Evolve HESI Fundamentals Questions And Answers Verified An Updated.

Evolve HESI Fundamentals Questions And Answers Verified An Updated. Urinary xcatheterization xis xprescribed xfor xa xpostoperative xfemale xclient xwho xhas xbeen xunable xto xvoid xfor x8 xhours. xThe xnurse xinserts xthe xcatheter, xbut xno xurine xis xseen xin xthe xtubing. xWhich xaction xwill xthe xnurse xtake xnext? A. xClamp xthe xcatheter xand xrecheck xit xin x60 xminutes. B. xPull xthe xcatheter xback x3 xinches xand xredirect xupward. C. xLeave xthe xcatheter xin xplace xand xreattempt xwith xanother xcatheter. D. xNotify xthe xhealth xcare xprovider xof xa xpossible xobstruction. x- xcorrect xanswers. xAnswer: xC It xis xlikely xthat xthe xfirst xcatheter xis xin xthe xvagina, xrather xthan xthe xbladder. xLeaving xthe xfirst xcatheter xin xplace xwill xhelp xlocate xthe xmeatus xwhen xattempting xthe xsecond xcatheterization x(C). xThe xclient xshould xhave xat xleast x240 xmL xof xurine xafter x8 xhours. x(A) xdoes xnot xresolve xthe xproblem. x(B) xwill xnot xchange xthe xlocation xof xthe xcatheter xunless xit xis xcompletely xremoved, xin xwhich xcase xa xnew xcatheter xmust xbe xused. xThere xis xno xevidence xof xa xurinary xtract xobstruction xif xthe xcatheter xcould xbe xeasily xinserted x(D). The xnurse xis xteaching xan xobese xclient, xnewly xdiagnosed xwith xarteriosclerosis, xabout xreducing xthe xrisk xof xa xheart xattack xor xstroke. xWhich xhealth xpromotion xbrochure xis xmost ximportant xfor xthe xnurse xto xprovide xto xthis xclient? A. x"Monitoring xYour xBlood xPressure xat xHome" B. x"Smoking xCessation xas xa xLifelong xCommitment" C. x"Decreasing xCholesterol xLevels xThrough xDiet" D. x"Stress xManagement xfor xa xHealthier xYou" x- xcorrect xanswers. xAnswer: xC A xhealth xpromotion xbrochure xabout xdecreasing xcholesterol x(C) xis xmost ximportant xto xprovide xthis xclient, xbecause xthe xmost xsignificant xrisk xfactor xcontributing xto xdevelopment xof xarteriosclerosis xis xexcess xdietary xfat, xparticularly xsaturated xfat xand xcholesterol. x(A) xdoes xnot xaddress xthe xunderlying xcauses xof xarteriosclerosis. x(B xand xD) xare xalso ximportant xfactors xfor xreversing xarteriosclerosis xbut xare xnot xas ximportant xas xlowering xcholesterol x(C). Ten xminutes xafter xsigning xan xoperative xpermit xfor xa xfractured xhip, xan xolder xclient xstates, x"The xaliens xwill xbe xcoming xto xget xme xsoon!" xand xfalls xasleep. xWhich xaction xshould xthe xnurse ximplement xnext? A. xMake xthe xclient xcomfortable xand xallow xthe xclient xto xsleep. B. xAssess xthe xclient's xneurologic xstatus. C. xNotify xthe xsurgeon xabout xthe xcomment. D. xAsk xthe xclient's xfamily xto xco-sign xthe xoperative xpermit. x- xcorrect xanswers. xAnswer: xB This xstatement xmay xindicate xthat xthe xclient xis xconfused. xInformed xconsent xmust xbe xprovided xby xa xmentally xcompetent xindividual, xso xthe xnurse xshould xfurther xassess xthe xclient's xneurologic xstatus x(B) xto xbe xsure xthat xthe xclient xunderstands xand xcan xlegally xprovide xconsent xfor xsurgery. x(A) xdoes xnot xprovide xsufficient xfollow-up. xIf xthe xnurse xdetermines xthat xthe xclient xis xconfused, xthe xsurgeon xmust xbe xnotified x(C) xand xpermission xobtained xfrom xthe xnext xof xkin x(D). The xnurse-manager xof xa xskilled xnursing x(chronic xcare) xunit xis xinstructing xUAPs xon xways xto xprevent xcomplications xof ximmobility. xWhich xintervention xshould xbe xincluded xin xthis xinstruction? A. xPerform