Fund 7 Welcome to your Fund 7 A nurse is providing discharge teaching to a client recovering from pneumonia. Which of the following statements indicate the client understands the instructions? (Select all that apply.) "I will complete my full course of antibiotics, even if I feel better." "I will limit my fluid intake to prevent fluid buildup in my lungs." "I will use a humidifier to keep my airways moist and loosen mucus." "I should avoid getting my pneumonia vaccine since I already had pneumonia." "I will perform deep breathing and coughing exercises several times a day to clear secretions." A nurse is providing discharge teaching to a client recovering from pneumonia. Which statement by the client indicates a need for further education? Deselect Answer "I will complete my entire course of antibiotics as prescribed." "I should avoid cigarette smoke and other lung irritants." "I will stay in bed all day to conserve my energy." "I should drink plenty of fluids to help loosen mucus." None A nurse is teaching a client recovering from pneumonia about preventing reinfection and promoting recovery. Which of the following instructions should the nurse include? (Select all that apply.) Use a humidifier or take warm showers to keep airways moist. Wash hands frequently to prevent infections. Stop taking antibiotics once symptoms improve. Receive a pneumonia vaccine as recommended. Avoid alcohol consumption while recovering. A nurse is evaluating a client’s understanding of pneumonia recovery. Which statement made by the client requires immediate intervention by the nurse? Deselect Answer "I will continue my deep breathing and coughing exercises every few hours." "I will call my doctor if I experience worsening shortness of breath." "I will save some of my leftover antibiotics in case I get sick again." None A nurse is caring for a hospitalized client with active pulmonary tuberculosis (TB). Which action should the nurse take first? Deselect Answer Initiate airborne precautions, including placing the client in a negative-pressure room. Encourage the client to increase fluid intake to loosen respiratory secretions. Educate the client on the importance of completing their medication regimen. Obtain a sputum sample for acid-fast bacillus (AFB) testing. None A nurse is teaching a client with tuberculosis about home infection control measures. Which of the following statements should the nurse include? (Select all that apply.) "You should always wear a surgical mask when around others at home." "Cover your mouth and nose with a tissue when coughing or sneezing." "Dispose of used tissues in a sealed plastic bag." "You may stop taking your TB medications if your symptoms improve." "Household members should be tested for tuberculosis." A charge nurse is observing a newly hired nurse caring for a client with active tuberculosis. Which action by the new nurse requires immediate intervention? Deselect Answer The nurse wears an N95 respirator when entering the client’s room. The nurse places a surgical mask on the client before transporting them to radiology. The nurse asks a nursing assistant to teach the client about airborne precautions. The nurse keeps the client’s door closed at all times except when providing care. None A nurse is caring for a client who had abdominal surgery and has a nasogastric (NG) tube connected to low intermittent suction. The client reports nausea and abdominal distension. Which action should the nurse take first? Deselect Answer Irrigate the NG tube with 30 mL of normal saline. Increase the suction pressure to high continuous suction. Remove the NG tube and notify the provider. Encourage the client to ambulate to promote peristalsis. None A nurse is monitoring a client receiving enteral feedings through a nasogastric (NG) tube after surgery. Which of the following findings indicate a potential complication? (Select all that apply.) Absent bowel sounds Diarrhea Gastric residual of 75 mL New onset of cough with crackles on auscultation Abdominal distension and discomfort A nurse is supervising a nursing assistant (UAP) who is assisting with the care of a client receiving nasogastric (NG) tube feedings. Which action by the UAP requires immediate intervention? Deselect Answer Keeping the client’s head of bed elevated at 30–45 degrees during feeding. Notifying the nurse when the client reports nausea and bloating. Checking the placement of the NG tube before initiating a feeding. Performing oral care for the client to prevent dryness and discomfort. None A nurse is assessing a postoperative client with a surgical wound. Which finding places the client at the greatest risk for delayed wound healing? Deselect Answer Hemoglobin level of 8.5 g/dL Blood glucose level of 140 mg/dL Albumin level of 3.5 g/dL White blood cell (WBC) count of 8,000/mm³ None A nurse