should the nurse identify the purpose of this medication? You Selected: • controls headache pain Correct response: • reduces the chance of blood clot formation Explanation: Remediation: Add a Note Question 41 See full question 2s Report this Question A client tells the nurse that “the hospital food is horrible.” What should the nurse tell the client? You Selected: • "Would you like to speak with the dietitian about the food and meal selection?" Correct response: • "Would you like to speak with the dietitian about the food and meal selection?" Explanation: Remediation: Add a Note Question 42 See full question 1s Report this Question A client is to take 8 ounces of magnesium sulfate solution. The calibrations on the measuring device are in milliliters. How many milliliters should the nurse give? You Selected: • 8 Correct response: • 240 Explanation: Add a Note Question 43 See full question 2s Report this Question A client has a total serum cholesterol level of 326 mg/dL (8.44 mmol/L). The nurse explains to the client that this level: You Selected: • is borderline normal and may require dietary modification. Correct response: • is high and will require dietary modification. Explanation: Remediation: Add a Note Question 44 See full question 1s Report this Question The nurse is drawing up medication into the syringe from the ampule when the ampule breaks and sprays the medication into the nurse’s eyes. Which action would be the priority for the nurse to perform? You Selected: • Obtain another ampule of the medication. Correct response: • Have eyes flushed with saline. Explanation: Remediation: Add a Note Question 45 See full question 2s Report this Question A client has several intravenous infusions, each running to a separate location. Which intravenous infusion line does the nurse select to attach secondary tubing to infuse an intravenous piggyback medication over 30 minutes? The line with: You Selected: • 25,000 units of heparin sodium in 250 mL 5% dextrose in water at 10 mL/hour. Correct response: • 1,000 mL normal saline at 50 mL/hour. Explanation: Add a Note Question 46 See full question 2s Report this Question A child who is 18 months of age is brought to the emergency department by her babysitter. The babysitter states, “She fell from the sofa an hour ago and has not been herself since.” On questioning, the babysitter appears to be unsure of time and other facts about the incident. Which question below would be most effective in obtaining more information about the child’s injuries? You Selected: • "Why did you leave the child alone on the couch?” Correct response: • “Tell me what was happening before she fell.” Explanation: Add a Note Question 47 See full question 1s Report this Question What is the nurse’s priority intervention for a toddler who has just had a hip spica cast applied? You Selected: • Reduce the risk of constipation by avoiding pain medications. Correct response: • Assess sensation, circulation, and motion of the child’s feet and toes. Explanation: Remediation: Add a Note Question 48 See full question 2s Report this Question A nurse is caring for a client who suffered a stroke. The family reports that the nurse on the previous shift failed to administer medications properly or maintain client privacy. What is the best action by the nurse? You Selected: • Notify the health care provider and social services. Correct response: • Inform the charge nurse of the family’s concerns. Explanation: Add a Note Question 49 See full question 4s Report this Question The nurse is assessing a client with chronic obstructive pulmonary disease. The client weighs 200 lb (90.7 kg) and is 6 feet (183 cm) tall. Using the diagram shown here, how should the nurse describe the client’s chest in the record in the health history? You Selected: • normal for the client’s age, height, and weight Correct response: • barrel-shaped Explanation: Remediation: Add a Note Question 50 See full question 2s Report this Question A nurse manager is auditing the nursing unit’s adherence to infection control practices. Which observation causes the nurse manager to be most concerned that the clients on the unit are at risk for infection? You Selected: • Several nurses fail to perform hand hygiene between clients. Correct response: • Several nurses fail to perform hand hygiene between clients. Explanation: Remediation: Add a Note Question 51 See full question 3s Report this Question Which client statement leads a nurse to suspect depression? You Selected: • "At least not everything in my life is bad." Correct response: • "I just know my child doesn't love me any more." Explanation: Remediation: Add a Note Question 52 See full question 2s Report this Question The client is ordered oxycodone/acetaminophen 20mg tablets, one or two prn pain. The client rates the pain as a 7 on the numeric scale of 0/10. How many tablets of oxycodone/acetaminophen should the nurse administer? You Selected: • 8 Correct response: • 2 Explanation: Remediation: Add a Note Question 53 See full question 1s Report this Question An older adult client with moderate dementia is being admitted to the memory wing of an assisted living unit. When the family brings the personal