xrange-of-motion xexercises xto xprevent xcontractures. B. xDecrease xthe xclient's xfluid xintake xto xprevent xdiarrhea. C. xMassage xthe xclient's xlegs xto xreduce xembolism xoccurrence. D. xTurn xthe xclient xfrom xside xto xback xevery xshift. x- xcorrect xanswers. xAnswer: xA Performing xrange-of-motion xexercises x(A) xis xbeneficial xin xreducing xcontractures xaround xjoints. x(B, xC, xand xD) xare xall xpotentially xharmful xpractices xthat xplace xthe ximmobile xclient xat xrisk xof xcomplications. The xnurse xis xassisting xa xclient xto xthe xbathroom. xWhen xthe xclient xis x5 xfeet xfrom xthe xbathroom xdoor, xhe xstates, x"I xfeel xfaint." xBefore xthe xnurse xcan xget xthe xclient xto xa xchair, xthe xclient xstarts xto xfall. xWhich xis xthe xpriority xaction xfor xthe xnurse xto xtake? A. xCheck xthe xclient's xcarotid xpulse. B. xEncourage xthe xclient xto xget xto xthe xtoilet. C. xIn xa xloud xvoice, xcall xfor xhelp. D. xGently xlower xthe xclient xto xthe xfloor. x- xcorrect xanswers. xAnswer: xD (D) xis xthe xmost xprudent xintervention xand xis xthe xpriority xnursing xaction xto xprevent xinjury xto xthe xclient xand xthe xnurse. xLowering xthe xclient xto xthe xfloor xshould xbe xdone xwhen xthe xclient xcannot xsupport xhis xown xweight. xThe xclient xshould xbe xplaced xin xa xbed xor xchair xonly xwhen xsufficient xhelp xis xavailable xto xprevent xinjury. x(A) xis ximportant xbut xshould xbe xdone xafter xthe xclient xis xin xa xsafe xposition. xBecause xthe xclient xis xnot xsupporting xhimself, x(B) xis ximpractical. x(C) xis xlikely xto xcause xchaos xon xthe xunit xand xmight xalarm xthe xother xclients. A xfemale xnurse xis xassigned xto xcare xfor xa xclose xfriend, xwho xsays, x"I xam xworried xthat xfriends xwill xfind xout xabout xmy xdiagnosis." xThe xnurse xtells xher xfriend xthat xlegally xshe xmust xprotect xa xclient's xconfidentiality. xWhich xresource xdescribes xthe xnurse's xlegal xresponsibilities? A. xCode xof xEthics xfor xNurses B. xState xNurse xPractice xAct C. xPatient's xBill xof xRights D. xANA xStandards xof xPractice x- xcorrect xanswers. xAnswer: xB The xState xNurse xPractice xAct x(B) xcontains xlegal xrequirements xfor xthe xprotection xof xclient xconfidentiality xand xthe xconsequences xfor xbreaches xin xconfidentiality. x(A) xoutlines xethical xstandards xfor xnursing xcare xbut xdoes xnot xinclude xlegal xguidelines. x(C xand xD) xdescribe xexpectations xfor xnursing xpractice xbut xdo xnot xaddress xlegal ximplications. The xnurse xis xteaching xa xclient xhow xto xperform xprogressive xmuscle xrelaxation xtechniques xto xrelieve xinsomnia. xA xweek xlater xthe xclient xreports xthat xhe xis xstill xunable xto xsleep, xdespite xfollowing xthe xsame xroutine xevery xnight. xWhich xaction xshould xthe xnurse xtake xfirst? A. xInstruct xthe xclient xto xadd xregular xexercise xas xa xdaily xroutine. B. xDetermine xif xthe xclient xhas xbeen xkeeping xa xsleep xdiary. C. xEncourage xthe xclient xto xcontinue xthe xroutine xuntil xsleep xis xachieved. D. xAsk xthe xclient xto xdescribe xthe xroutine xthat xthe xclient xis xcurrently xfollowing. x- xcorrect xanswers. xAnswer: xD The xnurse xshould xfirst xevaluate xwhether xthe xclient xhas xbeen xadhering xto xthe xoriginal xinstructions x(D). xA xverbal xreport xof xthe xclient's xroutine xwill xprovide xmore xspecific xinformation xthan xthe xclient's xwritten xdiary x(B). xThe xnurse xcan xthen xdetermine xwhich xchanges xneed xto xbe xmade x(A). xThe xroutine xpracticed xby xthe xclient xis