is reviewing the risk factors for delayed wound healing in a group of clients. Which of the following conditions increase the risk of poor wound healing? (Select all that apply.) Peripheral arterial disease (PAD) Uncontrolled diabetes mellitus A diet high in protein and vitamin C Long-term corticosteroid use Immobility and prolonged pressure on the wound A nurse is caring for a client with a stage III pressure injury. Which action by a nursing assistant (UAP) requires immediate intervention? Deselect Answer Repositioning the client every 2 hours. Applying a heating pad over the wound site to promote circulation. Assisting the client with oral nutrition to promote healing. Notifying the nurse if there is an increase in wound drainage. None A nurse is monitoring a client receiving IV vancomycin for a severe bacterial infection. Which assessment finding requires immediate intervention? Deselect Answer Red rash on the upper body and neck Blood pressure of 120/78 mmHg Complaints of mild nausea Increased thirst and dry mouth None A nurse is teaching a client about ciprofloxacin, a fluoroquinolone antibiotic. Which of the following statements by the client indicate a need for further education? (Select all that apply.) "I will take my medication with a glass of milk to reduce stomach upset." "I should avoid prolonged sun exposure while taking this medication." "I will report any new joint pain or swelling to my provider." "If I feel better, I can stop taking the antibiotic before finishing the full course." "I will drink plenty of fluids while on this medication to prevent kidney damage." A client taking warfarin is prescribed trimethoprim-sulfamethoxazole (Bactrim) for a urinary tract infection. Which action should the nurse take? Deselect Answer Administer the medication as prescribed. Monitor the client for signs of bleeding. Instruct the client to take both medications at the same time. Encourage the client to increase dietary vitamin K intake. None A nurse is providing tracheostomy care for a client. During suctioning, the client suddenly develops tachycardia and oxygen saturation drops from 96% to 88%. Which action should the nurse take first? Deselect Answer Stop suctioning and administer 100% oxygen. Increase suction pressure to remove secretions faster. Continue suctioning while reassuring the client. Remove the tracheostomy tube and replace it with a new one. None A nurse is providing discharge teaching to a client with a new tracheostomy. Which of the following instructions should the nurse include? (Select all that apply.) "Use a humidifier or saline nebulizer to keep secretions loose." "Clean the inner cannula with full-strength hydrogen peroxide daily. "Avoid swimming and protect the tracheostomy site from water." "Carry a spare tracheostomy tube of the same size in case of emergency." "Suction the tracheostomy tube routinely every 2 hours to prevent buildup of secretions." A nurse is caring for a client with a tracheostomy and mechanical ventilation. Which action is most effective in preventing ventilator-associated pneumonia (VAP)? Deselect Answer Suctioning the tracheostomy tube every 4 hours. Cleaning the tracheostomy stoma with sterile water once a day. Elevating the head of the bed to 30–45 degrees. Using clean gloves instead of sterile gloves for suctioning. None A nurse is assessing a client receiving intravenous (IV) fluids at 150 mL/hr. The client has dyspnea, crackles in the lungs, and jugular vein distension (JVD). Which action should the nurse take first? Deselect Answer Stop the IV infusion. Administer a prescribed diuretic. Elevate the client’s legs. Notify the healthcare provider. None A nurse is caring for a client with fluid overload due to excessive IV fluid administration. Which of the following interventions should the nurse implement? (Select all that apply.) Elevate the head of the bed to high Fowler’s position. Monitor intake and output closely. Increase IV fluid rate to flush excess fluids faster. Administer oxygen if needed. Assess the client’s respiratory status frequently. A nurse is reviewing the laboratory results of a client experiencing IV fluid overload. Which finding is expected Deselect Answer Hematocrit 28% Blood urea nitrogen (BUN) 28 mg/dL Serum sodium 155 mEq/L Urine specific gravity 1.035 None A nurse is preparing to administer a crushed oral medication through a client’s nasogastric (NG) tube. Which action should the nurse take first? Deselect Answer Mix the crushed medication with the client’s enteral feeding formula. Verify the placement of the NG tube. Flush the tube with 60 mL of sterile water before administering the medication. Clamp the NG tube for 30 minutes after medication administration. None A nurse is administering medications through a gastric (G-tube) feeding tube. Which of the following actions