PN FUNDAMENTALS PROCTORED EXAM TEST BANK 2024-2025, Exams of Nursing

Download PN FUNDAMENTALS PROCTORED EXAM TEST BANK 2024-2025 and more Exams Nursing in PDF only on Docsity! 1 | P a g e PN FUNDAMENTALS PROCTORED EXAM TEST BANK 2024-2025 WITH ACTUAL CORRECT QUESTIONS AND VERIFIED DETAILED ANSWERS |FREQUENTLY TESTED QUESTIONS AND SOLUTIONS |ALREADY GRADED A+|NEWEST |GUARANTEED PASS |LATEST UPDATE An unlicensed assistive personnel (UAP) places a client in a left lateral position prior to administering a soap suds enema. Which instruction should the LPN/LVN provide the UAP? Reposition in a Sim's position with the client's weight on the anterior ilium. A client who is a Jehovah's Witness is admitted to the nursing unit. Which concern should the LPN have for planning care in terms of the client's beliefs? Blood transfusions are forbidden The LPN/LVN observes that a male client has removed the covering from an ice pack applied to his knee. What action should the nurse take first? Observe the appearance of the skin under the ice pack The LPN/LVN mixes 50 mg of Nipride in 250 ml of D5W and plans to administer the solution at a rate of 5 mcg/kg/min to a client weighing 182 pounds. Using a drip factor of 60 gtt/ml, how many drops per minute should the client receive? 124 gtt/min A hospitalized male client is receiving nasogastric tube feedings via a small-bore tube and a continuous pump infusion. He reports that he had a 2 | P a g e bad bout of severe coughing a few minutes ago, but feels fine now. What action is best for the LPN/LVN to take? After clearing the tube with 30 ml of air, check the pH of fluid withdrawn from the tube. A male client being discharged with a prescription for the bronchodilator theophylline tells the nurse that he understands he is to take three doses of the medication each day. Since, at the time of discharge, timed-release capsules are not available, which dosing schedule should the LPN advise the client to follow? 8 a.m., 4 p.m., and midnight A client is to receive 10 mEq of KCl diluted in 250 ml of normal saline over 4 hours. At what rate should the LPN/LVN set the client's intravenous infusion pump? 63 ml/hour An obese male client discusses with the LPN/LVN his plans to begin a long-term weight loss regimen. In addition to dietary changes, he plans to begin an intensive aerobic exercise program 3 to 4 times a week and to take stress management classes. After praising the client for his decision, which instruction is most important for the nurse to provide? Be sure to have a complete physical examination before beginning your planned exercise program. The LPN is teaching a client proper use of an inhaler. When should the client administer the inhaler-delivered medication to demonstrate correct use of the inhaler? During the inhalation. The healthcare provider prescribes the diuretic metolazone (Zaroxolyn) 7.5 mg PO. Zaroxolyn is available in 5 mg tablets. How much should the LPN/LVN plan to administer? 1½ tablets. hand is Lasix 20 mg/2 ml. How many milliliters should the LPN/LVN administer? 1.5 ml. Heparin 20,000 units in 500 ml D5W at 50 ml/hour has been infusing for 5½ hours. How much heparin has the client received? 11,000 units. 5 | P a g e An elderly client who requires frequent monitoring fell and fractured a hip. Which LPN/LVN is at greatest risk for a malpractice judgment? The nurse who transferred the client to the chair when the fall occurred A postoperative client will need to perform daily dressing changes after discharge. Which outcome statement best demonstrates the client's readiness to manage his wound care after discharge? The client demonstrates the wound care procedure correctly. When evaluating a client's plan of care, the LPN determines that a desired outcome was not achieved. Which action will the LPN implement first? Note which actions were not implemented The healthcare provider prescribes 1,000 ml of Ringer's Lactate with 30 Units of Pitocin to run in over 4 hours for a client who has just delivered a 10 pound infant by cesarean section. The tubing has been changed to a 20 gtt/ml administration set. The LPN/LVN plans to set the flow rate at how many gtt/min? 83 gtt/min Seconal 0.1 gram PRN at bedtime is prescribed to a client for rest. The scored tablets are labeled grain 1.5 per tablet. How many tablets should the LPN/LVN plan to administer? 1 tablet. Which assessment data would provide the most accurate determination of proper placement of a nasogastric tube? Examining a chest x-ray obtained after the tubing was inserted. The nurse is caring for a client who is receiving 24-hour total parenteral nutrition (TPN) via a central line at 54 ml/hr. When initially assessing the client, the nurse notes that the TPN solution has run out and the next TPN solution is not available. What immediate action should the LPN/LVN take? Infuse 10 percent dextrose and water at 54 ml/hr When assisting an 82-year-old client to ambulate, it is important for the LPN/LVN to realize that the center of gravity for an elderly person is the Upper torso In developing a plan of care for a client with dementia, the LPN/LVN should remember that confusion in the elderly often follows relocation to new surroundings. 