xclearly xunsuccessful, xso xencouragement xalone xis xinsufficient x(C). A x65-year-old xclient xwho xattends xan xadult xdaycare xprogram xand xis xwheelchair-mobile xhas xredness xin xthe xsacral xarea. xWhich xinstruction xis xmost ximportant xfor xthe xnurse xto xprovide? A. xTake xa xvitamin xsupplement xtablet xonce xa xday. B. xChange xpositions xin xthe xchair xat xleast xevery xhour. C. xIncrease xdaily xintake xof xwater xor xother xoral xfluids. D. xPurchase xa xnewer xmodel xwheelchair. x- xcorrect xanswers. xAnswer: xB The xmost ximportant xteaching xis xto xchange xpositions xfrequently x(B) xbecause xpressure xis xthe xmost xsignificant xfactor xrelated xto xthe xdevelopment xof xpressure xulcers. xIncreased xvitamin xand xfluid xintake x(A xand xC) xmay xalso xbe xbeneficial xpromote xhealing xand xreduce xfurther xrisk. x(D) xis xan xintervention xof xlast xresort xbecause xthis xwill xbe xvery xexpensive xfor xthe xclient. When xturning xan ximmobile xbedridden xclient xwithout xassistance, xwhich xaction xby xthe xnurse xbest xensures xclient xsafety? A. xSecurely xgrasp xthe xclient's xarm xand xleg. B. xPut xbed xrails xup xon xthe xside xof xbed xopposite xfrom xthe xnurse. C. xCorrectly xposition xand xuse xa xturn xsheet. D. xLower xthe xhead xof xthe xclient's xbed xslowly. x- xcorrect xanswers. xAnswer: xB Because xthe xnurse xcan xonly xstand xon xone xside xof xthe xbed, xbed xrails xshould xbe xup xon xthe xopposite xside xto xensure xthat xthe xclient xdoes xnot xfall xout xof xbed x(B). x(A) xcan xcause xclient xinjury xto xthe xskin xor xjoint. x(C xand xD) xare xuseful xtechniques xwhile xturning xa xclient xbut xhave xless xpriority xin xterms xof xsafety xthan xuse xof xthe xbed xrails. A xfemale xclient xwith xfrequent xurinary xtract xinfections x(UTIs) xasks xthe xnurse xto xexplain xher xfriend's xadvice xabout xdrinking xa xglass xof xjuice xdaily xto xprevent xfuture xUTIs. xWhich xresponse xis xbest xfor xthe xnurse xprovide? A. xOrange xjuice xhas xvitamin xC xthat xdeters xbacterial xgrowth. B. xApple xjuice xis xthe xmost xuseful xin xacidifying xthe xurine. C. xCranberry xjuice xstops xpathogens' xadherence xto xthe xbladder. D. xGrapefruit xjuice xincreases xabsorption xof xmost xantibiotics. x- xcorrect xanswers. xAnswer: xC Cranberry xjuice x(C) xmaintains xurinary xtract xhealth xby xreducing xthe xadherence xof xEscherichia xcoli xbacteria xto xcells xwithin xthe xbladder. x(A, xB, xand xD) xhave xnot xbeen xshown xto xbe xas xeffective xas xcranberry xjuice x(C) xin xpreventing xUTIs. The xnurse xis xaware xthat xmalnutrition xis xa xcommon xproblem xamong xclients xserved xby xa xcommunity xhealth xclinic xfor xthe xhomeless. xWhich xlaboratory xvalue xis xthe xmost xreliable xindicator xof xchronic xprotein xmalnutrition? A. xLow xserum xalbumin xlevel B. xLow xserum xtransferrin xlevel C. xHigh xhemoglobin xlevel D. xHigh xcholesterol xlevel x- xcorrect xanswers. xAnswer: xA Long-term xprotein xdeficiency xis xrequired xto xcause xsignificantly xlowered xserum xalbumin xlevels x(A). xAlbumin xis xmade xby xthe xliver xonly xwhen xadequate xamounts xof xamino xacids x(from xprotein xbreakdown) xare xavailable. xAlbumin xhas xa xlong xhalf-life, xso xacute xprotein xloss xdoes xnot xsignificantly xalter xserum xlevels. x(B) xis xa xserum xprotein xwith xa xhalf-life xof xonly x8 xto x10 xdays, xso xit xwill xdrop xwith xan xacute xprotein xdeficiency. xNeither x(C xor xD) xare xclinical xmeasures xof xprotein xmalnutrition. The xnurse xidentifies xa