Directions: Answer the question and give rationale as to why you choose your answer. 1. A nurse rates a clients bicep reflex as 2+. Which of the following characteristics should the nurse document about the client’s reflexes?A. DiminishedB. AverageC. BriskD. Hyperactive Rationale: 2. A nurse is planning care for a hospitalized client who is immobile and in a continuous mitten restraint. Which of the following interventions should be included in the client’s care plan? (Select all that apply.)A. Document restraint checks and client status every 2 hr.B. Educate the client’s family about restraint use.C. Obtain the provider’s prescription renewal every 72 hr.D. Implement passive range-of-motion exercises.Rationale:3. A nurse is providing breast self-examination teaching to a client who is menopausal. Which of the following statements should the nurse identify as an indication that the teaching was effective? (Select all that apply.)A. “I don’t have to lie down to check my breasts. I can stand in the shower.”B. “If I feel a firm ridge in the lower curve of my breasts I should report this immediately.”C. “It is important to press firmly when feeling my breasts to detect changes.”D. “Since I no longer have periods, I can perform an examination at any time of the month.”E. “I will make sure to feel for changes in my underarm area.” Rationale: 4. A nurse is assessing a client’s thyroid gland. Which of the following instructions should the nurse give the client before inspecting and palpating this gland?A. “Tilt your head slightly forward”B. “Keep your head straight and look ahead of you.”C. “Tilt you head back and swallow”D. “Turn your head to the side and against my hand.”Rationale: 5. A nurse is caring for a client who is dying. The nurse should incorporate the principle of nonmaleficence into practice by taking which of the following actions?A. Discussing advance directives with the client and the client’s familyB. Providing comfort care measures to the clientC. Withholding a dose of narcotic pain medication when the client has respiratory depressionD. Allowing the client’s family unlimited visitation at the time of deathRationale:6. A nurse is caring for a client who is unconscious. Which of the following actions should the nurse take when providing oral care for the client? A. Test for the presence of the client’s gag reflexB. Place the client in the supine positionC. Use a firm toothbrush for tooth and gum careD. Use 2 gauze wrapped fingers to hold the mouth open.Rationale: 7. A newly licensed nurse is applying prescribed wrist restraints on a client. Which of the following actions should the nurse take?A. Secure the restraints using a quick-release tie.B. Ensure four fingers fit under the restraints to prevent constriction.C. Secure the restraints to the lowest bar of the side rail.D. Anticipate removing the restraints every 4 hr.Rationale:8. A nurse is caring for an older adult client who was alert and oriented at admission, but now seems increasingly restless and intermittently confused. Which of the following actions should the nurse take to address the client’ssafety needs??A. Call the family and ask them to stay with the client.B. Move the client to a room closer to the nurses’ station.C. Apply wrist and leg restraints to the client.D. Administer medication to sedate the client.?Rationale:9. A nurse is teaching a middle-aged female client about disease prevention and health maintenance. Which of the following diagnostic test should the nurse recommend as part of this client’s routine health screening? A. Annual Papanicolaou pap testingB. Mammogram every 2 yearsC. Eye exam every 2 yearsD. Annual Colonoscopy.Rationale: 10. A nurse on medical surgical unit is caring for a client who is at risk for experiencing seizures. Which of the following pieces of equipment must be available at the clients bedside at all times?A. Suction equipmentB. Clean glovesC. BlanketsD. OxygenRationale: Health Science Science NursingNURSING 101
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