should the nurse take? (Select all that apply.) Administer each medication separately. Flush the tube with 15–30 mL of water before and after each medication. Use enteric-coated tablets when possible to prevent stomach irritation. Crush sustained-release medications to ensure full absorption. Stop the feeding and leave the tube clamped for 30 minutes after administration if the medication should be given on an empty stomach. A nurse is administering a liquid oral medication to a client via an enteral feeding tube. The client suddenly coughs and exhibits signs of respiratory distress. What is the nurse’s priority action? Deselect Answer Continue administering the medication more slowly. Check the placement of the feeding tube. Suction the client’s airway immediately. Notify the healthcare provider. None A nurse is preparing to administer a newly prescribed medication to a client for the first time. Which action should the nurse take first? Deselect Answer Verify the medication order in the provider’s prescription. Check the client’s identification using two identifiers. Administer the medication as soon as possible to maintain the schedule. Educate the client about the purpose and possible side effects of the medication. None A nurse is preparing to administer a new medication to a client. Which actions should the nurse take to prevent medication errors? (Select all that apply.) Compare the medication label with the MAR (Medication Administration Record) three times. Administer the medication without questioning if the provider prescribed an unusually high dose. Check for client allergies before administering the medication. Consult a drug reference to review potential side effects and interactions. Correct A provider prescribes a new medication for a client. The nurse notices that the medication dose is higher than the recommended range in the drug reference guide. What is the nurse’s priority action? Deselect Answer Administer the medication as prescribed. Contact the pharmacy for clarification. Hold the medication and notify the healthcare provider. Ask another nurse if the dose seems too high. None A nurse is caring for a client with a newly placed colostomy. The client states, "I don’t think I can take care of this on my own." Which response by the nurse is most appropriate? Deselect Answer "It’s normal to feel that way at first. Let’s practice together so you feel more comfortable." "You will get used to it quickly, and it won’t be as hard as you think." "Your provider will give you instructions when you go home." "Don’t worry, home health nurses will take care of it for you." None A nurse is teaching a client with a colostomy about stoma care and prevention of complications. Which instructions should the nurse include? (Select all that apply.) "Change the colostomy pouch every 3 to 7 days or sooner if it leaks." "The stoma should be moist and pink or red in color." "Use soap and water to clean around the stoma and dry thoroughly." "Apply adhesive tape around the edges of the pouch to keep it secure." "Avoid gas-producing foods like beans, broccoli, and carbonated drinks if excessive gas is a concern." A client with a colostomy reports skin irritation and redness around the stoma site. What is the nurse’s priority action? Deselect Answer Apply a steroid-based cream to reduce inflammation. Remove the pouch and leave the area open to air. Ensure the ostomy appliance fits properly without leakage. Increase fluid intake to promote hydration. None A nurse is performing an eye assessment on an older adult client. Which of the following findings would the nurse consider a normal age-related change? Deselect Answer Loss of peripheral vision Cloudy appearance of the lens Increased intraocular pressure Yellow sclera with no other symptoms None A nurse is assessing the pupils of a client during an eye exam. Which findings are expected in a healthy adult? (Select all that apply.) Pupils are equal in size. Pupils constrict in response to bright light. Pupils dilate when focusing on a near object. Pupils react sluggishly to light. Both pupils constrict when light is shined in one eye. A nurse is assessing a client’s vision using the Snellen chart. The client’s result is 20/40 in the right eye. What does this mean? Deselect Answer The client has better than normal vision. The client can read at 40 feet what a person with normal vision reads at 20 feet. The client can read at 20 feet what a person with normal vision reads at 40 feet. The client has normal vision, and no intervention is needed. None A nurse is providing health education to an older adult client about osteoporosis prevention. Which instruction should the nurse include as the most effective way to reduce the risk of osteoporosis? Deselect Answer Increase intake of high-phosphorus foods such as processed meats