belongings of the client, the nurse should warn against leaving which item into the unit? You Selected: • word-find books Correct response: • a pair of sewing scissors Explanation: Remediation: Add a Note Question 54 See full question 2s Report this Question A nurse teaches a client with newly diagnosed hypothyroidism about the need for thyroid hormone replacement therapy to restore normal thyroid function. Which thyroid preparation is the agent of choice for thyroid hormone replacement therapy? You Selected: • levothyroxine Correct response: • levothyroxine Explanation: Remediation: Add a Note Question 55 See full question 1s Report this Question Following a sexual assault the client tells the nurse that she is on long-lasting birth control and has no intention of taking any legal action against her assailant. The nurse advises the client that she stills needs follow-up care for early detection of which problem? You Selected: • menstrual difficulties Correct response: • sexually transmitted disease Explanation: Remediation: Add a Note Question 56 See full question 2s Report this Question Which activity would be appropriate for the nurse to delegate to an unlicensed assistive personnel (UAP) for a client diagnosed with a myocardial infarction who is stable? You Selected: • Evaluate the lung sounds. Correct response: • Record the intake and output. Explanation: Remediation: Add a Note Question 57 See full question 2s Report this Question A client is receiving chemotherapy and tells the nurse about also taking herbal therapy. What should the nurse do next? You Selected: • Recommend that the client stop using the alternative medicines immediately. Correct response: • Determine what substances the client is using, and make sure that the health care provider (HCP) is aware of all therapies the client is using. Explanation: Remediation: Add a Note Question 58 See full question 1s Report this Question A client is entering the chemical dependency unit for treatment of alcohol dependency. Which of the client's possessions should the nurse place in a locked area? You Selected: • antiseptic mouthwash Correct response: • antiseptic mouthwash Explanation: Remediation: Add a Note Question 59 See full question 2s Report this Question A child is admitted to the emergency department with dyspnea related to bronchospasms. The nurse should place the client in which position? You Selected: • supine Correct response: • high Fowler's Explanation: Remediation: Add a Note Question 60 See full question 2s Report this Question A distraught father is waiting for his son to come out of surgery. He accidentally backed the car into his son, causing multiple fractures and a serious head injury. Which statement by the father would most alert the nurse to the need for a psychiatric consultation? You Selected: • "This accident will probably cost me my marriage.” Correct response: • "If he dies, there will be nothing for me to do but join him." Explanation: Remediation: Add a Note Question 61 See full question 3s Report this Question A mother asks the nurse how to handle her 4-year-old child, who recently has had episodes of urinary incontinence after being completely toilet-trained. What is the best response by the nurse? You Selected: • "Is your child angry with you about something?" Correct response: • "Has your child experienced any recent changes in routine?" Explanation: Add a Note Question 62 See full question 1s Report this Question A school-age client with diabetes is placed on an intermediate-acting insulin and regular insulin before breakfast and before dinner. She will receive a snack of milk and cereal at bedtime. What does the nurse tell the client the snack is intended to do? You Selected: • Help her regain lost weight. Correct response: • Prevent late night hypoglycemia. Explanation: Remediation: Add a Note Question 63 See full question 2s Report this Question A nurse is teaching bicycle safety to a child and parents. What protective device should the nurse tell the parents is most important in preventing or lessening the severity of injury related to bicycle crashes? You Selected: • knee pads Correct response: • helmet Explanation: Remediation: Add a Note Question 64 See full question 3s Report this Question The nurse is assessing an infant who has been brought for a scheduled clinic visit by a parent. When asked about the infant's immunization status, the parent pauses and then states, "I am just not comfortable pumping my baby full of mercury and causing autism." How should the nurse best address the parent's statement? You Selected: • "It sounds like you have some serious concerns about the safety of vaccines. Can we talk about those concerns?" Correct response: • "It sounds like you have some serious concerns about the safety of vaccines. Can we talk about those concerns?" Explanation: Remediation: Add a Note Question 65 See full question 2s Report this Question When teaching a client to perform testicular self-examination, when should the nurse instruct the client to perform the exam? You Selected: • after intercourse Correct response: • after a warm bath or shower Explanation: Remediation: Add a Note Question 66 See full