TRAINER 5
The nurse prepares a patient for an 8:00 AM outpatient electroconvulsive (ECT) treatment. Which of the
following questions is MOST important for the nurse to ask?
1. "Did you have anything to eat or drink before you came in today?"
2. "Have you had any headaches since your last treatment?"
3. "Who came with you to the hospital today?"
4. "Have you had much memory loss since you began your treatments?" (1) correct—client given general
anesthesia for ECT; NPO after midnight
(2) not relevant to ECT
(3) not most important
(4) memory loss is an expected outcome
A client is diagnosed with a flaccid bladder following a spinal cord injury. The nurse teaches the client
about dietary changes. Which of the following beverages, if selected by the client, indicates to the nurse
that teaching is effective?
Select all that apply.
1. Lemonade.
2. Prune juice.
3. Milk.
4. Orange juice.
5. Cranberry juice.
6. Tomato juice. (1) promotes alkaline urine; should also avoid citrus juices, excessive amounts of
milk, and carbonated beverages
(2) correct—promotes acidic urine, minimizes risk of urinary tract infection and stone formation; also use
cranberry, tomato juice, bouillon
,(3) excessive amounts of milk promote alkaline urine
(4) promotes alkaline urine; should also avoid citrus juices, excessive amounts of milk, and carbonated
beverages
(5) correct—promotes acidic urine, minimizes risk of urinary tract infection and stone formation; also use
cranberry, tomato juice, bouillon
(6) correct—promotes acidic urine, minimizes risk of urinary tract infection and stone formation; also use
cranberry, tomato juice, bouillon
The nurse cares for a client with a long history of alcohol and drug dependence. It is MOST important for
the nurse to include which of the following as part of the discharge planning?
1. Refer to a social service agency for assistance with housing.
2. Refer to an aftercare center in the community.
3. Encourage participation in Alcoholics Anonymous (AA) meetings with a sponsor.
4. Ask the client to obtain a prescription for an antidepressant medication. Strategy: All answers
are implementations. Determine the outcome of each answer choice. Is it desired?
(1) may be of some help, but will not directly provide support necessary to maintain sobriety
(2) may be of some help, but will not directly provide support necessary to maintain sobriety
(3) correct—self-help groups have greatest success rate as a sustained support system in the community
(4) is information to indicate client depressed
The client comes to the clinic for hepatitis B vaccine and asks if more than one injection is necessary.
Which of the following responses by the nurse is BEST?
1. "A booster shot is required yearly."
,2. "Additional injections are given at one and six months."
3. "Repeat doses are given at two and four months."
4. "Revaccination is not required." Strategy: All answers are implementations. Determine the
outcome of each answer choice. Is it desired?
(1) yearly doses are given for flu shots, not for hepatitis B vaccine
(2) correct—hepatitis B vaccine is repeated at 1 and 6 months
(3) schedule for infant immunizations for IPV and DPT
(4) inaccurate
The nurse plans care for a client returning from surgery after a bowel resection with an IV of 0.9 % NaCl
infusing at 100 mL/h into the left wrist. Which of the following actions, if performed by the nurse, is
BEST?
1. Change the IV tubing each time a new IV solution is hung.
2. Cleanse the IV site with an alcohol swab using long strokes.
3. Limit manipulation of the cannula at the IV insertion site.
4. Adjust the drop rate to keep the total volume of IV fluids on schedule.Strategy: The topic of the
question is unstated. Read the answer choices to determine the topic. "BEST" indicates that this is a
priority question. All answers are implementations. Determine the outcome of each answer choice. Is it
desired?
(1) unnecessary, changed every 48 to 72 h
(2) should move swab in a circular motion outward
(3) correct—will prevent dislodgment of needle
(4) should give IV at rate ordered by physician, don't play "catch-up" with fluids
, The nurse notes that one of the staff members caring for clients has a watery discharge from the right
eye and the eye appears red. Which of the following actions, if taken by the nurse, is BEST?
1. Send the staff member home.
2. Assess the staff member's compliance with standard precautions.
3. Assign the staff member only to clients with chronic diseases.
4. Reassign the staff member to clean the supply closet. (1) correct—extreme tearing, redness, foreign
body sensation are symptoms of viral conjunctivitis; highly contagious; infected employees cannot work
until symptoms have resolved in 3 to 7 days
(2) restrict from patient contact and the patient's environment
(3) restrict from patient contact and the patient's environment
(4) cannot work
The nursing staff plans to use behavior modification techniques for an elderly woman who constantly
screams. Which of the following nursing assessments is necessary to establish a successful program?
1. Monitor the client's ability to complete her activities of daily living (ADL).
2. Assess the client's levels of pain and correlate it with her response to analgesia.
3. Observe the client's behavior at regular intervals to obtain baseline information related to her
screaming.
4. Ask the client why she is screaming and document it on her nursing assessment record.
Strategy: Determine what is being assessed in each answer choice and how it relates to
screaming.
(1) important because activities of daily living can contribute to the targeted behavior of screaming;
assessing only the area of ADLs does not provide comprehensive data for developing a behavior
management program
(2) important because activities of pain can contribute to the targeted behavior of screaming; assessing
only the area of pain does not provide comprehensive data for developing a behavior management
program
The nurse prepares a patient for an 8:00 AM outpatient electroconvulsive (ECT) treatment. Which of the
following questions is MOST important for the nurse to ask?