and soft drinks. Engage in weight-bearing exercises such as walking for at least 30 minutes most days of the week. Limit calcium intake to 500 mg per day to prevent kidney stones. Avoid direct sunlight to reduce the risk of skin damage. None A nurse is teaching an older adult client ways to reduce the risk of osteoporosis. Which of the following strategies should the nurse recommend? (Select all that apply.) Consume calcium-rich foods such as dairy, leafy greens, and fortified orange juice. Perform weight-bearing exercises regularly. Increase caffeine intake to maintain energy levels. Take vitamin D supplements as needed to support calcium absorption. Avoid smoking and excessive alcohol consumption. modification should the nurse recommend to reduce the risk of fractures? Deselect Answer Remove throw rugs and improve lighting in hallways. Place frequently used items on high shelves to encourage stretching. Encourage the client to wear socks or smooth slippers around the house. Use low, soft chairs to prevent joint strain. None A nurse is conducting a cardiovascular risk assessment for a 45-year-old client during a routine checkup. Which modifiable risk factor should the nurse prioritize addressing to reduce the client’s risk for cardiovascular disease (CVD)? Deselect Answer Family history of hypertension Sedentary lifestyle Age over 40 years Male gender None A nurse is educating a group of middle-aged and older adults on risk factors for cardiovascular disease (CVD). Which of the following are modifiable risk factors for CVD? (Select all that apply.) Obesity High blood pressure Smoking Advancing age High cholesterol A 66-year-old client is at risk for cardiovascular disease. The nurse should instruct the client to report which symptom immediately, as it may indicate the onset of a cardiovascular event? Deselect Answer Indigestion and nausea Mild fatigue after walking short distances Occasional dizziness when standing up too quickly Headache after a stressful day None A nurse is caring for a client who has violent behavior and is placed in physical restraints per provider’s order. Which action should the nurse take first? Deselect Answer Secure the restraints to the side rails of the bed. Ensure that two fingers can fit between the restraint and the client's skin. Administer a sedative to calm the client before applying restraints. Remove the restraints every 4 hours for skin assessment. None A nurse is caring for a client in restraints due to agitation and a risk of self-harm. Which interventions should the nurse include in the plan of care? (Select all that apply.) Assess skin integrity and circulation every 2 hours. Offer fluids, toileting, and range-of-motion exercises regularly. Obtain a new provider order every 48 hours if restraints are still needed. Document the client’s behavior and response to restraints. Tie the restraints in a double knot to prevent accidental removal. A nurse is planning care for a client in soft wrist restraints. Which action by the nurse demonstrates appropriate care and adherence to client safety guidelines? Deselect Answer Releasing one restraint at a time every 4 hours. Ensuring the restraint order is renewed every 24 hours, if needed. Keeping the client in restraints continuously to prevent further agitation. Using restraints as a first intervention when the client becomes agitated. None A nurse is preparing a sterile field for a dressing change. Which action by the nurse breaks sterility and requires the setup to be restarted? Deselect Answer Holding sterile objects above waist level Turning away from the sterile field momentarily Keeping sterile items within the 1-inch border of the sterile drape Placing sterile gloves on before touching sterile supplies None A nurse is setting up a sterile field for a procedure. Which of the following actions maintain sterility? (Select all that apply.) Open the first flap of a sterile package away from the body. Keep sterile items at least 2 inches from the edge of the sterile drape. Reach across the sterile field to grab a sterile object. Discard a sterile package that has a tear in the wrapper. Place sterile objects directly onto the sterile field using sterile gloves or sterile forceps. A nurse is setting up a sterile field when a sterile gauze pad falls outside the sterile field. What is the nurse’s best action? Deselect Answer Pick up the gauze pad with sterile gloves and place it back in the sterile field. Use sterile forceps to move the gauze back onto the sterile field. Discard the gauze pad and obtain a new sterile one. Continue the procedure since only one item was contaminated. None A nurse is evaluating discharge teaching for an older adult client who lives alone. Which statement by the client indicates a need for further education regarding home safety? Deselect Answer "I