1. A nurse in an acute care facility is

preparing a discharge summary for a

client who is transferring to a long-term

care facility.Which of the following documentation should the nurse include?

A. Client flow sheet

B. Acuity ratings

C. Current medications

D. Incident reports

2. A nurse is reviewing protocol in preparation for suctioning secretions from

a client who has a new tracheostomy.

Which of the following actions should

the nurse plan to take?

A. Use a resuscitation bag with 80%

oxygen prior to the procedure.

B. Select a suction catheter that is half

the size of the lumen.

C. Place the end of the suction catheter

in water-soluble lubricant.

D. Adjust the wall suction apparatus to

a pressure of 170 mm Hg.

3. A nurse is caring for a client who has

decreased mobility. Which of the following actions should the nurse take to

decrease the client's risk of developing

plantar flexion contractures?

A. Place a pillow under the client's

knees.

B. Position a trochanter roll under each

of the client's hips.

C. Advise the client to wear rubber-soled slippers.

C. Current medications

The nurse should include the

client's medications in the discharge summary to ensure client

safety and continuity of care.

B. Select a suction catheter that is

half the size of the lumen.

The nurse should select a suction

catheter that is half the size of the

lumen to prevent hypoxemia and

trauma to the mucosa.

D. Apply an ankle-foot orthotic device to the client's feet.

The nurse should use a device to

maintain dorsiflexion, such as an

ankle-foot orthotic device or a foot

board placed perpendicular to the

mattress.