In the immediate post-operative period, the nurse assesses coarse, high-pitched sound on inspiration by listening over the trachea with a stethoscope. The nurse should immediately A. Position client to Fowler’s B. Reassure the client that he is doing fine C. Suction the tracheostomy tube D. Report to the surgeon

In the immediate post-operative period, the nurse assesses
coarse, high-pitched sound on inspiration by listening over
the trachea with a stethoscope. The nurse should
immediately
A. Position client to Fowler’s
B. Reassure the client that he is doing fine
C. Suction the tracheostomy tube
D. Report to the surgeon
by

1 Answer

Answer :

Which of the following expected outcomes for the patient is
most relevant for the nursing diagnosis “At risk for
imbalanced nutrition related to impaired swallowing”?
A. Appropriate body weight maintained
B. Fear of choking relieved
C. Oral intake increased
D. Swallowing of soft foods facilitated
by

Related questions

Before the nurse can develop a relevant care plan, the nurse understands that in post-laryngectomy, the trachea and the esophagus are permanently separated. Therefore, which of the following will the nurse expect? A. No risk of aspiration during swallowing; speech is lost B. Normal speaking, breathing and swallowing are restored C. Unable to communicate with difficulty of swallowing and breathing D. Permanent tracheostomy created; normal speech is lost

Description : Before the nurse can develop a relevant care plan, the nurse understands that in post-laryngectomy, the trachea and the esophagus are permanently separated. Therefore, which of the ... with difficulty of swallowing and breathing D. Permanent tracheostomy created; normal speech is lost

Last Answer : D. Permanent tracheostomy created; normal speech is lost

When the nurse auscultates chest sounds that are harsh and cracking, sounding like two pieces of leather being rubbed together, she records her finding as a) pleural friction rub. A pleural friction rub is heard secondary to inflammation and loss of lubricating pleural fluid. b) crackles. Crackles are soft, high-pitched, discontinuous popping sounds that occur during inspiration. c) sonorous wheezes. Sonorous wheezes are deep, low-pitched rumbling sounds heard primarily during expiration. d) sibilant wheezes. Sibilant wheezes are continuous, musical, high-pitched, whistle-like sounds heard during inspiration and expiration.

Description : When the nurse auscultates chest sounds that are harsh and cracking, sounding like two pieces of leather being rubbed together, she records her finding as a) pleural friction rub. A ... wheezes are continuous, musical, high-pitched, whistle-like sounds heard during inspiration and expiration.

Last Answer : a) pleural friction rub. A pleural friction rub is heard secondary to inflammation and loss of lubricating pleural fluid.

When the nurse observes that the patient always has difficulty breathing when lying flat, the nurse records that the patient is demonstrating a) Orthopnea Patients with orthopnea prefer not to lie flat and will need to maintain their beds in a semi- to high Fowler’s position

Description : When the nurse observes that the patient always has difficulty breathing when lying flat, the nurse records that the patient is demonstrating a) Orthopnea Patients with orthopnea prefer not ... Paroxysmal nocturnal dyspnea. Paroxysmal nocturnal dyspnea refers to orthopnea that occurs only at night.

Last Answer : a) Orthopnea Patients with orthopnea prefer not to lie flat and will need to maintain their beds in a semi- to high Fowler’s position

79. A scrub nurse is assisting an emergency Cesarian section on a 39-year-old laundry woman. Before closing the peritoneum, the surgeon asks, “How old is the client?” Holding the fallopian tube, the surgeon asks for a hemostat. The scrub nurse sensing that the surgeon is about to ligate the tube said, “Doctor there is no signed consent for tubal ligation.” The nurse just demonstrated which of the following?

Description : 79. A scrub nurse is assisting an emergency Cesarian section on a 39-year-old laundry woman. Before closing the peritoneum, the surgeon asks, How old is the client? Holding the fallopian ... there is no signed consent for tubal ligation. The nurse just demonstrated which of the following?