question 3s Report this Question During a conversation with the client, the nurse observes that the client is shaking his leg and tapping his fingers on the table next to him. Which statement by the nurse is best? You Selected: • “I see that you’re anxious. I’ll be back later when you’re calmer.” Correct response: • “I noticed that your leg is shaking and you’re tapping your fingers on the table. How are you feeling now?” Explanation: Remediation: Add a Note Question 67 See full question 1s Report this Question Which principle forms the basis for the teaching plan about avoiding nonprescription medication for a primiparous client who is breastfeeding? You Selected: • Breast milk quality and richness are decreased. Correct response: • Medications may be excreted in breast milk to the nursing neonate. Explanation: Remediation: Add a Note Question 68 See full question 2s Report this Question A nurse walks into the room of a client who has had surgery for testicular cancer. The client says that he'll be undesirable to his wife. Becoming tearful, he says he's been spoiled by a happy, satisfying sex life with his wife. Which nursing diagnosis is appropriate? You Selected: • risk for situational low self-esteem Correct response: • risk for situational low self-esteem Explanation: Remediation: Add a Note Question 69 See full question 2s Report this Question The nurse is caring for an infant with severe diarrhea that has lasted 3 days. The child has poor skin turgor and dry mucous membranes. What is the priority nursing diagnosis for the nurse to use when planning care for this child? You Selected: • risk for infection Correct response: • fluid volume deficit Explanation: Remediation: Add a Note Question 70 See full question 2s Report this Question While helping clients brought to a crisis center during a severe flood, the nurse interviews a client whose pregnant wife is missing and whose home has been destroyed. The client keeps talking rapidly about his experience and says, “I can’t see how I can ever rebuild my life.” Which response by the nurse would be most appropriate? You Selected: • "This has been a terrible experience. Tell me more about how you feel." Correct response: • "This has been a terrible experience. Tell me more about how you feel." Explanation: Remediation: Add a Note Question 71 See full question 7s Report this Question A physician writes an order for a nurse to administer an I.V. medication which, according to hospital policy, is not a nursing protocol. The nurse informs the physician that it is not a nursing protocol, and the physician states, “Give it, and I will cover you.” What should the nurse do in this situation? You Selected: • Administer the medication as ordered. Correct response: • Refuse to administer the medication. Explanation: Remediation: Add a Note Question 72 See full question 2s Report this Question A client with diabetes begins to cry and says, “I just can’t stand the thought of having to give myself a shot every day.” What would be the best response by the nurse? You Selected: • “We can teach a family member to give the shots so you won’t have to do it.” Correct response: • "What is it about giving yourself the insulin shots that bothers you?" Explanation: Remediation: Add a Note Question 73 See full question 2s Report this Question A client has just been diagnosed with pneumonia. What is the nurse’s priority action? You Selected: • Provide information about how to avoid a recurrence. Correct response: • Maintain airway clearance. Explanation: Remediation: Add a Note Question 74 See full question 1s Report this Question A client has chest pain rated at 8 on a 10-point visual analog scale. The 12-lead electrocardiogram reveals ST elevation in the inferior leads and troponin levels are elevated. What should the nurse do first? You Selected: • Limit visitation by family and friends. Correct response: • Reduce pain and myocardial oxygen demand. Explanation: Remediation: Add a Note Question 75 See full question 2s Report this Question A nurse gives a client 0.25 mg of digoxin instead of the prescribed dose of 0.125 mg. What should the nurse do next? You Selected: • Give another 0.125 mg as soon as possible. Correct response: • Assess the client and notify the client’s physician. Explanation: Remediation: Add a Note Question 76 See full question 1s Report this Question The nurse discusses safety and accident prevention with the parent of a 9-month-old. The nurse understands that the teaching has been effective when the parent makes which statement? You Selected: • “I’ve found that those child-protective cabinet locks don’t work very well.” Correct response: • "I make sure that I keep my cleaning supplies locked up." Explanation: Remediation: Add a Note Question 77 See full question 2s Report this Question A nurse is teaching a group of nursing assistants about infection-control measures. What is the priority information to include in this teaching? You Selected: • hand-washing techniques Correct response: • hand-washing techniques Explanation: Remediation: Add a Note Question 78 See full question 1s Report this Question The nurse is offering nutritional instruction to the parents of a