will remove loose rugs from my home to reduce my risk of falling." "I will use a nightlight in my bedroom and bathroom to improve visibility at night." "I will keep my medications in different bottles without labels so I don’t mix them up." "I will install grab bars in my bathroom to help prevent falls." None A nurse is reinforcing home safety measures with an older adult client at discharge. Which recommendations should the nurse include? (Select all that apply.) Keep the home well-lit, especially hallways and staircases. Store cleaning products and chemicals in unlocked cabinets for easy access. Use nonskid mats in the bathroom and kitchen. Set the water heater temperature to no higher than 120°F (49°C). Arrange frequently used items on high shelves to reduce clutter. A nurse is teaching an older adult client about fire safety at home. Which statement by the client indicates understanding of the teaching? Deselect Answer "I will place space heaters near curtains to warm up the house faster." "I will test my smoke detectors every six months." "I will avoid using extension cords for multiple appliances in one outlet." "I will use candles for lighting in case of a power outage." None A nurse is caring for an unconscious client who requires an emergency surgical procedure. No family members or legal representatives are available to provide consent. What is the nurse’s best action? Deselect Answer Proceed with the surgery without informed consent since it is an emergency. Delay the surgery until a family member can be contacted. Obtain a court order for emergency consent before proceeding. Request that another healthcare provider sign the consent form. None A nurse is preparing to obtain informed consent for a client’s surgical procedure. Which of the following statements are true regarding informed consent? (Select all that apply.) The healthcare provider is responsible for explaining the procedure, risks, and alternatives to the client. The nurse can obtain consent if the provider is unavailable. The client must sign the consent form voluntarily and without coercion. If the client is unconscious, a legally authorized representative can provide consent. A client who received opioid pain medication 30 minutes ago can still provide informed consent. A nurse is caring for an unconscious client in the intensive care unit. The client has a living will that states they do not want life-prolonging treatments. However, the client’s family insists on initiating mechanical ventilation. What is the nurse’s best action? Deselect Answer Follow the family’s wishes and proceed with mechanical ventilation. Honor the client’s living will and notify the healthcare provider. Obtain a court order to override the living will. Delay any decision until the client regains consciousness. None A nurse is admitting a client with suspected active pulmonary tuberculosis (TB). Which intervention should the nurse implement first? Deselect Answer Initiate airborne precautions, including placing the client in a negative-pressure room. Start the client on antibiotic therapy immediately. Encourage the client to wear a surgical mask at all times. Obtain a sputum sample for acid-fast bacillus (AFB) testing. None A nurse is providing discharge teaching to a client with active tuberculosis (TB) about infection control measures at home. Which of the following instructions should the nurse include? (Select all that apply.) Cover your mouth and nose with a tissue when coughing or sneezing. Dispose of used tissues in a sealed plastic bag. Stop taking TB medications once symptoms improve. Avoid close contact with family members until cleared by a healthcare provider. Wear an N95 respirator when leaving home for medical appointments. A nurse is preparing a client for surgery. Which action should the nurse take first before sending the client to the operating room (OR)? Deselect Answer Ensure the client has signed the informed consent form. Administer preoperative sedative medication as prescribed. Remove the client's dentures and jewelry. Verify the client’s last meal and document the fasting status. None Verify the client’s last meal and document the fasting status. "I will be asked to take deep breaths and cough after surgery to prevent complications." "I should stop eating or drinking at midnight before my surgery." "I will be able to drive myself home after my procedure." "The nurse will remove my hearing aids before I go into surgery." "I should notify the nurse if I have an allergy to latex or medications." A nurse is conducting a health assessment for a 50-year-old female client. Which factor in the client’s history places her at the greatest risk for osteoporosis? Deselect Answer Sedentary lifestyle Family history of osteoporosis Postmenopausal status High intake of dietary calcium None A nurse is