6 | P a g e An elderly male client who suffered a cerebral vascular accident is receiving tube feedings via a gastrostomy tube. The LPN knows that the best position for this client during administration of the feedings is Fowler's. The nurse notices that the mother a 9-year-old Vietnamese child always looks at the floor when she talks to the nurse. What action should the LPN take? Continue asking the mother questions about the child. When conducting an admission assessment, the LPN should ask the client about the use of complimentary healing practices. Which statement is accurate regarding the use of these practices? Many complimentary healing practices can be used in conjunction with conventional practices A young mother of three children complains of increased anxiety during her annual physical exam. What information should the LPN/LVN obtain first? Nutritional history. Three days following surgery, a male client observes his colostomy for the first time. He becomes quite upset and tells the LPN that it is much bigger than he expected. What is the best response by the nurse? Instruct the client that the stoma will become smaller when the initial swelling diminishes. At the time of the first dressing change, the client refuses to look at her mastectomy incision. The LPN tells the client that the incision is healing well, but the client refuses to talk about it. What would be an appropriate response to this client's silence? It is OK if you don't want to talk about your surgery. I will be available when you are ready. A client who is in hospice care complains of increasing amounts of pain. The healthcare provider prescribes an analgesic every four hours as needed. Which action should the LPN/LVN implement? Give an around-the-clock schedule for administration of analgesics. When assessing a client with wrist restraints, the nurse observes that the fingers on the right hand are blue. What action should the LPN implement first? Loosen the right wrist restraint. 7 | P a g e The LPN/LVN is assessing the nutritional status of several clients. Which client has the greatest nutritional need for additional intake of protein? A lactating woman nursing her 3-day-old infant. A client is in the radiology department at 0900 when the prescription levofloxacin (Levaquin) 500 mg IV q24h is scheduled to be administered. The client returns to the unit at 1300. What is the best intervention for the LPN/LVN to implement? Give the missed dose at 1300 and change the schedule to administer daily at 1300. While instructing a male client's wife in the performance of passive range- of-motion exercises to his contracted shoulder, the nurse observes that she is holding his arm above and below the elbow. What nursing action should the LPN/LVN implement? Acknowledge that she is supporting the arm correctly What is the most important reason for starting intravenous infusions in the upper extremities rather than the lower extremities of adults? A decreased flow rate could result in the formation of a thrombosis The LPN observes an unlicensed assistive personnel (UAP) taking a client's blood pressure with a cuff that is too small, but the blood pressure reading obtained is within the client's usual range. What action is most important for the nurse to implement? Reassess the client's blood pressure using a larger cuff A client is to receive cimetidine (Tagamet) 300 mg q6h IVPB. The preparation arrives from the pharmacy diluted in 50 ml of 0.9% NaCl. The LPN plans to administer the IVPB dose over 20 minutes. For how many ml/ hr should the infusion pump be set to deliver the secondary infusion? 150 Twenty minutes after beginning a heat application, the client states that the heating pad no longer feels warm enough. What is the best response by the LPN/LVN The body's receptors adapt over time as they are exposed to heat The LPN is instructing a client with high cholesterol about diet and life style modification. What comment from the client indicates that the teaching has been effective? I will limit my intake of beef to 4 ounces per week 10 | P a g e A charge nurse smells smoke, enters the visitor restroom, and sees flames in the trash can. What is the sequence of actions that the nurse should take? evacuate clients from the area, Pull the lever on the fire alarm, close the fire doors on the unit, use a fire extinguisher to put out the fire. A nurse is using Maslow's hierarchy of needs in assisting with discharge planning for a client. Which of the following activities should the nurse recommend as the priority for this client? Attend an exercise program. A nurse is reinforcing teaching with a client about using guided imagery. Which of the following actions should the nurse take? Direct the client to visualize tension leaving the body. A nurse is caring for a client who has recently undergone a total bilateral mastectomy. Which of the following statements by the client requires immediate action by the nurse? "When i look at myself in the mirror, I don't know if i can go on." A nurse is assisting with the plan of care for a client who has aphasia following a stroke. Which of the following interventions should the nurse use to assist the client with communication? Ask the client close-ended questions. A nurse is reinforcing teaching about the use of crutches with a client who has a fractured right tibia and fibula. Which of the following statements by the client indicates an understanding of the teaching? I will be sure to keep the crutch tips frequently and keep them dry at all times. A nurse is reinforcing