xpotential xfor xinfection xin xa xpatient xwith xpartial-thickness x(second-degree) xand xfull-thickness x(third-degree) xburns. xWhat xintervention xhas xthe xhighest xpriority xin xdecreasing xthe xclient's xrisk xof xinfection? A. xAdministration xof xplasma xexpanders B. xUse xof xcareful xhand xwashing xtechnique C. xApplication xof xa xtopical xantibacterial xcream D. xLimiting xvisitors xto xthe xclient xwith xburns x- xcorrect xanswers. xAnswer: xB Careful xhand xwashing xtechnique x(B) xis xthe xsingle xmost xeffective xintervention xfor xthe xprevention xof xcontamination xto xall xclients. x(A) xreverses xthe xhypovolemia xthat xinitially xaccompanies xburn xtrauma xbut xis xnot xrelated xto xdecreasing xthe xproliferation xof xinfective xorganisms. x(C xand xD) xare xrecommended xby xvarious xburn xcenters xas xpossible xways xto xreduce xthe xchance xof xinfection. x(B) xis xa xproven xtechnique xto xprevent xinfection. Which xserum xlaboratory xvalue xshould xthe xnurse xmonitor xcarefully xfor xa xclient xwho xhas xa xnasogastric x(NG) xtube xto xsuction xfor xthe xpast xweek? A. xWhite xblood xcell xcount B. xAlbumin C. xCalcium D. xSodium x- xcorrect xanswers. xAnswer: xD Monitoring xserum xsodium xlevels x(D) xfor xhyponatremia xis xindicated xduring xprolonged xNG xsuctioning xbecause xof xloss xof xfluids. xChanges xin xlevels xof x(A, xB, xor xC) xare xnot xtypically xassociated xwith xprolonged xNG xsuctioning. In xcompleting xa xclient's xpreoperative xroutine, xthe xnurse xfinds xthat xthe xoperative xpermit xis xnot xsigned. xThe xclient xbegins xto xask xmore xquestions xabout xthe xsurgical xprocedure. xWhich xaction xshould xthe xnurse xtake xnext? A. xWitness xthe xclient's xsignature xto xthe xpermit. B. xAnswer xthe xclient's xquestions xabout xthe xsurgery. C. xInform xthe xsurgeon xthat xthe xoperative xpermit xis xnot xsigned xand xthe xclient xhas xquestions xabout xthe xsurgery. D. xReassure xthe xclient xthat xthe xsurgeon xwill xanswer xany xquestions xbefore xthe xanesthesia xis xadministered. x- xcorrect xanswers. xAnswer: xC The xsurgeon xshould xbe xinformed ximmediately xthat xthe xpermit xis xnot xsigned x(C). xIt xis xthe xsurgeon's xresponsibility xto xexplain xthe xprocedure xto xthe xcliesxnt xand xobtain xthe xclient's xsignature xon xthe xpermit. xAlthough xthe xnurse xcan xwitness xan xoperative xpermit x(A), xthe xprocedure xmust xfirst xbe xexplained xby xthe xhealth xcare xprovider xor xsurgeon, xincluding xanswering xthe xclient's xquestions x(B). xThe xclient's xquestions xshould xbe xaddressed xbefore xthe xpermit xis xsigned x(D). The xnurse xis xpreparing xan xolder xclient xfor xdischarge. xWhich xmethod xis xbest xfor xthe xnurse xto xuse xwhen xevaluating xthe xclient's xability xto xperform xa xdressing xchange xat xhome? A. xDetermine xhow xthe xclient xfeels xabout xchanging xthe xdressing. B. xAsk xthe xclient xto xdescribe xthe xprocedure xin xwriting. C. xSeek xa xfamily xmember's xevaluation xof xthe xclient's xability xto xchange xthe xdressing. D. xObserve xthe xclient xchange xthe xdressing xunassisted. x- xcorrect xanswers. xAnswer: xD Observing xthe xclient xdirectly x(D) xwill xallow xthe xnurse xto xdetermine xif xmastery xof xthe xskill xhas xbeen xobtained xand xprovide xan xopportunity xto xaffirm xthe xskill. x(A) xmay xbe xtherapeutic xbut xwill xnot xprovide xan xopportunity xto xevaluate xthe xclient's xability xto xperform xthe xprocedure. x(B) xmay xbe xthreatening xto xan xolder xclient xand xwill xnot xdetermine xhis