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•A client had 20 mg of Lasix (furosemide) PO at 10 AM. Which would be
essential for the nurse to include at the change of shift report?
A) The client lost 2 pounds in 24 hours
,NURSING 11456 NCSBN QUESTIONS & ANSWERS BEST
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B) The client’s potassium level is 4 mEq/liter.
C) The client’s urine output was 1500 cc in 5 hours
D) The client is to receive another dose of Lasix at 10 PM
C: The client’s urine output was 1500 cc in 5 hours. Although all of these may
be correct information to include in report, the essential piece would be the
urine output.
• A client has been tentatively diagnosed with Graves' disease (hyperthyroidism).
Which of these findings noted on the initial nursing assessment requires quick
intervention by the nurse?
A) a report of 10 pounds weight loss in the last month
B) a comment by the client "I just can't sit still."
C) the appearance of eyeballs that appear to "pop" out of the client's eye
sockets
D) a report of the sudden onset of irritability in the past 2 weeks
C: the appearance of eyeballs that appear to "pop" out of the client''s eye
sockets. Exophthalmos or protruding eyeballs is a distinctive characteristic of
Graves'' Disease. It can result in corneal abrasions with severe eye pain or
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damage when the eyelid is unable to blink down over the protruding eyeball.
Eye drops or ointment may be needed.
• The nurse has performed the initial assessments of 4 clients admitted with
an acute episode of asthma. Which assessment finding would cause the nurse
to call the provider immediately?
A) prolonged inspiration with each breath
B) expiratory wheezes that are suddenly absent in 1 lobe
C) expectoration of large amounts of purulent mucous
D) appearance of the use of abdominal muscles for breathing
B: expiratory wheezes that are suddenly absent in 1 lobe. Acute asthma is
characterized by expiratory wheezes caused by obstruction of the airways.
Wheezes are a high pitched musical sounds produced by air moving through
narrowed airways. Clients often associate wheezes with the feeling of tightness
in the chest. However, sudden cessation of wheezing is an ominous or bad sign
that indicates an emergency -- the small airways are now collapsed.
• During the initial home visit, a nurse is discussing the care of a client newly
diagnosed with Alzheimer's disease with family members. Which of these
interventions would be most helpful at this time?
A) leave a book about relaxation techniques
B) write out a daily exercise routine for them to assist the client to do
C) list actions to improve the client's daily nutritional intake
D) suggest communication strategies
D: suggest communication strategies. Alzheimer''s disease, a progressive
chronic illness, greatly challenges caregivers. The nurse can be of greatest
assistance in helping the family to use communication strategies to enhance
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EXAM SOLUTION ALL ANSWERS GUARANTEED
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their ability to relate to the client. By use of select verbal and nonverbal
communication strategies the family can best support the client’s strengths
and cope with any aberrant behavior.
• A client has been hospitalized after an automobile accident. A full leg cast was
applied in the emergency room. The most important reason for the nurse to
elevate the casted leg is to
A) Promote the client's comfort
B) Reduce the drying time
C) Decrease irritation to the skin
D) Improve venous return
D: Improve venous return. Elevating the leg both improves venous return and
reduces swelling. Client comfort will be improved as well.
• The nurse is reviewing with a client how to collect a clean catch urine
specimen. What is the appropriate sequence to teach the client?
A) Clean the meatus, begin voiding, then catch urine stream
B) Void a little, clean the meatus, then collect specimen
C) Clean the meatus, then urinate into container
D) Void continuously and catch some of the urine
A: Clean the meatus, begin voiding, then catch urine stream. A clean catch
urine is difficult to obtain and requires clear directions. Instructing the client
to carefully clean the meatus, then void naturally with a steady stream
prevents surface bacteria from contaminating the urine specimen. As starting
and stopping flow can be difficult, once the client begins voiding it’s best to
just slip the container into the stream. Other responses do not reflect correct
technique