preschooler who has undergone a tonsillectomy and adenoidectomy. What food choice by the parents would indicate successful teaching? You Selected: • hot dog and potato chips Correct response: • cream of chicken soup and orange sherbet Explanation: Remediation: Add a Note Question 79 See full question 2s Report this Question A client says, “I hate the idea of being an invalid after they cut off my leg.” Which response by the nurse would be the most therapeutic? You Selected: • “Tell me more about how you’re feeling.” Correct response: • “Tell me more about how you’re feeling.” Explanation: Remediation: Add a Note Question 80 See full question 2s Report this Question The nurse is instructing the unlicensed assistive personnel (UAP) about the correct technique for obtaining a clean-catch urine culture from a female client. Which statement indicates that the teaching was successful? You Selected: • "I will have the client completely empty her bladder into the specimen cup." Correct response: • "I will ask the client to clean her labia, void into the toilet, and then into the specimen cup." Explanation: Remediation: Add a Note Question 81 See full question 1s Report this Question When interviewing an adolescent client, in which of the following instances will the nurse be most successful in obtaining relevant health information? You Selected: • Maintaining objectivity by avoiding assumptions, judgments, and lectures Correct response: • Maintaining objectivity by avoiding assumptions, judgments, and lectures Explanation: Remediation: Add a Note Question 82 See full question 1s Report this Question A client receiving care from a hospice agency dies while the nurse is providing care. Which action should the nurse take after pronouncing the client’s death? You Selected: • Turn off the intravenous pain medication infusion. Correct response: • Turn off the intravenous pain medication infusion. Explanation: Add a Note Question 83 See full question 2s Report this Question A client admitted with a gastric ulcer has been vomiting bright red blood. The hemoglobin level is 5.11 g/dL (51.1 g/L), and blood pressure is 100/50 mm Hg. The client and family state that their religious beliefs do not support the use of blood products and refuse blood transfusions as a treatment for the bleeding. The nurse should collaborate with the health care provider and family to plan to take which action next? You Selected: • Attempt to stabilize the client through the use of fluid replacement. Correct response: • Attempt to stabilize the client through the use of fluid replacement. Explanation: Remediation: Add a Note Question 84 See full question 3s Report this Question The nurse is taking care of a client with a spinal cord injury. The extent of the client’s injury is shown in the accompanying image. Which finding is expected when assessing this client? You Selected: • dysfunction of bowel and bladder Correct response: • dysfunction of bowel and bladder Explanation: Add a Note Question 85 See full question 2s Report this Question A client with recurrent, endogenous depression has been hospitalized on the psychiatric unit for 3 days. He exhibits psychomotor retardation, anhedonia, indecision, and suicidal thoughts. Which goal of nursing care should have highest priority? You Selected: • Use measures to protect the client from harming himself. Correct response: • Use measures to protect the client from harming himself. Explanation: Remediation: Add a Note Question 86 See full question 2s Report this Question Which safeguard should the nurse take to ensure accuracy of a telephone order? You Selected: • Repeat the order to the prescriber. Correct response: • Repeat the order to the prescriber. Explanation: Remediation: Add a Note Question 87 See full question 1s Report this Question The client has been taking clomipramine for his obsessive-compulsive disorder. He tells the nurse, “I’m not really better, and I’ve been taking the medication faithfully for the past 3 days just like it says on this prescription bottle.” Which action should the nurse do first? You Selected: • Tell the client to continue taking the medication as prescribed because it takes 2 to 4 weeks for a full therapeutic effect. Correct response: • Tell the client to continue taking the medication as prescribed because it takes 2 to 4 weeks for a full therapeutic effect. Explanation: Add a Note Question 88 See full question 2s Report this Question A nurse is admitting a client with a possible diagnosis of PTSD (posttraumatic stress disorder). Which statement by the client most accurately describes PTSD? You Selected: • "I feel so angry, guilty and humiliated that this has happened to me." Correct response: • "I have these flashbacks and recurring dreams about the event so often." Explanation: Remediation: Add a Note Question 89 See full question 3s Report this Question An adolescent presents to the emergency department after a motor vehicle accident. Police inform the parent that the client was thrown from the vehicle, was not wearing a seatbelt, and they believe the client was driving while under the influence of alcohol. The health care provider updates the parent that the adolescent has a