xability. x(C) xis xnot xas xeffective xas xdirect xobservation xby xthe xnurse. A xclient xin xa xlong-term xcare xfacility xreports xto xthe xnurse xthat xhe xhas xnot xhad xa xbowel xmovement xin x2 xdays. xWhich xintervention xshould xthe xnurse ximplement xfirst? A. xInstruct xthe xcaregiver xto xoffer xa xglass xof xwarm xprune xjuice xat xmealtimes. B. xNotify xthe xhealth xcare xprovider xand xrequest xa xprescription xfor xa xlarge-volume xenema. C. xAssess xthe xclient's xmedical xrecord xto xdetermine xthe xclient's xnormal xbowel xpattern. D. xInstruct xthe xcaregiver xto xincrease xthe xclient's xfluids xto xfive x8-ounce xglasses xper xday. x- xcorrect xanswers. xAnswer: xC This xclient xmay xnot xroutinely xhave xa xdaily xbowel xmovement, xso xthe xnurse xshould xfirst xassess xthis xclient's xnormal xbowel xhabits xbefore xattempting xany xintervention x(C). x(A, xB, xor xD) xmay xthen xbe ximplemented, xif xwarranted. The xnurse xis xinstructing xa xclient xwith xcholecystitis xregarding xdiet xchoices. xWhich xmeal xbest xmeets xthe xdietary xneeds xof xthis xclient? A. xSteak, xbaked xbeans, xand xa xsalad B. xBroiled xfish, xgreen xbeans, xand xan xapple C. xPork xchops, xmacaroni xand xcheese, xand xgrapes D. xAvocado xsalad, xmilk, xand xangel xfood xcake x- xcorrect xanswers. xAnswer: xB Clients xwith xcholecystitis x(inflammation xof xthe xgallbladder) xshould xfollow xa xlow-fat xdiet, xsuch xas x(B). x(A) xis xa xhigh-protein xdiet xand x(C xand xD) xcontain xhigh-fat xfoods, xwhich xare xcontraindicated xfor xthis xclient. When xbathing xan xuncircumcised xboy xolder xthan x3 xyears, xwhich xaction xshould xthe xnurse xtake? A. xRemind xthe xchild xto xclean xhis xgenital xarea. B. xDefer xperineal xcare xbecause xof xthe xchild's xage. C. xRetract xthe xforeskin xgently xto xcleanse xthe xpenis. D. xAsk xthe xparents xwhy xthe xchild xis xnot xcircumcised. x- xcorrect xanswers. xAnswer: xC The xforeskin x(prepuce) xof xthe xpenis xshould xbe xgently xretracted xto xcleanse xall xareas xthat xcould xharbor xbacteria x(C). xThe xchild's xcognitive xdevelopment xmay xnot xbe xat xthe xlevel xat xwhich x(A) xwould xbe xeffective. xPerineal xcare xneeds xto xbe xprovided xdaily xregardless xof xthe xclient's xage x(B). x(D) xis xnot xindicated xand xmay xbe xperceived xas xintrusive. The xnurse xwho xis xpreparing xto xgive xan xadolescent xclient xa xprescribed xantipsychotic xmedication xnotes xthat xparental xconsent xhas xnot xbeen xobtained. xWhich xaction xshould xthe xnurse xtake? A. xReview xthe xchart xfor xa xsigned xconsent xfor xhospitalization. B. xGet xthe xhealth xcare xprovider's xpermission xto xgive xthe xmedication. C. xDo xnot xgive xthe xmedication xand xdocument xthe xreason. D. xComplete xan xincident xreport xand xnotify xthe xparents. x- xcorrect xanswers. xAnswer: xC The xnurse xshould xnot xgive xthe xmedication xand xshould xdocument xthe xreason x(C) xbecause xthe xclient xis xa xminor xand xneeds xa xguardian's xpermission xto xreceive xmedications. xPermission xto xgive xmedications xis xnot xgranted xby xa xsigned xhospital xconsent x(A) xor xa xhealth xcare xprovider's xpermission x(B), xunless xconditions xare xmet xto xjustify xcoerced xtreatment. x(D) xis xnot xnecessary xunless xthe xmedication xhad xpreviously xbeen xadministered. A xnurse xis xworking xin xan xoccupational xhealth xclinic xwhen xan xemployee xwalks xin xand xstates xthat xhe xwas xstruck xby xlightning xwhile xworking xin xa xtruck xbed. xThe xclient xis xalert xbut xreports xfeeling