response) Answered 100% Correct
1. A nurse in an extended-care facility is reinforcing teaching for with a group of
newly licensed nurses about the expected physiologic changes of aging. Which
of the following information should the nurse include? (Select all that apply.)
A. More difficulty seeing due to a greater sensitivity to glare
B. Decreased cough reflex
C. Decreased bladder capacity
D. Decreased systolic blood pressure
E. Dehydration of intervertebral discs
ABCE
2. A nurse is caring for an older adult client who has confusion and weakness.
The client has a Hct of 53%, a BUN of 25 mg/dL, and a urine specific gravity of
1.232. Which of the following actions should the nurse contribute to the
client's plan of care? (Select all that apply.)
A. Restrict the client's fluid intake.
B. Monitor the client's intake and output.
C. Weigh the client daily.
D. Instruct the client to sit on the side of the bed for a few minutes before
standing.
E. Check the client's orientation to person, place, and time regularly.
BCDE
3. A nurse is collecting data from a client who has Bell's palsy. Which of the
following findings should the nurse expect? (Select all that apply.)
A. Muscle distortion
B. Pain behind the ear
C. Hearing loss
D. Facial twitching
E. Impaired taste
ABE
4. A nurse is caring for a group of clients. For which of the following tasks should
the nurse wear gloves? (Select all that apply.)
A. Emptying urine from an indwelling urinary catheter collection bag.
B. Providing oral care.
C. Changing an ostomy pouch.
D. Delivering a food tray to a client who has AIDS.
E. Placing oral medication tablets into a client's hand.
ABC
,5. A nurse is caring for a group of clients. For which of the following tasks should
the nurse plan to wear protective eye equipment? (Select all that apply.)
A. Giving personal care to an infant who is HIV-positive
B. Providing a newborn's first bath
C) Withdrawing cord blood from a neonate
D. Transporting a cerebral spinal fluid specimen to the laboratory
E.) Suctioning secretions from a child's newly placed tracheostomy tube
CE
6 A nurse is monitoring a client for complications of immobility. Which of the
following findings should the nurse expect? (Select all that apply.)
A. Contractures of extremities
B. Hypertension
C. Diarrhea
D. Crackles in the lungs
E. Pressure ulcers
ADE
7. A nurse is collecting data from a client who has diabetes melitus and reports
foot pain. The nurse should evaluate the client for which of the following
alterations as indications that the client has an infection? (select all that apply)
A. Bradycardia
B. An increase in neutrophils
C. An increase in RBCs
D. An increase in platelets
E. Localized edema
BE
8. A nurse is reinforcing teaching with a client has reports constipation. Which of
the following should the nurse discuss as causes of constipation? (Select all that
apply.)
A. Excessive laxative use
B. Ignoring the urge to defecate
C. Inadequate fluid intake
D. Increased fiber in the diet
E. Increased activity
ABC
9. A nurse is caring for a client who is postoperative. When helping to manage the
client's pain, which of the following principles should the nurse apply? (Select all
that apply.)
A. Administer opioids with caution because they will eventually lead to addiction.
B. Consider the client's individual expression of pain.
C. To achieve fast-acting pain relief, administer analgesics PO.
, D. Use a scale from O to 10 to monitor the severity of the client's pain.
E. Expect the client to express his pain both verbally and nonverbally.
BD
10.A nurse is collecting data from a client who has narcolepsy. Which of the
following manifestations should the expect? (Select all that apply).
A. Feeling extremely tired upon waking
B. Sudden attacks of sleep
C. Sleep-wake cycle hallucinations
D. Sleep apnea
E. Urge to move the legs when trying to sleep
BC
11. A nurse is providing hygiene care for a client who is immobilized. Which of
the following actions should the take? (Select all that apply.)
A. Check the bed linens when removing them for personal items.
B. Place a clean gown on the strongest arm first.
C. Keep the bath water's temperature between 43.3°C (110° F) and 46.1° C (115°
F).
D.Shave the client's hair in the direction of the hair growth.
E. Wash the client's extremities from proximal to distal.
ACD
12. A nurse is discussing indications for urinary catheterization with a newly
licensed nurse. Which of following indications should the nurse include? (Select
all that apply.)
A. Relief of urinary retention
B. Convenience for the nursing staff or the client's family
C. Measurement of residual urine after urination
D. Routine acquisition of a urine specimen
E. Presence of an open perineal wound
ACE
13.A nurse in an urgent care center is caring for a client who fell and injured her
ankle. The ankle appears swollen and ecchymotic. While the client waits for the X-
ray technician, which of the following actions should the nurse take? (Select all
that apply.)
A. Apply ice to the ankle.
B. Encourage range-of-motion exercises of the foot.
C. Provide the client with a light snack.
D. Apply a compression bandage.
E. Elevate the foot.