NUR 215 EXAM 3 B
A nurse is performing an admission assessment on a client who has hypovolemic due
to vomiting and diarrhea. The nurse should expect which of the following findings?
(select all that apply) - answer Tachycardia
Syncope
Decreased skin turgor
A nurse is caring for a client who is receiving enteral tube feedings due to dysphagia.
Which of the following bed positions should the nurse use for safe care of this client? -
answer Semi-Fowler's
A nurse is caring for a client who is sitting in a chair and asks to return to bed. Which of
the following actions is the nurse's priority at this time? - answer Determine the client's
ability to help with the transfer
A nurse is instructing a client who has COPD about using the orthopneic position to
relieve shortness of breath. Which of the following statements should the nurse make? -
answer"Have a table beside your bed so you can sit on the beside and rest your arms
on the table"
A nurse manager is reviewing guidelines for preventing injury with staff nurses. Which of
the following instructions should the nurse manager include? (select all that apply) -
answerrequest assistance when repositioning a client.
Avoid twisting your spine or bending at the waist.
Use smooth movements when lifting and moving clients.
A nurse educator is reviewing proper body mechanics during employee orientation.
Which of the following statements should the nurse identify as an indication that an
attendee understands the teaching? (select all that apply) - answer"The wonder my
center of gravity, the more stability I have"
"To broaden my base of support, I should spread my feet apart"
"When I left an object, I should hold it as close to my body as possible"
A nurse is caring for a client who is at high risk for aspiration. Which of the following
actions should the nurse take? - answerInstruct the client to tuck their chin when
swallowing.
, A nurse is preparing a presentation about basic nutrients for a group of high school
athletes. She should explain that which of the following nutrients provides the body with
the most energy? - answerCarbohydrates
A nurse is caring for a client who requires a low-residue diet. The nurse should expect
to see which of the following foods on the client's meal tray? - answerVanilla custard
A nurse is caring for a client who weighs 80kg (176lb) and 1.6m (5ft 3in) tall. Calculate
the body mass index (BMI) and determine whether this client's BMI indicates a healthy
weight, underweight, overweight, or obese. - answerBMI-weight(kg)/height(m2)
1.6x1.6=2.56m2
80/2.56=31.25
greater than 30=pt is obese
A nurse in a senior center is counseling a group of older adults about their nutritional
needs and considerations. Which of the following information should the nurse include?
(select all that apply) - answerOlder adults are more prone to dehydration than younger
adults are.
Older adults need the same amount of most vitamins and minerals as younger adults
do.
Many older men and women need calcium supplementation.
A nurse is caring for a client who has been sitting in a chair for 1 hr. Which of the
following complications is the greatest risk to the client? - answerPressure injury
A nurse is caring for a client who is postoperative. Which of the following interventions
should the nurse take to reduce the risk of thrombus developmental? (select all that
apply) - answerApply elastic stockings.
Assist the client to change positions often.
A nurse is planning care for a client who is on bed rest. Which of the following
interventions should the nurse plan to implement? - answerEncourage the client to
perform antiembolic exercises every 2hr.
A nurse is evaluating a client's understanding of the use of sequential compression
device. Which of the following client statements indicates client understanding? -
answer"This device will keep the blood pumping through my leg"
A nurse is instructing a client, who has an injury of the left lower extremity, about the
use of a cane. Which of the following instructions should the nurse include? (select all
that apply) - answerHold 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 performing an admission assessment on a client who has hypovolemic due
to vomiting and diarrhea. The nurse should expect which of the following findings?
(select all that apply) - answer Tachycardia
Syncope
Decreased skin turgor
A nurse is caring for a client who is receiving enteral tube feedings due to dysphagia.
Which of the following bed positions should the nurse use for safe care of this client? -
answer Semi-Fowler's
A nurse is caring for a client who is sitting in a chair and asks to return to bed. Which of
the following actions is the nurse's priority at this time? - answer Determine the client's
ability to help with the transfer
A nurse is instructing a client who has COPD about using the orthopneic position to
relieve shortness of breath. Which of the following statements should the nurse make? -
answer"Have a table beside your bed so you can sit on the beside and rest your arms
on the table"
A nurse manager is reviewing guidelines for preventing injury with staff nurses. Which of
the following instructions should the nurse manager include? (select all that apply) -
answerrequest assistance when repositioning a client.
Avoid twisting your spine or bending at the waist.
Use smooth movements when lifting and moving clients.
A nurse educator is reviewing proper body mechanics during employee orientation.
Which of the following statements should the nurse identify as an indication that an
attendee understands the teaching? (select all that apply) - answer"The wonder my
center of gravity, the more stability I have"
"To broaden my base of support, I should spread my feet apart"
"When I left an object, I should hold it as close to my body as possible"
A nurse is caring for a client who is at high risk for aspiration. Which of the following
actions should the nurse take? - answerInstruct the client to tuck their chin when
swallowing.
, A nurse is preparing a presentation about basic nutrients for a group of high school
athletes. She should explain that which of the following nutrients provides the body with
the most energy? - answerCarbohydrates
A nurse is caring for a client who requires a low-residue diet. The nurse should expect
to see which of the following foods on the client's meal tray? - answerVanilla custard
A nurse is caring for a client who weighs 80kg (176lb) and 1.6m (5ft 3in) tall. Calculate
the body mass index (BMI) and determine whether this client's BMI indicates a healthy
weight, underweight, overweight, or obese. - answerBMI-weight(kg)/height(m2)
1.6x1.6=2.56m2
80/2.56=31.25
greater than 30=pt is obese
A nurse in a senior center is counseling a group of older adults about their nutritional
needs and considerations. Which of the following information should the nurse include?
(select all that apply) - answerOlder adults are more prone to dehydration than younger
adults are.
Older adults need the same amount of most vitamins and minerals as younger adults
do.
Many older men and women need calcium supplementation.
A nurse is caring for a client who has been sitting in a chair for 1 hr. Which of the
following complications is the greatest risk to the client? - answerPressure injury
A nurse is caring for a client who is postoperative. Which of the following interventions
should the nurse take to reduce the risk of thrombus developmental? (select all that
apply) - answerApply elastic stockings.
Assist the client to change positions often.
A nurse is planning care for a client who is on bed rest. Which of the following
interventions should the nurse plan to implement? - answerEncourage the client to
perform antiembolic exercises every 2hr.
A nurse is evaluating a client's understanding of the use of sequential compression
device. Which of the following client statements indicates client understanding? -
answer"This device will keep the blood pumping through my leg"
A nurse is instructing a client, who has an injury of the left lower extremity, about the
use of a cane. Which of the following instructions should the nurse include? (select all
that apply) - answerHold the cane on the right side.
Keep two points of support on the floor.
After advancing the cane, move the weaker leg forward.