xfaint. xWhich xassessment xwill xthe xnurse xperform xfirst? A. xPulse xcharacteristics B. xOpen xairway C. xEntrance xand xexit xwounds D. xCervical xspine xinjury x- xcorrect xanswers. xAnswer: xA Lightning xis xa xjolt xof xelectrical xcurrent xand xcan xproduce xa x"natural" xdefibrillation, xso xassessment xof xthe xpulse xrate xand xregularity x(A) xis xa xpriority. xBecause xthe xclient xis xtalking, xhe xhas xan xopen xairway x(B), xso xthat xassessment xis xnot xnecessary. xAssessing xfor x(C xand xD) xshould xoccur xafter xassessing xfor xadequate xcirculation. The xmental xhealth xnurse xplans xto xdiscuss xa xclient's xdepression xwith xthe xhealth xcare xprovider xin xthe xemergency xdepartment. xThere xare xtwo xclients xsitting xacross xfrom xthe xemergency xdepartment xdesk. xWhich xnursing xaction xis xbest? A. x Only xrefer xto xthe xclient xby xgender. xB. x Identify xthe xclient xonly xby xage. xC. x Avoid xusing xthe xclient's xname. xD. x Discuss xthe xclient xanother xtime. x- xcorrect xanswers. xAnswer: xD The xbest xnursing xaction xis xto xdiscuss xthe xclient xanother xtime x(D). xConfidentiality xmust xbe xobserved xat xall xtimes, xso xthe xnurse xshould xnot xdiscuss xthe xclient xwhen xthe xconversation xcan xbe xoverheard xby xothers. xDetails xcan xidentify xthe xclient xwhen xreferring xto xthe xclient xby xgender x(A) xor xage x(B), xand xeven xwhen xnot xusing xthe xclient's xname x(C). The xnurse xis xassessing xseveral xclients xprior xto xsurgery. xWhich xfactor xin xa xclient's xhistory xposes xthe xgreatest xthreat xfor xcomplications xto xoccur xduring xsurgery? A. xTaking xbirth xcontrol xpills xfor xthe xpast x2 xyears B. xTaking xanticoagulants xfor xthe xpast xyear C. xRecently xcompleting xantibiotic xtherapy D. xHaving xtaken xlaxatives xPRN xfor xthe xlast x6 xmonths x- xcorrect xanswers. xAnswer: xB Anticoagulants x(B) xincrease xthe xrisk xfor xbleeding xduring xsurgery, xwhich xcan xpose xa xthreat xfor xthe xdevelopment xof xsurgical xcomplications. xThe xhealth xcare xprovider xshould xbe xinformed xthat xthe xclient xis xtaking xthese xdrugs. xAlthough xclients xwho xtake xbirth xcontrol xpills x(A) xmay xbe xmore xsusceptible xto xthe xdevelopment xof xthrombi, xsuch xproblems xusually xoccur xpostoperatively. xA xclient xwith x(C xor xD) xis xat xless xof xa xsurgical xrisk xthan x(B). When xassisting xa xclient xfrom xthe xbed xto xa xchair, xwhich xprocedure xis xbest xfor xthe xnurse xto xfollow? A. xPlace xthe xchair xparallel xto xthe xbed, xwith xits xback xtoward xthe xhead xof xthe xbed xand xassist xthe xclient xin xmoving xto xthe xchair. B. xWith xthe xnurse's xfeet xspread xapart xand xknees xaligned xwith xthe xclient's xknees, xstand xand xpivot xthe xclient xinto xthe xchair. C. xAssist xthe xclient xto xa xstanding xposition xby xgently xlifting xupward, xunderneath xthe xaxillae. D. xStand xbeside xthe xclient, xplace xthe xclient's xarms xaround xthe xnurse's xneck, xand xgently xmove xthe xclient xto xthe xchair. x- xcorrect xanswers. xAnswer: xB (B) xdescribes xthe xcorrect xpositioning xof xthe xnurse xand xaffords xthe xnurse xa xwide xbase xof xsupport xwhile xstabilizing xthe xclient's xknees xwhen xassisting xto xa xstanding xposition. xThe xchair xshould xbe xplaced xat xa x45-degree xangle xto xthe xbed, xwith xthe xback xof xthe xchair xtoward xthe xhead xof xthe xbed x(A). xClients xshould xnever xbe xlifted xunder xthe xaxillae x(C); xthis xcould xdamage xnerves xand xstrain xthe xnurse's xback. xThe xclient xshould xbe