p p p p p p p p
UPDATE WITH VERIFIED ANSWERS GRADED A+
p p p p p
ApnursepispadministeringpIVpfluidsptopapclient.pWhenpmonitoringpforpadversepeffects,pwhichpofpthepfollowin
gpassessmentspshouldpthepnursepidentifypasptheppriority?
Auscultateplungpsounds.
Measurepurinepoutput.
Monitorpbloodppressurepreadings.p
Monitorpelectrolyteplevels.
CorrectpAnswer:
Auscultateplungpsounds.
Thepprioritypassessmentpthepnursepshouldpmakepwhenpusingpthepairway,pbreathing,pcirculationpapproac
hptopclientpcarepispauscultatingplungpsoundsptopmonitorpforpfluidpvolumepexcess,papcomplicationpofpIVpth
erapy.pManifestationspofpfluidpvolumepexcesspincludepmoistpcracklespinplungpfields,pdyspnea,pandpshortn
esspofpbreath.
IncorrectpAnswer:
Measurepurinepoutput.
ThepnursepshouldpmeasurepurinepoutputptopmonitorptheprenalpfunctionpofpapclientpwhopispreceivingpI
Vpfluid;phowever,pitpispnotpthepprioritypassessment.
Monitorpbloodppressurepreadings.
Thepnursepshouldpmonitorpbloodppressurepreadingsptopevaluatepthephemodynamicpstabilitypofpapclien
tpwhopispreceivingpIVpfluids;phowever,pitpispnotpthepprioritypassessment.
Monitorpelectrolyteplevels.
Thepnursepshouldpmonitorpelectrolyteplevels,pespeciallypsodium,ptopguidepthepplanningpofpinterventionsp
topcorrectpanypimbalancespinpapclientpwhopispreceivingpIVpfluids;phowever,pitpispnotpthepprioritypassessm
ent.
,Apnursepispcaringpforpapclientpwhopispexpressingpangerpaboutptheirpdiagnosispofpcolorectalpcancer.pWhichpof
pthepfollowingpactionspshouldpthepnurseptake?
Discusspthepriskpfactorspforpcolonpcancer.
Focuspteachingponpwhatpthepclientpwillpneedptopdopinpthepfutureptopmanageptheirpillness
.pProvidepthepclientpwithpwrittenpinformationpaboutpthepphasespofplosspandpgrief.
Reassurepthepclientpthatpthispispanpexpectedpresponseptopgrief.
CorrectpAnswer:
Reassurepthepclientpthatpthispispanpexpectedpresponseptopgrief.
Duringpthepangerpstagepofpthepclient'sppsychosocialpadaptationptopillness,pthepnursepshouldpsupportpthepcli
entpandpexplainpthatpthispispanpexpectedpreactionptopapcancerpdiagnosis.
IncorrectpAnswer:
Discusspthepriskpfactorspforpcolonpcancer.
Thepclientpmightpperceivepthispaspchallengingporpargumentativepandpreactpdefensively.pInstead,pthepn
ursepshouldplistenptopthepclient'spconcernspandpshouldpavoidpchallengingpthem.
Focuspteachingponpwhatpthepclientpwillpneedptopdopinpthepfutureptopmanageptheirpillness.
Duringpthepangerpstagepofpthepclient'sppsychosocialpadaptationptopillness,pthepnursepshouldpfocuspteachi
ngponptheppresent.pThepclientpispnotpyetpreadyptopfacepthepfuture.
Providepthepclientpwithpwrittenpinformationpaboutpthepphasespofplosspandpgrief.
Unlesspthepclientprequestspreadingpmaterialspaboutploss,pthispispnotpanpoptimalptimeptopprovidepthem.pAtpt
hispstage,pthepclientpneedsptopexpressptheirpfeelingspwithoutpanypexpectationspforplearning.
Apnursepispteachingpanpolderpadultpclientpwhopispatpriskpforposteoporosispaboutpbeginningpapprogrampo
fpregularpphysicalpactivity.pWhichpofpthepfollowingptypespofpactivitypshouldpthepnurseprecommend?
