Which of these instructions should a nurse include in the teaching plan for a client who had
removal of a cataract in the left eye? - Answer "Take the prescribed stool softener to avoid
increasing intraocular pressure."
A client vomits during a continuous nasogastric tube feeding. A nurse should stop the feeding
and take which of these actions? - Answer Check the residual volume.
Which of these actions best demonstrates cultural sensitivity by a nurse?. - Answer The nurse
asks clients about their beliefs and practices toward pregnancy.
Which of these manifestations should a nurse expect to observe in a 3-month-old infant who is
diagnosed with dehydration? - Answer Tachycardia.
When assessing a client's risk of developing nosocomial infection, a nurse plans to determine
potential entry portals, which include: - Answer the urinary meatus.
A client who is on the inpatient psychiatric unit has a history of violence. Which of these actions
should a nurse take if the client is agitated? - Answer Encourage the client to verbalize feelings.
Which of these measures should a nurse include when planning care for a school-aged child
during a sickle cell crisis episode? - Answer Providing pain relief.
Which of these instructions should a nurse include in the plan of care for a 32-week gestation
client who had an amniocentesis today? - Answer "Call the clinic if you experience any
abdominal cramps."
An adolescent has a nursing diagnosis of fatigue related to inadequate intake of iron-rich foods.
Selection of which of these lunches by the client indicates a correct understanding of foods high
in iron content? - Answer Beefburger with cheese.
A client has been admitted with acute pancreatitis. Which of these laboratory test results supports
this diagnosis? - Answer Elevated serum amylase level.
Which of these manifestations, if assessed in a client who is two-hours postoperative after
abdominal surgery, should a nurse report immediately? - Answer Vomiting and a pulse rate of
106/minute.
Which of these observations of a student nurse's behavior while interacting with a client who is
crying indicates a correct understanding of therapeutic communication? - Answer The student
sits quietly next to the client.
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