CORRECT ANSWERS
/. A nurse is preparing to administer a cleansing enema to a client. Which of the
following actions should the nurse take? - Answer-✅Hold the container of solution 30
cm (12in) above the anus.
/.A nurse is admitting a client who reports anorexia and is experiencing malnutrition.
Which of the following laboratory findings should the nurse expect to be altered? -
Answer-✅Albumin
A low albumin is a measure of plasma proteins which reflects the nutritional condition of
a client experiencing anorexia and malnutrition over an extended period of time.
/.A nurse is preparing a sterile field. Which of the following actions should the nurse
perform when opening the sterile pack? - Answer-✅Reach around the pack and open
the top flap away from the body.
/.A nurse is assessing a client who is experiencing prostatic hypertrophy. Which of the
following findings associated with urinary retention should the nurse expect? Select all
that apply. - Answer-✅*report of feeling pressure
*tenderness over the symphysis pubis
* distended bladder
* voiding 30 mL frequently
/.A nurse is preparing to administer ophthalmic solution to a client. Which of the
following actions should the nurse take? - Answer-✅Hold the ophthalmic solution 2cm
above the lower conjunctival sac.
/.A nurse has just finished a wound irrigation for a client who requires contact
precautions. Which of the following pieces of ppe should the nurse remove first? -
Answer-✅Gloves
/.A nurse in a long term care facility is assisting a client with eating during meal time and
recognizes another client indicating he is choking. Which of the following situations
requires the nurse to perform the Heimlich maneuver? - Answer-✅The client is not
making any sounds
, /.A nurse is planning care for an older adult who is at risk for developing pressure
ulcers. Which of the following interventions should the nurse use to help maintain the
integrity of the clients skin? - Answer-✅Use a transfer device to lift the client up in bed.
/.A nurse is assisting a provider with a sterile procedure and prepares to pour solution
onto a piece of gauze. Identify the sequence of steps the nurse should follow when
pouring the solution. - Answer-✅1) remove the bottle cap
2) place the bottle cap face up on clean surface.
3) pick up the bottle with the label facing his palm.
4) pour 1 to 2 mL into a receptacle.
5) pour the solution onto the gauze.
/.A nurse is filling out an incident report after finding a client lying on the floor. Which of
the following information should the nurse include? - Answer-✅The client was lying on
the floor next to his bed.
/.A nurse is planning to discharge a client who has quadriplegia to his home. The nurse
suggests that the family might need respite care services. When a family member asks
how respite care can help, which of the following responses should the nurse provide? -
Answer-✅Respite care allows the primary caregiver time away from day to day care
responsibilities.
/.A nurse is helping an older adult client ambulated in the hallways for the first time
since admission. The client has brought her standard walker from home. To ensure
proper use of the walker and the safety of the client, which of the following actions
should the nurse take? - Answer-✅Check that the client lifts the walker and then places
it down in front of her.
/.A nurse is caring who has emphysema and has difficulty with mobility. The client
receives home health care and spends most of his day in a reclining chair. Which of the
following physiological responses to prolonged immobility should the nurse expect? -
Answer-✅Increased calcium excretion
/.A nurse is orienting a new assistive personnel to the unit. For which of the following
actions should the nurse intervene? - Answer-✅Washes and rinses her hands for 10
seconds
/.A nurse is providing preoperative teaching for a client who will undergo surgery. The
nurse explains that the client will wear antiembolism stockings during and after the
procedure. When then client asks what the stockings do, which of the following
responses should the nurse make? - Answer-✅They improve your circulation to keep
blood from pooling in your legs
/.A nurse is caring for an older adult client who is alert and oriented at admission, but
now seems increasingly restless and intermittently confused. Which of the following