Last Answer : C. Advocacy

The client complained of abdominal pain, nausea and vomiting with abdominal distention. The nurse anticipates which of the following priority management after referring to the surgeon? A. Gastric decompression B. Possible surgery C. Endoscopy D. Rectal tube insertion

Description : The client complained of abdominal pain, nausea and vomiting with abdominal distention. The nurse anticipates which of the following priority management after referring to the surgeon? A. Gastric decompression B. Possible surgery C. Endoscopy D. Rectal tube insertion

Last Answer : A. Gastric decompression

Pre-operatively, the nurse identified the nursing dagnosis, “Knowledge Deficit: Post-operative communication strategies”. Which of the following is a relevant nursing intervention? A. Clarify information on purpose, anticipate benefits and consequences of total laryngectomy B. Explain that total laryngectomy results in loss of ability to verbally communicate C. Arrange a visit to a post-laryngectomy client who effectively uses an alternative form of verbal communication D. Illustrate means of communicating post- operatively

Description : Pre-operatively, the nurse identified the nursing dagnosis, Knowledge Deficit: Post-operative communication strategies . Which of the following is a relevant nursing intervention? A. ... uses an alternative form of verbal communication D. Illustrate means of communicating post- operatively

Last Answer : D. Illustrate means of communicating post- operatively

As the nurse monitors the client, she notices a bright red spot on the dressings which measures 4cm in diameter. The nurse should initially do which appropriate nursing intervention? A. Change the top dressing B. Continue to monitor the vital signs C. Notify the clients surgeon of a potential hemorrhage D. Assess the presence of a drain

Description : As the nurse monitors the client, she notices a bright red spot on the dressings which measures 4cm in diameter. The nurse should initially do which appropriate nursing intervention? A. Change the ... C. Notify the clients surgeon of a potential hemorrhage D. Assess the presence of a drain

Last Answer : D. Assess the presence of a drain

n assisting the client to do deep breathing, coughing and turning to the sides on the first post-operative day, which nursing action would be most helpful for the client? A. Restate the importance of respiratory exercises B. Give the client reassurance that can he can cough, breathe deeply and turn to sides safely C. Administer the prescribed analgesic round the clock as prescribed D. Apply abdominal splint (pillow) while coughing

Description : n assisting the client to do deep breathing, coughing and turning to the sides on the first post-operative day, which nursing action would be most helpful for the client? A. Restate ... the prescribed analgesic round the clock as prescribed D. Apply abdominal splint (pillow) while coughing

Last Answer : D. Apply abdominal splint (pillow) while coughing

Which of the following terms is used to describe inability to breathe easily except in an upright position? a) Orthopnea Patients with orthopnea are placed in a high Fowler’s position to facilitate breathing. b) Dyspnea Dyspnea refers to labored breathing or shortness of breath. c) Hemoptysis Hemoptysis refers to expectoration of blood from the respiratory tract. d) Hypoxemia Hypoxemia refers to low oxygen levels in the blood.

Description : Which of the following terms is used to describe inability to breathe easily except in an upright position? a) Orthopnea Patients with orthopnea are placed in a high Fowler's position to facilitate ... blood from the respiratory tract. d) Hypoxemia Hypoxemia refers to low oxygen levels in the blood.

Last Answer : a) Orthopnea Patients with orthopnea are placed in a high Fowler’s position to facilitate breathing.

When the intern-in-charge did the skin prep and catheterized the client, the circulating nurse noticed when the intern withdrew the catheter from the vagina. What is your appropriate and immediate action? A. Stop the intern and do the catheterization yourself B. Offer to change the catheter C. Alcoholize the tip of the catheter before reinserting the catheter

Description : When the intern-in-charge did the skin prep and catheterized the client, the circulating nurse noticed when the intern withdrew the catheter from the vagina. What is your appropriate and ... . Offer to change the catheter C. Alcoholize the tip of the catheter before reinserting the catheter

Last Answer : B. Offer to change the catheter

The nurse assesses subtle personality changes, restlessness, irritability, and confusion in a patient who has sustained a fracture. The nurse suspects a) fat embolism syndrome. Cerebral disturbances in the patient with fat embolism syndrome include subtle personality changes, restlessness, irritability, and confusion.

