A nurse is caring for a client who requires a 24-hr urine collection. Which of the

following statements by the client indicates an understanding of the teaching?

Answer - "I flushed what I urinated at 7:00 a.m. and have saved all urine since."

A nurse is assessing a client who has been on bed rest for the past month. Which of the

following findings should the nurse identify as an indication that the client has developed

thrombophlebitis?

Answer - Calf swelling

A nurse manager is overseeing the care on a unit. Which of the following situations

should the nurse manager identify as a violation of HIPAA guidelines?

Answer - A nurse asks a nurse from another unit to assist with her documentation.

A nurse is caring for a client who requires bed rest and has a prescription for

antiembolic stockings. Which of the following actions should the nurse take?

Answer - Remove the stockings at least once per shift.

A nurse is administering IV fluid to an older adult client. The nurse should perform which

priority assessment to monitor for adverse effects?

Answer - Auscultate lung sounds

A nurse is assessing a client's readiness to learn about insulin administration. Which of

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

ready to learn?

Answer - "I can concentrate best in the morning."

A nurse is performing a Romberg's test during the physical assessment of a client.

Which of the following techniques should the nurse use?

Answer - Have the client stand with her arms at her side and her feet together.

A nurse is planning an deduction session for an older adult client who has just learned

that she has type 2 diabetes mellitus. Which of the following strategies should the nurse

plan to use with this client?

Answer - Allow extra time for the client to respond to questions