1. "Did you have anything to eat or drink before you came in today?"
2. "Have you had any headaches since your last treatment?"
3. "Who came with you to the hospital today?"
4. "Have you had much memory loss since you began your treatments?" (1) correct—client given general
anesthesia for ECT; NPO after midnight
(2) not relevant to ECT
(3) not most important
(4) memory loss is an expected outcome
A client is diagnosed with a flaccid bladder following a spinal cord injury. The nurse teaches the client
about dietary changes. Which of the following beverages, if selected by the client, indicates to the nurse
that teaching is effective?
Select all that apply.
1. Lemonade.
2. Prune juice.
3. Milk.
4. Orange juice.
5. Cranberry juice.
6. Tomato juice. (1) promotes alkaline urine; should also avoid citrus juices, excessive amounts of
milk, and carbonated beverages
(2) correct—promotes acidic urine, minimizes risk of urinary tract infection and stone formation; also use
cranberry, tomato juice, bouillon
,(3) excessive amounts of milk promote alkaline urine
(4) promotes alkaline urine; should also avoid citrus juices, excessive amounts of milk, and carbonated
beverages
(5) correct—promotes acidic urine, minimizes risk of urinary tract infection and stone formation; also use
cranberry, tomato juice, bouillon
(6) correct—promotes acidic urine, minimizes risk of urinary tract infection and stone formation; also use
cranberry, tomato juice, bouillon
The nurse cares for a client with a long history of alcohol and drug dependence. It is MOST important for
the nurse to include which of the following as part of the discharge planning?
1. Refer to a social service agency for assistance with housing.
2. Refer to an aftercare center in the community.
3. Encourage participation in Alcoholics Anonymous (AA) meetings with a sponsor.
4. Ask the client to obtain a prescription for an antidepressant medication. Strategy: All answers
are implementations. Determine the outcome of each answer choice. Is it desired?
(1) may be of some help, but will not directly provide support necessary to maintain sobriety
(2) may be of some help, but will not directly provide support necessary to maintain sobriety
(3) correct—self-help groups have greatest success rate as a sustained support system in the community
(4) is information to indicate client depressed
The client comes to the clinic for hepatitis B vaccine and asks if more than one injection is necessary.
Which of the following responses by the nurse is BEST?
1. "A booster shot is required yearly."
,2. "Additional injections are given at one and six months."
3. "Repeat doses are given at two and four months."
4. "Revaccination is not required." Strategy: All answers are implementations. Determine the
outcome of each answer choice. Is it desired?
(1) yearly doses are given for flu shots, not for hepatitis B vaccine
(2) correct—hepatitis B vaccine is repeated at 1 and 6 months
(3) schedule for infant immunizations for IPV and DPT
(4) inaccurate
The nurse plans care for a client returning from surgery after a bowel resection with an IV of 0.9 % NaCl
infusing at 100 mL/h into the left wrist. Which of the following actions, if performed by the nurse, is
BEST?
1. Change the IV tubing each time a new IV solution is hung.
2. Cleanse the IV site with an alcohol swab using long strokes.
3. Limit manipulation of the cannula at the IV insertion site.
4. Adjust the drop rate to keep the total volume of IV fluids on schedule.Strategy: The topic of the
question is unstated. Read the answer choices to determine the topic. "BEST" indicates that this is a
priority question. All answers are implementations. Determine the outcome of each answer choice. Is it
desired?
(1) unnecessary, changed every 48 to 72 h
(2) should move swab in a circular motion outward
(3) correct—will prevent dislodgment of needle
(4) should give IV at rate ordered by physician, don't play "catch-up" with fluids
, The nurse notes that one of the staff members caring for clients has a watery discharge from the right
eye and the eye appears red. Which of the following actions, if taken by the nurse, is BEST?
1. Send the staff member home.
2. Assess the staff member's compliance with standard precautions.
3. Assign the staff member only to clients with chronic diseases.
4. Reassign the staff member to clean the supply closet. (1) correct—extreme tearing, redness, foreign
body sensation are symptoms of viral conjunctivitis; highly contagious; infected employees cannot work
until symptoms have resolved in 3 to 7 days
(2) restrict from patient contact and the patient's environment
(3) restrict from patient contact and the patient's environment
(4) cannot work
The nursing staff plans to use behavior modification techniques for an elderly woman who constantly
screams. Which of the following nursing assessments is necessary to establish a successful program?
1. Monitor the client's ability to complete her activities of daily living (ADL).
2. Assess the client's levels of pain and correlate it with her response to analgesia.
3. Observe the client's behavior at regular intervals to obtain baseline information related to her
screaming.
4. Ask the client why she is screaming and document it on her nursing assessment record.
Strategy: Determine what is being assessed in each answer choice and how it relates to
screaming.
(1) important because activities of daily living can contribute to the targeted behavior of screaming;
assessing only the area of ADLs does not provide comprehensive data for developing a behavior
management program
(2) important because activities of pain can contribute to the targeted behavior of screaming; assessing
only the area of pain does not provide comprehensive data for developing a behavior management
program