Description : The nurse assesses subtle personality changes, restlessness, irritability, and confusion in a patient who has sustained a fracture. The nurse suspects a) fat embolism syndrome. Cerebral disturbances in ... severe, burning pain, local edema, hyperesthesia, muscle spasms, and vasomotor skin changes.

Last Answer : a) fat embolism syndrome. Cerebral disturbances in the patient with fat embolism syndrome include subtle personality changes, restlessness, irritability, and confusion.

The nurse assesses the dressing of a patient with a basal skull fracture and sees the halo sign - a blood stain surrounded by a yellowish stain. The nurse knows that this sign a) is highly suggestive of a cerebrospinal fluid (CSF) leak. The halo sign - a blood stain surrounded by a yellowish stain is highly suggestive of a cerebrospinal fluid (CSF) leak.

Description : The nurse assesses the dressing of a patient with a basal skull fracture and sees the halo sign - a blood stain surrounded by a yellowish stain. The nurse knows that this sign a) is highly ... following a basal skull fracture. The halo sign is highly suggestive of a cerebrospinal fluid (CSF) leak.

Last Answer : a) is highly suggestive of a cerebrospinal fluid (CSF) leak. The halo sign - a blood stain surrounded by a yellowish stain is highly suggestive of a cerebrospinal fluid (CSF) leak.

When the nurse assesses the patient and observes blue-red and dark brown plaques and nodules, she recognizes that these manifestations are associated with a) Kaposi’s sarcoma. Kaposi’s sarcoma is a frequent comorbidity of the patient with AIDS.

Description : When the nurse assesses the patient and observes blue-red and dark brown plaques and nodules, she recognizes that these manifestations are associated with a) Kaposi's sarcoma. Kaposi's sarcoma is ... syphilis. A painless chancre or ulcerated lesion is a typical finding in the patient with syphilis.

Last Answer : a) Kaposi’s sarcoma. Kaposi’s sarcoma is a frequent comorbidity of the patient with AIDS.

When the nurse observes the patient’s urine to be orange, she further assesses the patient for a) intake of medication such as phenytoin (Dilantin). Urine that is orange may be caused by intake of Dilantin or other medications. Orange to amber colored urine may also indicate concentrated urine due to dehydration or fever.

Description : When the nurse observes the patient's urine to be orange, she further assesses the patient for a) intake of medication such as phenytoin (Dilantin). Urine that is orange may be caused by intake ... white urine may indicate infection, pyruria, or in the female patient, the use of vaginal creams.

Last Answer : a) intake of medication such as phenytoin (Dilantin). Urine that is orange may be caused by intake of Dilantin or other medications. Orange to amber colored urine may also indicate concentrated urine due to dehydration or fever.

To prevent footdrop, the patient is positioned in: a) Order to keep the feet at right angles to the leg When the patient is supine in bed, padded splints or protective boots are used. b) A semi-sitting position in bed Semi-fowlers positioning is used to decrease the pressure of abdominal contents on the diaphragm. c) A sitting position with legs hanging off the side of the bed In order to prevent footdrop, the feet must be supported. d) A side-lying position Side-lying positions do not provide support to prevent footdrop.

Description : To prevent footdrop, the patient is positioned in: a) Order to keep the feet at right angles to the leg When the patient is supine in bed, padded splints or protective boots are used. b) ... must be supported. d) A side-lying position Side-lying positions do not provide support to prevent footdrop.

Last Answer : a) Order to keep the feet at right angles to the leg When the patient is supine in bed, padded splints or protective boots are used.

51. Albert came to the hospital with chest pain and fever. After a thorough assessment by the doctor, he was admitted for pericarditis management. The nurse positions the client to reduce pain and discomfort. Describe this position.

Description : 51. Albert came to the hospital with chest pain and fever. After a thorough assessment by the doctor, he was admitted for pericarditis management. The nurse positions the client to reduce pain and discomfort. Describe this position.

Last Answer : C. Sit the client upright and lean forward

The nurse instructs the nursing attendant to perform cleansing enema until the return flow is clear. The nursing attendant understood the instruction when she says, “I will A. Call you when the return flow is clear” B. Stop the enema only if the return flow is without formed fecal material” C. Need 1 liter of tap water to have clear return flow” D. Put the client in left Sim’s position to achieve the desired return flow.”

