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A nurse is caring for a client who has been sitting in a chair for 3 hr. Which of the following problems is
the client at risk for developing - CORRECT CORRECT ANSWER>>Pressure Ulcer
A nurse is caring for a client who is on bed rest. Which of the following interventions should the nurse
implement to maintain the patency of the client's airway - CORRECT CORRECT ANSWER>>Promote
incentive spirometer use
A nurse is caring for a client who is postoperative. Which of the following nursing interventions reduce
the risk of thrombus development - CORRECT CORRECT ANSWER>>Apply elastic stockings, Assist the
client to change position often
A nurse is instructing a client who is postoperative about the sequential compression device the
provider has prescribed. Which of the following client statements should indicate to the nurse that the
client understnads the teaching - CORRECT CORRECT ANSWER>>"This thing will keep the blood pumping
through my leg."
To promote the safe use of a cane for a client who is recovering froma minor musculoskeletal injury of
the left lower extremity, which of the following instructions should the nurse provide - CORRECT
CORRECT ANSWER>>Hold the cane on the right side, Keep two points of support on the floor, after
advancing the cane, move the weaker leg forward
A nurse is caring for a client who recently had a cerebrovascular accident and has aphasia. Which of the
following interventions should the nurse use to promote communication with this client? - CORRECT
CORRECT ANSWER>>Speak fast and loudly, Minimize background noise
A nurse is caring for a client who had an amphetamine overdose and has sensory overload. Which of the
following interventions should the nurse implement? - CORRECT CORRECT ANSWER>>Provide a private
room, and limit stimulation
A nurse is caring for a lcient who reports difficulty hearing. Which of the following assessment findings
indicate a sensorineural hearing loss in the left ear? - CORRECT CORRECT ANSWER>>Weber test showing
lateralization to the right ear, No signs of obstruction in the left ear canal, Rinne test showing length of
time is decreased for air and bone conduction
, A nurse is reviewing instructions with a client who is hearing impaired and has just started wearing
hearing ids. Which of the following statements by the client indicates understanding of the instructions?
- CORRECT CORRECT ANSWER>>"I take the batteries out of my hearing aids when I take them off at
night"
A nurse is caring for a client who has several risk factors for hearing loss. As the nurse reviews the
client's medication history, which of the following medications the client takes should alert the nurse to
a further risk for ototoxicity? - CORRECT CORRECT ANSWER>>Ibuprofen (Advil) Cimetidine (Tagamet),
Simvastatin (Zocor), Amiodarone (Cordarone)
A nurse in a provider's office is assessing a client who reports losing control of urine whenever she
coughs, laughs, or sneezes. The client relates a history of three vaginal births, but no serious accidents or
illnesses. Which of the following interventions are appropriate for helping to control of eliminate the
client's incontinence? - CORRECT CORRECT ANSWER>>Decrease or avoid caffeine. Avoid the intake of
Alcohol
A client who has an indwelling catheter reports a need to urinate. Which of the following interventions
should the nurse perform? - CORRECT CORRECT ANSWER>>Check to see whether the catheter is patent.
A provider prescribes a 24 hr urine collection for a client. Which of the following actions should the
nurse take - CORRECT CORRECT ANSWER>>Discard the first voiding
A nurse is preparing to initiate a bladder training program for a client who has a voiding disorder. Which
of the following actions should the nurse take? - CORRECT CORRECT ANSWER>>Have the client record
voiding times. Gradually increase the voiding intervals. Remind client to hold urine until next scheduled
voiding time.
A nurse educator on a medical unit is reviewing factors that increase the risk of urinary tract infections
with a group of assistive personnel. Which of the following should be included in the review. - CORRECT
CORRECT ANSWER>>Having sexual intercourse on frequent basis. Undergoing frequent catheterization.
A nurse is assessing the pain level of a client who has come to the emergency department reporting
severe abdominal pain. The nurse asks the client whether he has nausea and has been vomiting. The
nurse is assessing which of the following - CORRECT CORRECT ANSWER>>Presence of associated
symptoms
A nurse is assessing a client who is reporting pain despite analgesia. The nurse can best assess the
intensity of th eclient's pain by - CORRECT CORRECT ANSWER>>Offering the client a pain scale to
measure his pain
A nurse is obtaining a history from a client who has pain. The nurse's guiding principle throughout this
process should be that - CORRECT CORRECT ANSWER>>Pain is whatever the client says it is