xinstructed xto xuse xthe xarms xof xthe xchair xand xshould xnever xplace xhis xor xher xarms xaround xthe xnurse's xneck x(D); xthis xplaces xundue xstress xon xthe xnurse's xneck xand xback xand xincreases xthe xrisk xfor xa xfall. The xnurse xis xinstructing xa xclient xin xthe xproper xuse xof xa xmetered-dose xinhaler. xWhich xinstruction xshould xthe xnurse xprovide xthe xclient xto xensure xthe xoptimal xbenefits xfrom xthe xdrug? A. x"Fill xyour xlungs xwith xair xthrough xyour xmouth xand xthen xcompress xthe xinhaler." B. x"Compress xthe xinhaler xwhile xslowly xbreathing xin xthrough xyour xmouth." C. x"Compress xthe xinhaler xwhile xinhaling xquickly xthrough xyour xnose." D. x"Exhale xcompletely xafter xcompressing xthe xinhaler xand xthen xinhale." x- xcorrect xanswers. xAnswer: xB The xmedication xshould xbe xinhaled xthrough xthe xmouth xsimultaneously xwith xcompression xof xthe xinhaler x(B). xThis xwill xfacilitate xthe xdesired xdestination xof xthe xaerosol xmedication xdeep xin xthe xlungs xfor xan xoptimal xbronchodilation xeffect. x(A, xC, xand xD) xdo xnot xallow xfor xdeep xlung xpenetration. The xnurse xfinds xa xclient xcrying xbehind xa xlocked xbathroom xdoor. xThe xclient xwill xnot xopen xthe xdoor. xWhich xaction xshould xthe xnurse ximplement xfirst? A. xInstruct xan xunlicensed xassistive xpersonnel x(UAP) xto xstay xand xkeep xtalking xto xthe xclient. B. xSit xquietly xin xthe xclient's xroom xuntil xthe xclient xleaves xthe xbathroom. C. xAllow xthe xclient xto xcry xalone xand xleave xthe xclient xin xthe xbathroom. D. xTalk xto xthe xclient xand xattempt xto xfind xout xwhy xthe xclient xis xcrying. x- xcorrect xanswers. xAnswer: xD The xnurse's xfirst xconcern xshould xbe xfor xthe xclient's xsafety, xso xan ximmediate xassessment xof xthe xclient's xsituation xis xneeded x(D). x(A) xis xincorrect; xthe xnurse xshould ximplement xthe xintervention. xThe xnurse xmay xoffer xto xstay xnearby xafter xfirst xassessing xthe xsituation xmore xfully x(B). xAlthough x(C) xmay xbe xcorrect, xthe xnurse xshould xdetermine xif xthe xclient's xsafety xis xcompromised xand xoffer xassistance, xeven xif xit xis xrefused. Which xstep(s) xshould xthe xnurse xtake xwhen xadministering xear xdrops xto xan xadult xclient? x(Select xall xthat xapply.) A. xPlace xthe xclient xin xa xside-lying xposition. B. xPull xthe xauricle xupward xand xoutward. C. xHold xthe xdropper x6 xcm xabove xthe xear xcanal. D. xPlace xa xcotton xball xinto xthe xinner xcanal. E. xPull xthe xauricle xdown xand xback. x- xcorrect xanswers. xAnswer: xA, xB The xcorrect xanswers x(A xand xB) xare xthe xappropriate xadministration xof xear xdrops. xThe xdropper xshould xbe xheld x1 xcm x(½ xinch) xabove xthe xear xcanal x(C). xA xcotton xball xshould xbe xplaced xin xthe xoutermost xcanal x(D). xThe xauricle xis xpulled xdown xand xback xfor xa xchild xyounger xthan x3 xyears xof xage, xbut xnot xan xadult x(E). The xnurse xis xusing xthe xGlasgow xComa xScale xto xperform xa xneurologic xassessment. xA xcomatose xclient xwinces xand xpulls xaway xfrom xa xpainful xstimulus. xWhich xaction xshould xthe xnurse xtake xnext? A. xDocument xthat xthe xclient xresponds xto xpainful xstimulus. B. xObserve xthe xclient's xresponse xto xverbal xstimulation. C. xPlace xthe xclient xon xseizure xprecautions xfor x24 xhours. D. xReport xdecorticate xposturing xto xthe xhealth xcare xprovider. x- xcorrect xanswers. xAnswer: xA The xclient xhas xdemonstrated xa xpurposeful xresponse xto xpain, xwhich xshould xbe xdocumented