Description : The nurse instructs the nursing attendant to perform cleansing enema until the return flow is clear. The nursing attendant understood the instruction when she says, I will A. Call you when the return flow is ... flow D. Put the client in left Sim's position to achieve the desired return flow.

Last Answer : A. Call you when the return flow is clear”

88. When the nurse ensures that the client has plan for continuous care after leaving the health care facility and assists from the transition from one environment to another, she is doing a

Description : 88. When the nurse ensures that the client has plan for continuous care after leaving the health care facility and assists from the transition from one environment to another, she is doing a

Last Answer : A. Discharge plan

77. Nurse Kristine is to inject Demerol 75 mg to a post-TURP (transurethral resection of the prostate) client who is in pain. When she checked the narcotic cabinet, she found out a vial that is almost empty. She was able to aspirate 60 mg only. Nurse Kristine decided to inject it instead of making the client wait until the next Demerol vial is available. The action of the nurse violates which of the following ethical principles?

Description : 77. Nurse Kristine is to inject Demerol 75 mg to a post-TURP (transurethral resection of the prostate) client who is in pain. When she checked the narcotic cabinet, she found out a ... next Demerol vial is available. The action of the nurse violates which of the following ethical principles?

Last Answer : A. Justice

The first dressing change for an autografted area is performed a) as soon as foul odor or purulent drainage is noted, or 3-5 days after surgery. A foul odor or purulent infection may indicate infection and should be reported to the surgeon immediately.

Description : The first dressing change for an autografted area is performed a) as soon as foul odor or purulent drainage is noted, or 3-5 days after surgery. A foul odor or purulent ... is noted. Sanguineous drainage on a dressing covering an autograft is an anticipated abnormal observation postoperatively.

Last Answer : a) as soon as foul odor or purulent drainage is noted, or 3-5 days after surgery. A foul odor or purulent infection may indicate infection and should be reported to the surgeon immediately.

When the surgeon performs an appendectomy, the nurse recognizes that the surgical category will be identified as a) clean contaminated. Clean-contaminated cases are those with a potential, limited source for infection, the exposure to which, to a large extent, can be controlled. b) clean. Clean cases are those with no apparent source of potential infection. c) contaminated. Contaminated cases are those that contain an open and obvious source of potential infection. d) dirty. A traumatic wound with foreign bodies, fecal contamination, or purulent drainage would be considered a dirty case.

Description : When the surgeon performs an appendectomy, the nurse recognizes that the surgical category will be identified as a) clean contaminated. Clean-contaminated cases are those with a potential, limited ... with foreign bodies, fecal contamination, or purulent drainage would be considered a dirty case.

Last Answer : a) clean contaminated. Clean-contaminated cases are those with a potential, limited source for infection, the exposure to which, to a large extent, can be controlled.

85. When the surgeon asked for suture to close the abdomen, sponge count has not been completed. Which of the following is the appropriate action of the scrub nurse?

Description : 85. When the surgeon asked for suture to close the abdomen, sponge count has not been completed. Which of the following is the appropriate action of the scrub nurse?

Last Answer : D. Informs the surgeon that sponge count has not been completed

After the last stitch, the surgeon is ready to apply dressing to the incision wound. Which of the following does the nurse expect the surgeon to do? A. Remove his gloves and apply the dressing B. Apply the dressings and tape and then remove his gloves C. Put the dressings and remove his gloves to apply the tape D. Tape the dressing and remove the gloves

Description : After the last stitch, the surgeon is ready to apply dressing to the incision wound. Which of the following does the nurse expect the surgeon to do? A. Remove his gloves and apply the dressing B. ... the dressings and remove his gloves to apply the tape D. Tape the dressing and remove the gloves

Last Answer : C. Put the dressings and remove his gloves to apply the tape

When performing endotracheal suctioning, the nurse applies suctioning while withdrawing and gently rotating the catheter 360 degrees for which of the following time periods? a) 10-15 seconds In general, the nurse should apply suction no longer than 10-15 seconds because hypoxia and dysrhythmias may develop, leading to cardiac arrest. b) 30-35 seconds Applying suction for 30-35 seconds is hazardous and may result in the patient’s developing hypoxia, which can lead to dysrhythmias and, ultimately, cardiac arrest.