teaching a 45-year-old client about risk factors for osteoporosis. Which of the following factors increase the client’s risk for osteoporosis? (Select all that apply.) Smoking Regular weight-bearing exercise Long-term corticosteroid use High alcohol consumption Adequate vitamin D intake A nurse is assessing a client’s risk factors for heart disease. Which modifiable risk factor should the nurse address first? Deselect Answer Family history of heart disease Sedentary lifestyle Male gender Age over 50 years None A nurse is providing health promotion education to a group of clients about preventing heart disease. Which of the following lifestyle changes should the nurse recommend? (Select all that apply.) Engage in at least 150 minutes of moderate-intensity exercise per week. Maintain a low-sodium diet to help control blood pressure Drink at least three alcoholic beverages daily to promote circulation. Avoid smoking and exposure to secondhand smoke. Monitor cholesterol levels and follow a heart-healthy diet. A nurse is monitoring a client who received penicillin for the first time. The client develops wheezing, dyspnea, and swelling of the lips. What is the nurse’s priority action? Deselect Answer Administer diphenhydramine (Benadryl) IV. Stop the infusion and administer epinephrine. Place the client in Trendelenburg position. Encourage the client to take slow, deep breaths. None A nurse is assessing a client for anaphylaxis after receiving an IV antibiotic. Which clinical manifestations indicate an anaphylactic reaction? (Select all that apply.) Urticaria (hives) Hypertension Angioedema (swelling of lips and face) Bradycardia Stridor A nurse is preparing to perform postural drainage on a client with chronic bronchitis. Which action should the nurse take first? Deselect Answer Administer a bronchodilator if prescribed before the procedure. Position the client supine with the head of the bed elevated. Perform postural drainage immediately after meals for better tolerance. Encourage the client to take deep breaths and hold them before coughing. None A nurse is positioning a client for postural drainage due to copious lung secretions. Which of the following positioning techniques are appropriate? (Select all that apply.) Place the client in Trendelenburg position for lower lung lobe drainage. Position the client in a high Fowler’s position for apical lobe drainage. Encourage the client to lie prone to drain the posterior lower lobes. Position the client on their left side to drain the right middle lobe. Perform chest physiotherapy before postural drainage for better secretion mobilization. A nurse is assisting a client with a lower back injury to reposition in bed. Which technique should the nurse use to minimize strain on the client’s back? Deselect Answer Encourage the client to sit up and use their arms to push themselves into position. Use a logrolling technique when turning the client to their side. Elevate the client’s legs higher than the heart before repositioning. Place a firm pillow under the lower back before turning the client. None A nurse is repositioning a client with a lower back injury. Which of the following interventions should the nurse implement? (Select all that apply.) Keep the client's spine in alignment while turning. Elevate the head of the bed to 90 degrees before repositioning. Use assistive devices such as a draw sheet to reduce strain. Encourage the client to bend their knees before being repositioned. Place a pillow under the knees when the client is in the supine position. A nurse is preparing to administer a prescribed medication to a client. Before administration, which action should the nurse take first to ensure medication safety? Deselect Answer Compare the medication label to the Medication Administration Record (MAR) three times. Ask another nurse to verify the medication before administration. Prepare the medication and administer it promptly to avoid delays. Assess the client’s knowledge about the medication being administered. None A nurse is verifying a client’s medication order by comparing the Medication Administration Record (MAR) to the medication label. Which of the following steps should the nurse take to prevent medication errors? (Select all that apply.) Confirm the client’s full name and date of birth match the MAR. Check the expiration date on the medication label. Verify the dose, route, and time on the MAR and medication label. Assume the pharmacy always provides the correct medication. Ensure the provider’s order, MAR, and medication label are consistent before administration. A nurse obtains a blood pressure reading of 168/94 mmHg from a client during a routine check-up. Which action should the nurse take first? Deselect Answer Reassess the blood pressure in 5 minutes on the same arm. Notify the healthcare provider