1) A nurse is assessing an adult client who has been immobile for the past 3 weeks. The

nurse should identify that which of the following findings requires further intervention?

ANS: Erythema on pressure points

2) A nurse is caring for a client who is postoperative. When the nurse prepares tochange

her dressing she says, "Every time you change my bandage, it hurts so much" which

of the following interventions is the nurse's priority action?

ANS: administer pain medication 45 min before changing the client's dressing

3) A nurse is teaching a client whose left leg is in a cast about using crutches. Whichof the

following statements should the nurse identify as an indication that the client understands

the teaching?

ANS: "when descending stair, I will first shift my weight to my right leg."

4) A client who is postoperative is verbalizing pain as a 2 on a pain scale of 0-10.Which

of the following statements should the nurse identify as an indication that the client

understands the preoperative teaching she received about pain management?

ANS: "It might help me to listen to music while i'm lying in bed."

5) A nurse is caring for a client who has a pharyngeal diphtheria. Which of the

following types of transmission precautions should the nurse initiate?

ANS: droplet

6) A nurse is admitting a client who is having an exacerbation of heart failure. In

planning this client's care, when should the nurse initiate discharge planning?

ANS: during the admission process

7) A middle adult client tells the nurse, "I feel so useless now that my children do not need

me anymore." Which of the following responses should the nurse make? ANS: "People

in middle adulthood often find satisfaction in nurturing and guidingyoung people."

8) A nurse enters a client's room ad finds her on the floor. The client's roommate reports

that the client fell getting out of bed. Which of the following statements shouldthe

nurse document?

ANS: "client was found lying on floor."

9) A nurse is caring for a patient with behind the ear hearing aid.

ANS: remove before showe