1. A75-year-old cient who is newy admitted to a longterm care…

Question Answered step-by-step 1. A75-year-old cient who is newy admitted to a longterm care… 1. A75-year-old cient who is newy admitted to a longterm care facility which nursing diagnosed is the priority O sleep pattern disturbance O chronic pain O Anxiety o risk for injury 2.Which action is priority for a client reporting fatigue loss of appetite, and feeling light headed following working outside in the summer O Check the clients body temperature. O Cluster activities to provide rest periods. O Measure the dients curenineighrandherght. O Encourage the dent to drink fluids. 3.The nurse charts on all assigned clients at 2:00 P.M. The nurse then remembers sometting that happened to a client at 9:00 am treatment charted. Which action would the nurse take? O Put the information in the margin and indicate the accurate time placement by drawing an arrow . O Enter the scenario after the original 2,00 P.M. charting and mark it as a “late entry” O Include the 9,00 A.M. scenario in the shift report. O Draw a line through the previous charting with error and then re record everything including the new information. 4. Which assignment, delegated to unlicensed assistive personnel by a nurse is appropriate O The UAP signed to measure a clients intake and output OThe UAP is assigned to assess a client’s lung sound O The UAP is assigned to teach a client about diet 5.A client has had a laparoscopic bilateral tubal ligation (BTL)in the delivery room Which intervention should the nurse plan to include in the client postoperative care? O Keep the head of the client bed flat for six hours O Provide the client with an abdominal binder O Encourage the client to drink cold, carbonated fluids throughout the day O Advise the client t hat she may experience shoulder pain 6.A nurse observes that a client who underwent major abdominal surgery yesterday is lying in bed crying with muscle tensed which action should the nurse takes to establish a nursing diagnosis of pain related to an abdominal incision? O Continue to observe the client O Ask the client describe the discomfort . O Administer the prescribed analgesic and document the client’s response O ask the client to progressively relax the muscle groups 7. Which action should the nurse take after assessing a 2-day old wound that has a crust along the edges is red and appears slightly O Apply warm soaks to reduce the inflammation . O Place the client on contact wound precautions O Notify the health care provider immediately of the infection . O Document the findings and continue to montor the wound8. Which assignment, delegated to unlicensed assistive personnel(UAP) by a nurse is appropriate O The UAP is assigned to measure a clients intake and out put O The UAP assigned to assess a client’s lung sounds O The UAP is assigned to change a client postoperative wound dressing O The UAP is assigned to teach a client about diet 9. A client with osteoarthritis of the hips and knees has received instructions on how to use a walker for ambulation which behaviors does by the does the nurse indicate the client understands the instructions? O The client places full weight on the walker with the arms while taking steps O The client bears weight on both Feet while moving The Walker ahead O The client keeps the feet close together While while standing In place O The client Leans forward Add at 60 Degree while Stepping into the walker 10.A 1-year-old client with human immunodeficiency virus (HIV) is diagnosed with cerebellar atrophy Which benar would be Consider with cerebella atrophy? O The client is unable to hold a crayon O The client vomits when positioning is changed O The client has Tachypnea O The client has become incontment of urine 11.A primigravida who is at 40 weeks gestation is admitted to the labor and delivery unit in Active labor To Help Facilitate the progress Off the client labor, which nursing action should be included in her nursing care? O Encourage her to apply downward pressure on her uterus during Contractions. O Have her ambulate every 30 minutes until she is completely dilated. O Encourage her to void at frequent Interval O Have her inhale some Oxygenwith each Contraction. 12.When turning a client to the side-lying position, which actions should a nurse tate? O Pace a rolled allow Parallel/to the denis bode O Place a small allow under the ciensumbe sphe. O Put a small pillow under the diens antes OPutafootboardagans:the botomotederstret. 13.When using wrist restraints, to which part of the bed should the nurse secure the his in order to keep a chert sle? O The side ralls. O The footbeard. O The movable frame. O The headboard 14.Which of these clients is at increased risk for developing a nosocomial infection? O A 55 year-old client who suffered multiple trauma and is In bed Balanced traction. O A71.year-old dient who had a stroke and has a Foley catheter. O A 44 year-old dient who has a fractured leg in a long leg cast. C A 79year-old client who has decreased mobility related to chronic osteoporosis. 15.An 18-month-old child is admitted to the hospital for repair of a cleft palate. After the surgery, the client transferred to the pediatric unit the childis to be offered liquids by mouth. Which method would be most appropriate to use in feeding the child? O Aplastic cup. O A paper cup with a straw. O A bottle with a large hole nipple. O A training cup with a mouthpiece. 16.A woman is treated in the emergency room for a broken arm and multiple facial bruises caused by her spouse Witch Statement Made by nurse Is it therapeutic? O Can you think of what you did to cause this abuse O You should leave this relationship now or you will be sorry O This type of abuse typically recurs after a period of remorse by the abuser: O ‘Are you aware that women who reman in abuse relationships eventually are killed 17.A client says to a nurse, “I am the queen bee You need to bow before me ” Which of these responses if made by the nurse is non Therapeutic O.How can you be a queen? O let’s talk about the unit schedule” O We are in a hospital* O ‘Right now, we are discussing your medications* 18.A12-month-old client is admitted to the hospital for open heart surgery for repair of the ventricular sectal defect When preparing the client for surgery, which intervention would be most appropriate? O Allow the child’s mother to stay in the preoperative area until the chid Sedated prior to surgery O Explain to the child the functioning of the cardiopulmonary Bypass machine To be used during surgery O show the child the surgical room and all the equipment OHave the child play with suture material similar to what will be used on the Child’s skin incision  Health Science Science Nursing EXAM 123A Share QuestionEmailCopy link Comments (0)