immediately. Have the client lie down and administer an antihypertensive medication. Ask the client if they have consumed caffeine or smoked recently. None A nurse is caring for a client with consistently elevated blood pressure. Which nursing interventions are appropriate to help manage the client’s hypertension? (Select all that apply.) Encourage the client to engage in regular physical activity. Educate the client on reducing sodium intake in their diet. Administer IV antihypertensive medications for blood pressure readings above 140/90 mmHg. Encourage smoking cessation to promote cardiovascular health. Assess the client’s adherence to prescribed antihypertensive medications. A nurse is providing postmortem care for a client who has just passed away. Which action should the nurse take first? Deselect Answer Remove all tubes and medical devices from the client’s body. Allow the family to spend time with the deceased before performing care. Verify the client's death has been pronounced by the healthcare provider. Place the client in a supine position with arms extended at the sides. None A nurse is performing postmortem care for a deceased client in a hospital setting. Which actions should the nurse take? (Select all that apply.) Close the client’s eyes and place a pillow under the head. Remove all tubes and catheters unless an autopsy is required. Wash the body and apply clean linens before family viewing. Lower the head of the bed to a flat position. Place identification tags on the body according to facility policy. A nurse is teaching a client how to use crutches after a right leg fracture. The client is partially weight-bearing on the affected leg. Which crutch gait pattern is most appropriate for this client? Deselect Answer Two-point gait Four-point gait Three-point gait Swing-through gait None A nurse is evaluating a client’s understanding of crutch gait patterns. Which of the following statements by the client indicate correct knowledge about crutch use? (Select all that apply.) "For a three-point gait, I will move both crutches forward and then swing my good leg forward." "For a two-point gait, I will move my right crutch and left foot together, then my left crutch and right foot together." "The four-point gait provides maximum stability because it moves one crutch or foot at a time." "I should put my weight on my armpits when using crutches to avoid falling." "When going upstairs with crutches, I should step up with my strong leg first." goes wrong?" Which response by the nurse demonstrates therapeutic communication? Deselect Answer "There’s nothing to worry about. The surgeons do this all the time." "It’s normal to feel nervous. Can you tell me more about what concerns you the most?" "You should focus on staying positive. Everything will be fine." "Just try to relax. Stressing about it won’t help." None A nurse is caring for a client who is experiencing moderate anxiety before a diagnostic procedure. Which therapeutic communication techniques should the nurse use? (Select all that apply.) Maintain eye contact and use an open posture while listening Provide clear, concise information about what to expect during the procedure. Say, "Everything will be fine," to reassure the client. Encourage deep breathing exercises to help the client relax. Allow the client to express their fears and concerns without interruption. A nurse is preparing to administer oral medications to a client with dysphagia. Which action should the nurse take first? Deselect Answer Crush all the client’s medications and mix them with pudding. Have the client drink water before taking the medications. Assess the client’s ability to swallow and risk of aspiration. Request a liquid formulation of all prescribed medications. None A nurse is administering medications to a client with dysphagia. Which interventions should the nurse implement to promote safe medication administration? (Select all that apply.) Offer medications with thickened liquids instead of water. Place the client in a high Fowler’s position during administration. Administer multiple pills at once to reduce the number of swallows. Check with the pharmacist for alternative medication forms, such as liquid or transdermal patches. Allow the client to self-administer the medication if they are able. A nurse is caring for a client with major depressive disorder who states, "I feel so hopeless. I don’t think things will ever get better." Which response by the nurse demonstrates therapeutic communication? Deselect Answer "You have a great support system. I’m sure things will improve soon." "Why do you feel that way? You should try to stay positive." "It sounds like you’re feeling very discouraged. Can you tell me more about what’s been bothering you?" "If you think like that, you’ll never be able to move forward." None