teaching with a group of clients about carbon monoxide poisoning. Which of the following information should the nurse include in the teaching? Headache is a manifestation of carbon monoxide poisoning. A nurse is contributing to the plan of care for a client who has a prescription for elastic bandages to the lower extremities. Which of the following actions should the nurse recommend for the plan of care? compare thr client's pedal pulses bilaterally everyy 4 hr. A client who has advanced cancer tells the nurse that he has a difficult time talking to anyone about the illness. Which of the following actions should the nurse take to encourage therapeutic communication? let the client know that he is avalable and willing to listen A nurse is reviewing the medical record of a client who has heart failure. The nurse should identify which of the following lab results as an indication that the client has fluid volume excess? BUN 8mg/dL A nurse is reinforcing teaching with a client who has a prescription for a transcutaneous electrical nerve stimulation (TENS) unit. Which of the following information should the nurse include in the teaching? 11 | P a g e Place the electrodes near the pain site. A nurse is caring for a client who has an NG tube and is receiving a continuous enteral feeding. Which of the following actions should the nurse take? Hold the feeding for two consecutive gastric residuals greater than 250 mL. A client who has a recent below-the-knee amputation says, "I don't know how i can continue to live my life without my leg." Which of the following responses should the nurse make? "Tell me what concerns you have about your future." A nurse is reinforcing teaching with an older adult client who reports an inability to sleep. Which of the following information should the nurse include when teaching the client about aging and sleep? Sleep patterns change with age. A nurse is assisting with a presentation to a group of older adults at a community center about hypothermia and hyperthermia. Which of the following information should the nurse include about age- related changes? Circulation becomes less efficient with age. A nurse is caring for a client who is refusing medical treatment. Which of the following actions should the nurse take? Document the client'a refusal of the treatment A nurse is preparing to administer an enteral feeding to a client who has an NG tube in place. Which of the following methods should the nurse use to verify correct placement of the NG tube? Check the pH of gastric aspirate A nurse is caring for a client who is postoperative and is experiencing cause and vomiting. The nurse should identify which of the following findings as indications that the client has fluid volume deficit? (Select all that apply) Decreased skin turgor, orthostatic hypotension, flat neck veins. A nurse is contributing to the plan of care for a client who has a positive throat culture for strep. Which of the following interventions should the nurse recommend to be included in the plan of care? Ensure the client wears a surgical mask during transportation throughout the facility. A nurse is caring for a client who has a prescription for potassium supplement. The client tells the nurse that the pill is too large to swallow and refuses to take it. The nurse offers to break to pill into two smaller pieces. The nurse is demonstrating which of the following ethical principles? Beneficence A nurse is reinforcing teaching with a client who has hearing loss about how to modify his home environment. Which of the following is a priority modification that the nurse should include? 12 | P a g e Flashing smoke alarm A nurse has delegated various client care tasks to the assistive personnel (AP) on the care team. Which of the following actions by the AP should the nurse identify as correct? Donning a mask to measure the vital signs of a client who has pertussis. A nurse is collecting data from a client who is menopausal. Which of the following statements indicates that the nurse should screen the client for depression? "My family doesn't need me anymore. I've failed them in so many ways." A nurse is preparing to administer a topical medication to a client. Which of the following actions should the nurse take first? Compare the label of the medication container with the medication administration record (MAR) three times. A nurse is speaking with a client who has type 2 diabetes and a prescription for insulin. The client verbalizes anger about having to take insulin. Which of the following responses should the nurse make? "I see that you are angry. Let's sit down and talk." A nurse is collecting data from an older adult client. Which of the following findings should the nurse report to the provider? The client reports urinary incontinence A nurse is reinforcing teaching with an older adult client about oral hygiene. Which of the following should the nurse include in the teaching? Replace her toothbrush following an illness A nurse is caring for a client who has metastatic cancer and practices Catholicism. The client asks the nurse to discuss the afterlife with her. Which of the following statements by the nurse assists in meeting the client's spiritual needs? "Tell me what the afterlife means to you." A nurse is caring for a client who is receiving continuous NG tube feedings. The nurse listens to the client's bowel