answered 2023 2024
A nurse is teaching a client how to self-administer insulin. Which of the following actions should the
nurse take to evaluate the client's understanding of the process within the psychomotor domain of
learning. - answer Have the client demonstrates the procedure.
Having the client demonstrate the procedure provides the nurse the ability to evaluate the client's
understanding within the psychomotor domain of learning.
A nurse is preparing to administer a cleansing enema to a client. Which of the following actions should
the nurse plan to take? - answer Position the client on his left side.
Positioning is an important aspect of administering an enema. Having the client lie on his left side
facilitates the flow of the enema solution into the sigmoid and descending colon.
A client who reports shortness of breath requests her nurse's help in changing positions. After
repositioning the client, which of the following actions should the nurse take next? - answer Observe the
rate, depth, and character of the client's respirations.
The nurse should apply the nursing process priority-setting framework when caring for this client. The
nurse can use the nursing process to plan client care and prioritize nursing actions. Each step of the
nursing process builds on the previous step, beginning with assessment or data collection. Before the
nurse can formulate a plan of action, implement a nursing intervention, or notify a provider of a change
in the client's status, the nurse must first collect adequate data from the client. Assessing or collecting
additional data will provide the nurse with knowledge to make an appropriate decision; therefore, the
first action the nurse should take is to assess the client's respiratory status.
A nurse is caring for a client who has bilateral casts on her hands. Which of the following actions should
the nurse take when assisting the client with feeding? - answer Sit at the bedside while feeding the
client.
, The nurse should avoid appearing to be in a hurry. Sitting at the bedside provides the client with the
nurse's full attention during the feeding.
A nurse is caring for a client who, while sitting in a chair, starts to experience a seizure. Which of the
following actions should the nurse take? - answer Lower the client to the floor and place a pad under
the clients head.
To reduce the risk of injury to the client, the nurse should lower the client to the floor and place a pillow
or other soft object under the client's head.
A home health nurse is planning to provide health promotion activities for a group of clients in the
community. Which of the following activities is an example of the nurse promoting primary prevention?
- answer Educating clients about the recommended immunization schedule for adults.
Primary prevention includes health education about disease prevention.
An assistive personnel (AP) is assisting a nurse with the care of a female client who has an indwelling
urinary catheter. Which of the following actions by the AP indicates for further teaching? - answer The
AP hangs the collection bag at the level of the bladder.
The AP should place the drainage bag below the level of the bladder to ensure proper drainage by
gravity.
A nurse is performing a neurological assessment for a client. Which of the following examinations should
the nurse use to check the client's balance? - answer Romberg Test
When using the Romberg test, the nurse instructs the client to stand with his feet together and arms at
sides, first with his eyes open and then with eyes closed. The inability to maintain balance is a positive
Romberg test.
A nurse is providing discharge teaching to a client who is recovering from lung cancer. The provider
instructed the client that he could resume lower-intensity activities of daily living. Which of the following
activities should the nurse recommend to the client? - answer Washing dishes