Description : When performing endotracheal suctioning, the nurse applies suctioning while withdrawing and gently rotating the catheter 360 degrees for which of the following time periods? a) 10-15 seconds In general ... suction for 0-5 seconds would provide too little time for effective suctioning of secretions.

Last Answer : a) 10-15 seconds In general, the nurse should apply suction no longer than 10-15 seconds because hypoxia and dysrhythmias may develop, leading to cardiac arrest.

A staff nurse was found charting blood glucose result without actually doing the procedure. What is the appropriate initial action of the senior nurse? A. Write and submit an explanation and reprimand as necessary B. Go on leave without pay C. Write an incident report D. Explain to the patient

Description : A staff nurse was found charting blood glucose result without actually doing the procedure. What is the appropriate initial action of the senior nurse? A. Write and submit an explanation and reprimand as necessary B. Go on leave without pay C. Write an incident report D. Explain to the patient

Last Answer : A. Write and submit an explanation and reprimand as necessary

The term given to the category of triage that refers to lifethreatening or potentially life-threatening injury or illness requiring immediate treatment is a) emergent. The patient triaged as emergent must be seen immediately.

Description : The term given to the category of triage that refers to lifethreatening or potentially life-threatening injury or illness requiring immediate treatment is a) emergent. The patient triaged as emergent ... . The triage category of immediate refers to non-acute, non-lifethreatening injury or illness.

Last Answer : a) emergent. The patient triaged as emergent must be seen immediately.

Bladder retraining following removal of an indwelling catheter begins with instructing the patient to follow a 2-3 hour timed voiding schedule. Immediately after the removal of the indwelling catheter, the patient is placed on a timed voiding schedule, usually two to three hours. At the given time interval, the patient is instructed to void. a) encouraging the patient to void immediately. Immediate voiding is not usually encouraged. The patient is commonly placed on a timed voiding schedule, usually within two to three hours.

Description : Bladder retraining following removal of an indwelling catheter begins with instructing the patient to follow a 2-3 hour timed voiding schedule. Immediately after the removal of the indwelling ... in the bladder after voiding, straight catheterization may be performed for complete bladder emptying.

Last Answer : a) encouraging the patient to void immediately. Immediate voiding is not usually encouraged. The patient is commonly placed on a timed voiding schedule, usually within two to three hours.

The figure shows a diagrammatic view of human respiratory system with labels A, B, C and D. Select the option which gives correct identification and main function and / or characteristic. (a) C - Alveoli - Thin walled vascular bag like structures for exchange of gases. (b) D - Lower end of lungs - Diaphragm pulls it down during inspiration. (c) A - Trachea - Long tube supported by complete cartilaginous rings for conducting inspired air. (d) B - Pleural membrane - Surround ribs on both sides to provide cushion against rubbing.

Description : The figure shows a diagrammatic view of human respiratory system with labels A, B, C and D. Select the option which gives correct identification and main function and / or characteristic. (a) C - ... air. (d) B - Pleural membrane - Surround ribs on both sides to provide cushion against rubbing.

Last Answer : (a) C - Alveoli - Thin walled vascular bag like structures for exchange of gases.

When the indication for surgery is without delay, the nurse recognizes that the surgery will be classified as a) emergency. Emergency surgery means that the patient requires immediate attention and the disorder may be life-threatening. b) urgent. Urgent surgery means that the patient requires prompt attention within 24-30 hours. c) required. Required surgery means that the patient needs to have surgery, and it should be planned within a few weeks or months. d) elective. Elective surgery means that there is an indication for surgery, but failure to have surgery will not be catastrophic.

Description : When the indication for surgery is without delay, the nurse recognizes that the surgery will be classified as a) emergency. Emergency surgery means that the patient requires immediate attention and the ... there is an indication for surgery, but failure to have surgery will not be catastrophic.