sounds. Which of the following actions should the nurse take? Decrease the rate of the feeding A nurse is assisting with the plan of care for four clients. Which of the following tasks should the nurse assign to an assistive personnel (AP)? "Assist a client to get out of bed after breathing treatment." A nurse is assisting with the plan of acre for a client who has bacterial interventions and a specific oral temperature should the nurse include in the plan of acer etc treat that fever? administer acetaminophen 15 | P a g e A nurse is reinforcing teaching with the partner of a client who has left-sided weakness about how to safely move the client from a bed to a chair at home. which of the following statements by the partner indicates an understanding of the teaching? I'll bend at the knees when lifting to get better leverage A nurse is reinforcing teaching about health promotion with an older adult client. Which of the following instructions to the client is an example of secondary prevention? Participate in screenings for tuberculosis A nurse is monitoring an assistive personnel (AP) who is measuring a client's oxygen saturation using a pulse oximeter. Which of the following observations by the nurse indicates that the AP is correctly performing the task? The AP chooses a site with a capillary refill of less than 2 seconds. A nurse is reviewing the laboratory results of a client who has malnutrition and has been receiving total parenteral nutrition (TPN). The nurse should identify that which of the following laboratory values indicates the treatment has been effective? Prealbumin 28 mg/dL A nurse is preparing to perform wound irrigation for a client who has a stage IV pressure ulcer. Which of the following images indicates the appropriate supply the nurse should plan to use? Nurse should select a 30 to 60 mL syringe and use an 18 to 19 gauge needle to irrigate the client's wound. A nurse is caring for a client who has vancomycin-resistant enterococci (VRE) in a wound. Which of the following actions should the nurse take to control the transmission of this infection? Wear a gown when assisting the client with hygiene care A nurse is contributing to the plan of care for a client who follows a kosher diet. Which of the following dietary interventions should the nurse expect to include in the plan? Withhold foods that contain both meat and dairy products A nurse is caring for a client who states that he is concerned that his neighbor, who works as an assistive personnel (AP) on another inpatient unit, will access his records and share his information with others. Which of the following is an appropriate response by the nurse? "only those who are involved with some aspect of your care may access your health care information" A nurse is preparing to administer a medication intramuscularly to an adult client. Which of the following is the preferred site for administering the medication to this client? Ventrogluteal 16 | P a g e A nurse is reinforcing discharge teaching about preventing thrombophlebitis with a client who is postoperative. Which of the following statements by the client indicates an understanding of the teaching? "I will do leg exercises every 1 to 2 hours while I am awake" A nurse is reinforcing teaching about health promotion with a client. Which of the following actions should the nurse take first to promote effective learning? Identify areas of concern A nurse is providing change-of-shift report for a client who had a stroke 48 hr ago. Which of the following information should the nurse include in the report? The client's Glasgow coma scale score A nurse is caring for a client who has cancer and is asking about hospice care. Which of the following responses should the nurse make? The hospice staff's focus is to relieve your pain and distress A nurse in a community center is reinforcing teaching about health risks with a group of adolescent clients. Which of the following topics is the priority for this age group? Driving while intoxicated A nurse is caring for a client who is upset about receiving a terminal diagnosis. The client states, "I want some time alone to pray," Which of the following is an appropriate response by the nurse? How much time alone do you think you will need A nurse is caring for a client who reports difficulty sleeping due to the noise on the nursing unit. Which of the following actions should the nurse take to reduce environmental noise? Close the door to the client's room A nurse is collecting date from an older adult client. Which of the following findings is an indication of infection? Change in mental status A nurse is reinforcing teaching about guided imagery with a client who has chronic pain. Which of the following information should the nurse include? This method uses the mind to create pictures to produce physical changes in the body A nurse is assisting with the admission of a client who has varicella. Which of the following isolation precautions should the nurse implement? Place a surgical mask on the client during transport. 