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A collection of questions and answers related to nursing interventions, client teaching, and ethical principles. It covers various topics such as medication administration, home safety, pressure ulcer prevention, and end-of-life care. The answers also include rationale and references to ati pn comprehensive predictor form a,b,c questions and answers latest 2023-2024 test bank.
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. If a client develops cor pulmonale (right-sided heart failure), the nurse would expect to observe
A nurse is caring for a client following an acute myocardial infarction. The client is concerned that providing self-care will be difficult due to extreme fatigue. Which of the following strategies should the nurse implement to promote the client's independence? a) request an occupational therapy consult to determine the need for assistive devices b) assign assistive personnel to perform self-care tasks for client c) instruct the client to focus on gradually resuming self-care tasks d) ask the client if a family member is available to assist with his care - ansC A nurse is caring for a client receiving IV fluids. During a routine check, the nurse determines that the client has developed phlebitis and removes the IV catheter. Which of the following actions should the nurse take next? a) place a warm compress over the IV site b) record the findings in the client's chart c) notify the client's primary care provider d) prepare to insert a new IV catheter - ansA A nurse is caring for a client who decides not to have surgery despite significant blockages in his coronary arteries. The nurse understands that this clients choice is an example of what principles? A. Fidelity B. Autonomy C. Justice D. Nonmalificience - ansA A nurse is caring for a client who has a prescription for wound irrigation. Which of the following actions should the nurse take? a) wear sterile gloves when removing the old dressing b) warm the irrigation solution to 40.5C (105F) c) cleanse the wound from the center outwards d) use a 20 mL syringe to irrigate the wound - ansC A nurse is caring for a client who has an NG tube that is to be irrigated every 8 hr. Which of the following should be used to irrigate the tube in order to maintain fluid and electrolyte balance? a) tap water b) sterile water c) 0.9% sodium chloride d) 0.45% sodium chloride - ansC A nurse is caring for a client who has dementia. Which of the following interventions should the nurse take to minimize the risk for injury for this client? a) use a bed exit alarm system b) raise 4 side rails while client is in bed c) apply one soft wrist restraint d) dim the lights in the client's room - ansA
A nurse is delegating the ambulation of a client who had knee arthroplasty 5 days ago to an AP. Which of the following info should the nurse share with the AP? Select all: A. the roommate is up independently B. The client ambulates with his slippers on over his antiembolic stockings C. The client uses a front wheeled walker when ambulating D. The client had pain meds 30 minutes ago E. The client is allergic to codeine F. the client ate 50 % of his breakfast this morning - ansB C D A nurse is implementing a plan of care for a client who is at risk for falls. Which of the following is an appropriate nursing action? a) implement a regular toileting schedule b) encourage the client to wear athletic socks when ambulating c) place all 4 bed rails in the upright position c) require a family member to remain at the bedside - ansA A nurse is instructing a group of nursing students about the responsibilities involved with organ donation and procurement. When the nurse explains that all clients waiting for a kidney transplant have to meet the same qualifications, the students should understand that this aspect of care delivery is an example of which ethical principle A. Fidelity B. Autonomy C. Justice D. Nonmaleficence - ansC a nurse is obtaining a medication history from a client who is to start a new prescription for warfarin ( Coumadin). which of the following over the counter medication should the nurse instruct the client to avoid - ansAspirin A nurse is preparing an inservice program about delegation. Which of the following elements should she identify when presenting the 5 rights of delegation. Select all: A. Right client B. Right supervision/evaluation C. Right direction/communication D. Right time E. Right circumstances - ansB C E a nurse is preparing to care for a client in the surgical unit who will be receiving lorazapam ( ativan IV). for what adverse effect should the nurse monitor this client - ansthe nurse should monitor the client respiratory depression A nurse is providing discharge instructions to a client who has a prescription for the use of oxygen in his home. Which of the following should the nurse teach the client about using oxygen safely in his home? (Select all that apply.)