Walkingpbrisklyp
Ridingpapbicycle
,PerformingpisometricpexercisespE
ngagingpinphigh-
impactpaerobicspCorrectpAnswer:
Walkingpbriskly
Weight-
bearingpexercisesparepessentialpforpmaintainingpbonepmass,pwhichphelpsptoppreventposteoporosis.pWalk
ingpengagespolderpadultpclientspinpthisppreventivepandptherapeuticpstrategy.
IncorrectpAnswer:
Ridingpapbicycle
Cyclingphaspnopweight-bearingpadvantages;ptherefore,pitpdoespnotphelpppreventposteoporosis.
Performingpisometricpexercises
Isometricpexercisesphavepnopweight-
bearingpadvantages;ptherefore,ptheypdopnotphelpppreventposteoporosis.
Engagingpinphigh-impactpaerobics
High-
impactpaerobicspcanpinjurepbonespthatphaveplostpdensity;ptherefore,pthepnursepshouldpnotprecommendpthe
sepexercisespforpapclientpwhopispatpriskpforpdevelopingposteoporosis.
Apnursepispcaringpforpapclientpwhophaspdecreasedpmobility.pWhichpofpthepfollowingpactionspshouldpth
epnurseptakeptopdecreasepthepclient'spriskpofpdevelopingpplantarpflexionpcontractures?
Placepappillowpunderpthepclient'spknees.
Positionpaptrochanterprollpunderpeachpofpthepclient'sphips
.pAdvisepthepclientptopwearprubber-soledpslippers.
Applypanpankle-footporthoticpdeviceptopthepclient'spfeet.
CorrectpAnswer:
Applypanpankle-footporthoticpdeviceptopthepclient'spfeet.
, Thepnursepshouldpusepapdeviceptopmaintainpdorsiflexion,psuchpaspanpankle-
footporthoticpdeviceporpapfootpboardpplacedpperpendicularptopthepmattress.
IncorrectpAnswer:
Placepappillowpunderpthepclient'spknees.
Thepnursepshouldpplacepappillowpunderpthepclient'splowerplegsptoppreventppressureponpthepheels.
Positionpaptrochanterprollpunderpeachpofpthepclient'sphips.
Thepnursepshouldpplacepaptrochanterprollpunderpthepclient'spbuttockspandpalongsidepthephipsptoppreven
tpexternalprotationpofpthephipspwhilepthepclientpispsupine.
Advisepthepclientptopwearprubber-soledpslippers.
Thepsolespofpthepclient'spslippersphavepnopimpactponpthepalignmentpofpthepfeetpwhilepinpbed.
Apnursepinpapmedical-surgicalpunitpispcaringpforpsixpclients.
Completepthepfollowingpsentencepbypusingptheplistpofpoptions.
Thepfirstpclientpthepnursepshouldpassesspis followedpby .
Clientp1:pClientpispadmittedpwithpapnewpdiagnosispofprheumatoidparthritis.Clientp2:pClientphaspaphistorypofp
hyperlipidemia.pAtorvastatinp20pmgpPOpadministeredpaspprescribed.Clientp3:pClientpisp1pdayppostoperativ
e.pReportsppainpasp8ponpapscalepofp0ptop10.pMorphinep5pmgpsubcutaneouspadministeredpaspprescribed.Cli
entp4:pClientpispadmittedpwithpapnewpdiagnosispofpheartpfailure.Clientp5:pClientphaspapstagep2ppressurepinju
ryponpthepleftpheel.Clientp6:pClientpispadmittedpwithpapnewpdiagnosispofpdiabetespmellitus.
CorrectpAnswerp(1):
Clientp3
Whenpusingpthepairway,pbreathing,pcirculationpapproachptopclientpcare,pthepnursepshouldpdeterminepth
atpthispclientpispthepprioritypclientptopassess.pThepclientphaspanpoxygenpsaturationpthatpisplesspthanpthepex
pectedpreferenceprange,pwhichpispanpindicationpofphypoxia.