17 | P a g e A nurse is caring for a client who is 1 day postoperative following an abdominal hysterectomy. The client states, "I am so sad that I can't have any more children." Which of the following is a therapeutic response by the nurse? "I will stay with you while we talk some more about this." A nurse is reinforcing dietary teaching with a client who is receiving chemotherapy and has lost 6.8 kg (15 lb) since beginning therapy. Which of the following client statements indicates an understanding of the teaching? "I will replace water in recipes with whole milk" A nurse is caring for a client who is postoperative following an above-the-knee amputation. The client tells the nurse he doesn't want to go to physical therapy and is "ready to give up." Which of the following responses should the nurse make? "You sound like you are feeling pretty discourage." A nurse is reinforcing teaching with an older adult client about home safety. Which of the following instructions should the nurse include? Refrigerate foods within 2 hours after being at room temperature A nurse is reviewing a client's laboratory results. Which of the following findings should the nurse report to the charge nurse as a manifestation of infection? Neutrophils 80% A nurse is documenting client care in a client's medical record. The nurse should document which of the following notes as a subjective data? The client reports a mild burning pain on his buttocks A nurse is assisting in the plan of care for a client who has a closed-wound drainage system. Which of the following interventions should the nurse include in the plan? Compress the bulb to re-establish constant low negative pressure A nurse is assisting with the plan of care for an older adult client. When planning care, the nurse should consider that which on the following is a common physiological change that occurs with aging? Decreased subcutaneous fat A nurse is reinforcing teaching with an assistive personnel (AP) about positioning a client who has GERD. Which of the following actions by the AP indicates an understanding of the teaching? The AP positions the foot of the client's bed lower than the head of the bed. A nurse is reinforcing teaching with a client who has a new prescription for home oxygen therapy with an oxygen tank. Which of the following statements by the client indicates an understanding of the teaching? "I will replace my wool blanket with one made of cotton material." 20 | P a g e A nurse is reinforcing teaching with a client who has a prescription for crutches. What is the correct method of going up stairs when using crutches? ( Move the steps into the box on the right, placing them in the selected order of performance. Use all the steps.) Stand in the tripod position, place the unaffected food onto the stair, shift body weight to the unaffected leg, A nurse observes an assistive personnel (AP) reprimanding a client for not using the urinal properly. The AP tells him she will put a diaper on him if she does not use the urinal more carefully next time. Which of the following torts is the AP committing? Assault A nurse is caring for a competent adult client who tells the nurse that he is thinking about leaving the hospital against medical advice. The nurse believes that this is not in the client's best interest, so she prepares to administer PRN sedative medication the client has not requested along with his usual medication. Which of the following types of tort is the nurse about to commit? False imprisonment A nurse in a surgeon's office is providing preoperative teaching for a client who is scheduled for surgery the following week. The client tells the nurse that he will prepare his advance directives before he goes to the hospital. Which of the following statements made by the client should indicate to the nurse an understanding of advance directives? I plan to write that I don't want them to keep me on a breathing machine." A nurse is caring for a client who is about to undergo an elective surgical procedure. The nurse should take which of the following actions regarding informed consent? (Select all that apply.) Make sure the surgeon obtained the client's consent. Witness the client's signature Zon the consent form. A nurse has noticed several occasions in the past week when another nurse on the unit seemed drowsy and unable to focus on the issue at hand. Today, she found the nurse asleep in a chair in the break room when she was not on a break. Which of the following actions should the nurse take? Report the observations to the When entering a client's room to change a surgical dressing, a nurse notes that the client is coughing and sneezing. Which of the following actions should the nurse take when preparing the sterile field? Place a mask on the client to limit the spread of micro-organisms into the surgical wound. A nurse has removed a sterile pack from its outside cover and placed it on a clean work surface in preparation for an invasive procedure. Which of the following flaps should the nurse unfold first? The flap farthest from the body A nurse is wearing sterile gloves in preparation for performing sterile procedure. Which of the a touch without following objects can the nurse breaching sterile technique? (Select all that apply) 21 | P a g e The inner wrapping of an item on the sterile field An irrigation syringe on the sterile field One gloved hand with the other gloved hand A nurse is reviewing hand hygiene techniques with a group of assistive personnel (AP). Which of the following instructions should the nurse include when discussing handwashing? (Select all that apply) Wash the hands with soap and water for at least 15 seconds. Use a clean paper towel to turn off hand faucets. A