xas xsuch x(A). xResponse xto xpainful xstimulus xis xassessed xafter xresponse xto xverbal xstimulus, xnot xbefore x(B). xThere xis xno xindication xfor xplacing xthe xclient xon xseizure xprecautions x(C). xReporting x(D) xis xnonpurposeful xmovement. A xhospitalized xclient xhas xhad xdifficulty xfalling xasleep xfor x2 xnights xand xis xbecoming xirritable xand xrestless. xWhich xaction xby xthe xnurse xis xbest? A. xDetermine xthe xclient's xusual xbedtime xroutine xand xinclude xthese xrituals xin xthe xplan xof xcare xas xsafety xallows. B. xInstruct xthe xUAP xnot xto xwake xthe xclient xunder xany xcircumstances xduring xthe xnight. C. xPlace xa x"Do xNot xDisturb" xsign xon xthe xdoor xand xchange xassessments xfrom xevery x4 xto xevery x8 xhours. D. xEncourage xthe xclient xto xavoid xpain xmedication xduring xthe xday, xwhich xmight xincrease xdaytime xnapping. x- xcorrect xanswers. xAnswer: xA Including xhabitual xrituals xthat xdo xnot xinterfere xwith xthe xclient's xcare xor xsafety xmay xallow xthe xclient xto xgo xto xsleep xfaster xand xincrease xthe xquality xof xcare x(A). x(B, xC, xand xD) xdecrease xthe xclient's xstandard xof xcare xand xcompromise xsafety. While xreviewing xthe xside xeffects xof xa xnewly xprescribed xmedication, xa x72-year-old xclient xnotes xthat xone xof xthe xside xeffects xis xa xreduction xin xsexual xdrive. xWhich xis xthe xbest xresponse xby xthe xnurse? A. x"How xwill xthis xaffect xyour xpresent xsexual xactivity?" xB. x"How xactive xis xyour xcurrent xsex xlife?" xC. x"How xhas xyour xsex xlife xchanged xas xyou xhave xbecome xolder?" xD. x"Tell xme xabout xyour xsexual xneeds xas xan xolder xadult." x- xcorrect xanswers. xAnswer: xA (A) xoffers xan xopen-ended xquestion xmost xrelevant xto xthe xclient's xstatement. x(B) xdoes xnot xoffer xthe xclient xthe xopportunity xto xexpress xconcerns. x(C xand xD) xare xeven xless xrelevant xto xthe xclient's xstatement. The xhealth xcare xprovider xhas xchanged xa xclient's xprescription xfrom xthe xPO xto xthe xIV xroute xof xadministration. xThe xnurse xshould xanticipate xwhich xchange xin xthe xpharmacokinetic xproperties xof xthe xmedication? xA. xThe xclient xwill xexperience xincreased xtolerance xto xthe xdrug's xeffects xand xmay xneed xa xhigher xdose. B. xThe xonset xof xaction xof xthe xdrug xwill xoccur xmore xrapidly, xresulting xin xa xmore xrapid xeffect. C. xThe xmedication xwill xbe xmore xhighly xprotein-bound, xincreasing xthe xduration xof xaction. D. xThe xtherapeutic xindex xwill xbe xincreased, xplacing xthe xclient xat xgreater xrisk xfor xtoxicity. x- xcorrect xanswers. xAnswer: xB Because xthe xabsorptive xprocess xis xeliminated xwhen xmedications xare xadministered xvia xthe xIV xroute, xthe xonset xof xaction xis xmore xrapid, xresulting xin xa xmore ximmediate xeffect x(B). xDrug xtolerance x(A), xprotein xbinding x(C), xand xthe xdrug's xtherapeutic xindex x(D) xare xnot xaffected xby xthe xchange xin xroute xfrom xPO xto xIV. xIn xaddition, xan xincreased xtherapeutic xindex xreduces xthe xrisk xof xdrug xtoxicity. A xmale xclient xis xlaughing xat xa xtelevision xprogram xwith xhis xwife xwhen xthe xevening xnurse xenters xthe xroom. xHe xsays xhis xfoot xis xhurting xand xhe xwould xlike xa xpain xpill. xHow xshould xthe xnurse xrespond? A. xAsk xhim xto xrate xhis xpain xon xa xscale xof x1 xto x10. B. xEncourage xhim xto xwait xuntil xbedtime xso xthe xpill xcan xhelp xhim xsleep. C. xAttend xto xan xacutely xill xclient's xneeds xfirst xbecause xthis xclient xis xlaughing