Last Answer : a) emergency. Emergency surgery means that the patient requires immediate attention and the disorder may be life-threatening.

Before the patient diagnosed with a concussion is released from the Emergency Department, the nurse teaches the family or friends who will be tending to the patient to contact the physician or return to the ED if the patient a) vomits. Vomiting is a sign of increasing intracranial pressure and should be reported immediately.

Description : Before the patient diagnosed with a concussion is released from the Emergency Department, the nurse teaches the family or friends who will be tending to the patient to contact the physician or ... for short periods of time. Difficulty in waking the patient should be reported or treated immediately.

Last Answer : a) vomits. Vomiting is a sign of increasing intracranial pressure and should be reported immediately.

The nurse who provides teaching to the female patient regarding prevention of recurrent urinary tract infections includes which of the following statements? a) Void immediately after sexual intercourse. Voiding will serve to flush the urethra, expelling contaminants.

Description : The nurse who provides teaching to the female patient regarding prevention of recurrent urinary tract infections includes which of the following statements? a) Void immediately after sexual intercourse. Voiding ... encouraged to void every 2-3 hours during the day and completely empty the bladder.

Last Answer : a) Void immediately after sexual intercourse. Voiding will serve to flush the urethra, expelling contaminants.

When the female client reports a frothy yellow-brown vaginal discharge, the nurse suspects the client has a vaginal infection caused by a) trichomonas vaginalis. Trichomonas vaginalis causes a frothy yellow-white or yellow-brown vaginal discharge.

Description : When the female client reports a frothy yellow-brown vaginal discharge, the nurse suspects the client has a vaginal infection caused by a) trichomonas vaginalis. Trichomonas vaginalis causes a ... the external vulva and vaginal walls. d) chlamydia. Chlamydia causes a profuse purulent discharge.

Last Answer : a) trichomonas vaginalis. Trichomonas vaginalis causes a frothy yellow-white or yellow-brown vaginal discharge.

99. The companion asks why the client was advised to avoid iron supplements or vitamins. The correct response of the nurse would be

Description : 99. The companion asks why the client was advised to avoid iron supplements or vitamins. The correct response of the nurse would be

Last Answer : A. “These supplements enhance the production of RBC.”

76. A client is being positioned for radical vulvectomy and a couple of clinical clerks wanted to come in to watch the surgery. The circulating nurse advise them to enter the OR suite later. Foremost, this decision of the nurse is directed towards

Description : 76. A client is being positioned for radical vulvectomy and a couple of clinical clerks wanted to come in to watch the surgery. The circulating nurse advise them to enter the OR suite later. Foremost, this decision of the nurse is directed towards

Last Answer : D. Preserving privacy

72. The client is to have surgery in 10 days. Lugol’s solution 4 gtts po was prescribed in 10 days. The client asked the nurse for the purpose of the drug. Which response of the nurse is correct?

Description : 72. The client is to have surgery in 10 days. Lugol’s solution 4 gtts po was prescribed in 10 days. The client asked the nurse for the purpose of the drug. Which response of the nurse is correct?

Last Answer : A. It decreases the risk of bleeding

69. When Marina checked the capillary blood glucose of the client at 6 PM before meals as instructed by the senior nurse, the result showed 65 mg/dl. Which of the following will Marina do first?

Description : 69. When Marina checked the capillary blood glucose of the client at 6 PM before meals as instructed by the senior nurse, the result showed 65 mg/dl. Which of the following will Marina do first?

Last Answer : C. Check the physician’s order in case CBG is below 70 mg/dl

64. The client was placed on a low sodium diet. The wife asks the nurse which foods to include in the client’s diet while at home. The nurse should instruct to include which of these?

Description : 64. The client was placed on a low sodium diet. The wife asks the nurse which foods to include in the client’s diet while at home. The nurse should instruct to include which of these?