nurse has prepared a sterile field for assisting a provider with a chest tube insertion. Which of the following events should the nurse recognize as contaminating the sterile field? (Select all that apply) The nurse moistens a cotton ball with sterile normal saline and places it on the sterile field. The procedure is delayed 1 hr because the provider receives an emergency call. The nurse turns to speak to someone who enters through the door behind the nurse. A nurse is discussing restorative health care with a newly licensed nurse. Which of the following examples should the nurse include in the teaching? Home health care Rehab facilities Skilled nursing facilities A nurse is explaining the various types of health care coverage. Which of the following health care financing mechanisms are federally funded? Medicare Medicaid A nurse manager is developing strategies to care for the increasing number of clients who have obesity. Which of the following actions should the nurse include as a primary health care strategy? Collaborating with providers to perform obesity screenings during routine office visits A nurse is discussing the purpose of regulatory agencies during a staff meeting. Which of the following tasks should the nurse identify as the responsibility of state licensing boards? Ensuring that health care providers comply with regulations A nurse is explaining the various levels of health care services to a group of newly licensed nurses. Which of the following examples of care or care settings should the nurse classify as tertiary care? (SATA) ICU Oncology treatment center Burn center Which clients should a nurse initiate a referral to a social worker 22 | P a g e A client with terminal cancer requests hospice care in home A client asks about community resources available for older adults A client requests an electric wheelchair for use after discharge Who should you refer a patient to see that has trouble with self feeding Occupational therapist Who can help a client understand medications and their effects? Provider Pharmacist RN A patient who has dysphagia should be referred to Speech-language pathologist CNAs can assist with Bathing Ambulation Toileting Vitals A patient refuses surgery for his blockages, his choice is an example of Autonomy Giving pain medicine to a client before ambulation is an example of Beneficence Organ donation requirements and qualifications ensures Justice A nurse questions a medication prescription as too extreme in light of the client's advanced age and unstable status. The nurse understands that this action is an example of which of the following ethical principles? A. Fidelity B. Autonomy C. Justice D. Nonmaleficence Nonmaleficence example of an ethical dilemma Family has conflicting feelings about initiation of enteral tube feedings What information should be included in the change of shift report 25 | P a g e Document the client wishes about organ donation Introduce the client to his roommate A client who had a stroke is about to be transferred to a rehab center what is the responsibility of the nurse Ensure the client has possession of his valuables confirm the rehab center has a room available at the time of transfer give verbal transfer report over the telephone complete a transfer form to for the receiving facility A patient preparing to be discharged after knee surgery, what information does the nurse include in the discharge summary Follow up care instructions for diet and medications contact information for the home healthcare agency During admission of a patient with dementia to long-term care facility what priority information should the nurse obtain from the family in regards to diet If the patient has any difficulty swallowing What action should the nurse take prevent falls in a nursing home call bell within reach provide nonskid footwear complete fall risk assessment What statement by the nurse requires further instruction for patient with seizures I will go to the nurses station for assistance The nurse observes smoke coming from the door of the nurses lounge what is her first action Remove nearby clients A nurse has a patient with history of falls what is her first priority Complete a fall risk assessment When assigning rooms to clients to prevent falls which of the following clients should the nurse assign closest to the nurses station An older client who was postop knee amputation What is the rationale for reporting infectious diseases such as SARS Planning and evaluating control prevention strategies Determine public health priorities ensure proper medical treatment monitoring for a common source outbreaks Patient presents with linear clusters of fluid filled vesicles with some crusting the nurse should identify this manifestation as what 26 | P a g e Herpes zoster The client reports severe sore throat pain when swallowing and swollen lymph nodes the patient is experiencing what stage of infection Illness What is the prodromal period? short period after incubation; early, mild symptoms What is the incubation period? the period between exposure to an infection and the appearance of the first symptoms What is convalescence? period of recovery systematic infection affects the entire body Symptoms or manifestations of a systemic infection Fever malice increase in pulse and respiratory rate What intervention should be made for patient being admitted