A. Family members who smoke must be at least 10 ft from the client when oxygen is in use. B. Nail polish should not be used near a client who is receiving oxygen. C. A "No Smoking" sign should be placed on the front door. D. Cotton bedding and clothing should be replaced with items made from wool. E. A fire extinguisher should be readily available in the home. - ansB C E A nurse is providing home safety instructions to a group of older adult clients. Match the safety risk with the appropriate instruction. ____ Passive smoking ____ Carbon monoxide poisoning ____ Food poisoning A. Have water heaters inspected on an annual basis. B. Cook all meat at an appropriate temperature. C. Avoid enclosed areas with others who may be smoking. - ansC A B A nurse is providing teaching about a clear liquid diet. Which of the following should the nurse instruct the client to avoid? a) lemon-lime sports drinks b) ginger ale c) black coffee d) orange sherbet - ansD a nurse is reinforcing a teaching on a client who has a prescription for verapamil ( calan) which of the following statement by the client indicated need further teaching - ansi should decrease the amount of calcium in my diet while taking the medication A nurse is reinforcing teaching regarding the use of a cane to a client who has left-leg weakness. Which of the following should the nurse include in the teaching? a) use the cane on the weak side of the body b) advance the cane and the atrong leg simultaneously c) maintain two points of support on the floor d) advance the cane 30 to 45 cm (12-18 in) with each step - ansC a nurse is reinforcing teaching to a client who is prescribed diazepam tor anxiety of the following statement indicated the client understand the teaching - ansI will tell my doctor before I stop taking the medication a nurse is reinforcing teaching to a client who is starting amitriptyline ( Elavil) for treatment of depression which of the following should the nurse include - ans1. change position slowly to minimize dizziness
b) Instruct the patient to avoid prune or apple juice c) Suggest fluid intake of at least 2 L per day d) Assist the patient regarding the correct diet or to minimize food intake - ansC A positive Chvosteks sign is found in a patient. The nurse would anticipate IV administration of - anscalcium gluconate (because hypocalcemia causes Chvostek's sign) A young woman is transferred to a psychiatric crisis unit with a diagnosis of a dissociative disorder. The nurse knows which of the following comments by the client is MOST indicative of this disorder?
After teaching a group of students about the various organs of the upper gastrointestinal tract and possible disorders, the instructor determines that the teaching was successful when the students identify which of the following structures as possibly being affected? a) Large intestine b) Ileum c) Stomach d) Liver - ansC Alcohol Use Manifestations of Withdrawal - ansBody burns 0.5 oz of alcohol per hour
get a decent night's sleep anymore." Which suggestions should the nurse make to the daughter? Select all that apply.
Work output by staff is usually of good quality-good when cooperation and collaboration is necessary - ansDemocratic Interaction of diuretics and ACE inhibitors - ansexcessive reduction in blood pressure and symptomatic hypotension or hyperkalemia involves difficult progression through the expected stages of the grieving process grief work is prolonged and manifestations more severe client may develop suicidal ideation, intense feelings of guilt and lowered self-esteem somatic complaints persist for an extended period of time - ansdysfunctional grief Levothyroxine effects - ansUsed to restore client's metabolic rate
The home care nurse is instructing a client recently diagnosed with tuberculosis. It is MOST important for the nurse to include which of the following as a part of the teaching plan?
what are normal creatinine levels? what are normal BUN levels? - ans0.8-1.4 mg/dL 8-25 mg/dL What are positive actions to help others - ansBeneficience What are some things to teach about home safety with elderly patients? - ans- Removing items that could cause the client to trip, such as throw rugs and loose carpets
What can prevent MI, stroke, or death in high-risk patients - ansRamipril What comorbidities may be observed with a patient who is bipolar? - ansSubstance use disorder (experiences more rapid cycling), anxiety disorders, eating disorders, ADHD. What do the nurse need to keep in mind about the client when being their advocate? - ansClient's religion & culture What do you do when a client has a seizure - ans- lower to bed/floor