Last Answer : C. Fruits and vegetables

62. A 30-year-old client had cholesterol blood test before admission to the hospital. The nurse in charge would teach the family and significant others that the client should exercise to help keep the total cholesterol to a desired level of

Description : 62. A 30-year-old client had cholesterol blood test before admission to the hospital. The nurse in charge would teach the family and significant others that the client should exercise to help keep the total cholesterol to a desired level of

Last Answer : A. 140 mg/dl

61. A client with gout asks the nurse what food must be avoided so that the family can provide support. Which food has the highest in purine content and must be excluded from the dietary plan?

Description : 61. A client with gout asks the nurse what food must be avoided so that the family can provide support. Which food has the highest in purine content and must be excluded from the dietary plan?

Last Answer : D. Liver

57. The client was prescribed Ocreotide acetate (Sandostatin). Nurse Carla would monitor for which of the following side effects?

Description : 57. The client was prescribed Ocreotide acetate (Sandostatin). Nurse Carla would monitor for which of the following side effects?

Last Answer : A. Abdominal pain

55. The nurse wants to know if the client is aware of the side effects of NSAID. What would be the most appropriate question of the nurse?

Description : 55. The nurse wants to know if the client is aware of the side effects of NSAID. What would be the most appropriate question of the nurse?

Last Answer : B. “Have you ever vomited blood or noticed very black stools?”

42. The nurse is to inject Vitamin B intramuscularly to another elderly client. Before injecting, the nurse explained that the client may feel some discomfort. This is an example of

Description : 42. The nurse is to inject Vitamin B intramuscularly to another elderly client. Before injecting, the nurse explained that the client may feel some discomfort. This is an example of

Last Answer : C. Anticipatory response

41. For a client complaining of mild musculoskeletal pain, the nurse will anticipate that the treatment for this client’s level of discomfort will include which of the following?

Description : 41. For a client complaining of mild musculoskeletal pain, the nurse will anticipate that the treatment for this client’s level of discomfort will include which of the following?

Last Answer : B. Acetaminophen

40. The nurse should ensure that all components of medications are documented. Identify all these components. 1. Dosage, route and frequency 2. Name of client and medication 3. Date and time the medication was ordered 4. Dosage, route, frequency and strength 5. Physician’s signature and specialty 6. Physician’s signature and PRC license number

Description : 40. The nurse should ensure that all components of medications are documented. Identify all these components. 1. Dosage, route and frequency 2. Name of client and medication 3. Date and time ... and strength 5. Physician's signature and specialty 6. Physician's signature and PRC license number

Last Answer : C. All except 5 and 6

38. A nurse encounters a client who refuses to take a prescribed medication. What is the appropriate action of the nurse?

Description : 38. A nurse encounters a client who refuses to take a prescribed medication. What is the appropriate action of the nurse?

Last Answer : C. Explore the possible reason why the client refuses the prescribed medication

Reviewing the laboratory findings of the client, the nurse would found which findings are elevated? 1. White blood cell count 2. Total serum bilirubin 3. Alkaline phosphate 4. Red blood cell count 5. Cholesterol 6. Serum amylase A. 1, 2, and 3 B. 2, 3, and 4 C. 3, 5, and 6 D. 1, 2, and 6

Description : Reviewing the laboratory findings of the client, the nurse would found which findings are elevated? 1. White blood cell count 2. Total serum bilirubin 3. Alkaline phosphate 4. Red blood cell count 5. Cholesterol 6. Serum amylase A. 1, 2, and 3 B. 2, 3, and 4 C. 3, 5, and 6 D. 1, 2, and 6

Last Answer : A. 1, 2, and 3

To confirm the diagnosis of cholecystitis, the attending physician ordered a procedure that can detect gallstones as small as 1 – 2 cm and inflammation. The nurse would prepare the client for which specific diagnostic procedure? A. Cholangiography B. Ultrasonography C. Gall bladder series D. Oral cholecystogram

Description : To confirm the diagnosis of cholecystitis, the attending physician ordered a procedure that can detect gallstones as small as 1 - 2 cm and inflammation. The nurse would prepare ... specific diagnostic procedure? A. Cholangiography B. Ultrasonography C. Gall bladder series D. Oral cholecystogram

Last Answer : B. Ultrasonography