with pertussis Wear a mask within 3 feet of the client place a surgical mask on the client when transporting wear a gown when performing care that might result in secretions A patient and older patient who describes having difficulty dealing with several issues which is most concerning I keep forgetting which medications I have taken during the day Patient has lost 9.9 pounds since his admission six months ago what instructions should the nurse give Eat foods that are easy to eat such as finger foods invite family members to eat meals with you exercise every day to increase appetite Which interventions should the nurse plan to teach to a group of older adults about health promotion and disease prevention Pneumococcal immunization yearly eye exam periodic mental health screening annual physical occult blood test 27 | P a g e Recommendations given to an older adult on how to improve nutritional status Increase protein to increase muscle mass increase calcium intake to prevent osteoporosis limit sodium intake to prevent Edema increase fiber to prevent constipation What are normal findings on an assessment of an older client related to aging Decreased height nail thickening decreased bladder capacity A nurse is planning care for patient with hyper natremia which of the following actions should the nurse anticipate including in the plan of care Infuse hypotonic IV fluids What is a risk factor for developing hypocalcemia Crohn's disease If a patient has a potassium level of 5.2 what should the nurse anticipate Initiating continuous cardiac monitoring because it indicates hyperkalemia which increases the risk of arrhythmia's A patient has a history of long-term use of glucocorticoids causing hypercalcemia what findings should the nurse anticipate Confusion bone pain nausea and vomiting When providing education for patient with severe hypomagnesemia what information should you provide Educate your patient on deep tendon reflexes that will need to be monitored The nurse is caring for a patient who has been sitting in a chair for one hour what is the greatest risk to the client Pressure ulcer When caring for postop patient what are interventions to reduce the risk of thrombus Apply elastic stockings assist the client to change position often A nurse is planning care for a patient who was on bedrest what intervention should she include Encourage the patient to perform antiembolic exercises every two hours 30 | P a g e which of the following intervention should the nurse suggest for help in control or eliminate the clients imcotinence Decrease or avoid caffeine avoid drinking alcohol A client who has an indwelling catheter reports and need to urinate which of the following actions should the nurse take Check to see whether the catheter is patent. A nurse is caring for a client who has a prescription for 24 hour urine collection which of the following actions should the nurse take Discard the first void A nurse is reviewing factors that increase the risk of your new tract infections with a client who has recurrent UTIs which of the following factors should the nurse include Frequent sexual intercourse location of the new Reatha in relation to the anus frequent catheterization A nurse is preparing to initiate a bladder to re-training program for a client who has incontinence which of the following actions should the nurse take Have a client record urination times gradually increase the urination intervals remind the client to hold the year until the next scheduled urination time And nurse is assisting a client who has an acute respiratory infection that puts her at risk for hypoxemia which of the following findings are early indications that should alert the nurse the client is developing hypoxemia Restlessness tachypnea confusion pallor A provider is discharging a client who has a prescription for home oxygen therapy via a nasal cannula the client and family teach in by the nurse should include which of the following instructions select all that apply Check the position of the cannula frequently report any nasal stuffiness nausea or fatigue post no smoking signs in a prominent location A nurse is caring for a client who is having difficulty breathing the client is lying in bed and is already receive an oxygen therapy via nasal cannula which of the following interventions is the nurse is priority Assisted client to Fowler's position 31 | P a g e A nurse is preparing to perform in there tracheal suctioning for client the nurse should follow which of the following guidelines select all that apply Apply suction while withdrawing the catheter use a new catheter for each suctioning attempt limit total suctioning time to five minutes A nurse is caring for a client who has a tracheostomy which of the following actions should the nurse take one providing tracheostomy care Select all that apply Apply the oxygen source loosely if the SPO2 decreases during the procedure Use surgical asepsis to remove and clean the inner cannula clean the outer surfaces in a circular motion from the stoma site outward Non-breather mask allows higher levels of oxygen to be added to the air taken in by the patient Venturi mask an oxygen-delivery apparatus consisting of a mask with holes on each side that allow exhaled air to escape and color-coded entrainment ports that are adjustable to allow regulation of the concentration of oxygen delivered