A nurse is providing emotional support to a client with depression. Which of the following therapeutic communication techniques should the nurse use? (Select all that apply.) Deselect Answer Maintain eye contact and use an open posture when speaking with the client. Offer silence to allow the client time to express their thoughts. Say, "I understand exactly how you feel." Acknowledge the client’s feelings and provide empathetic statements. Encourage the client to express their feelings without judgment. None A nurse is caring for a client with dysphagia who is at risk for aspiration. Which action should the nurse take first when assisting the client with oral intake? Deselect Answer Encourage the client to drink water with meals. Instruct the client to tuck their chin while swallowing. Place the client in a high Fowler’s position before feeding. Offer large bites of food to facilitate easier swallowing. None A nurse is assisting a client with dysphagia during meals. Which interventions should the nurse implement to promote safe swallowing? (Select all that apply.) Deselect Answer Provide thickened liquids instead of thin liquids. Encourage the client to chew food slowly and thoroughly. Offer foods that require minimal chewing, such as mashed potatoes. Allow the client to drink liquids through a straw for easier intake. Observe for pocketing of food in the client’s cheeks after each bite. None A nurse is caring for a client experiencing chronic lower back pain who prefers to avoid medication. Which nonpharmacological intervention should the nurse suggest first? Deselect Answer Encourage the client to perform guided imagery and deep breathing exercises. Apply an ice pack to the client’s lower back for 30 minutes. Suggest the client take a warm bath to relax muscles. Refer the client to a pain management specialist for alternative therapies. None A nurse is providing nonpharmacological pain relief to a client with postoperative pain. Which interventions should the nurse implement? (Select all that apply.) Offer a massage to promote circulation and relaxation. Encourage the client to listen to calming music. Keep the room dimly lit and quiet to reduce sensory stimulation. Have the client increase physical activity to distract from the pain. Use distraction techniques, such as watching television or talking with family. A nurse is planning care for a client who is completely immobile due to a spinal cord injury. Which intervention should the nurse include first to prevent complications of immobility? Deselect Answer Encourage the client to use an incentive spirometer every hour. Turn and reposition the client every 2 hours. Perform passive range-of-motion exercises once a shift. Increase the client’s fluid intake to at least 3 liters per day. None A nurse is planning care for a bedridden client to prevent complications related to immobility. Which interventions should be included in the care plan? (Select all that apply.) Deselect Answer Perform passive range-of-motion exercises daily. Place a pillow under the client’s knees to prevent discomfort. Apply anti-embolism stockings as prescribed. Encourage a diet high in fiber and adequate fluid intake. Assess the client’s skin for redness or breakdown daily. None Using the matrix below, identify whether each potential risk is a high, moderate, or low priority concern for this client. Scenario: A 75-year-old client with a history of hypertension, type 2 diabetes, and osteoarthritis visits the clinic for a routine check-up. The client reports feeling dizzy and fatigued and is currently taking the following medications: Lisinopril (ACE inhibitor) for hypertension Metformin for diabetes Glipizide for diabetes Ibuprofen for osteoarthritis Lorazepam as needed for anxiety The nurse is assessing the client’s medication regimen for potential risks. Potential Risk High Priority Moderate Priority Low Priority Risk for hypoglycemia due to glipizide use Increased risk of falls due to dizziness and lorazepam use Gastrointestinal bleeding risk from ibuprofen use Metformin-induced lactic acidosis in an older adult Hypotension due to ACE inhibitor use Rationales: Get a pneumonia vaccine (High Priority ✅) The pneumococcal vaccine helps prevent future pneumonia infections, especially for older adults and those with chronic illnesses. Avoid crowded places and sick individuals (High Priority ✅) Since the immune system is still recovering, exposure to viruses and bacteria increases the risk of reinfection. Resume vigorous exercise (Low Priority ❌) Incorrect— The client should focus on gradual activity rather than intense workouts, as overexertion can worsen fatigue and delay recovery. Monitor for worsening symptoms (High Priority ✅) Fever, shortness of breath (SOB), or worsening cough could indicate pneumonia recurrence or complications and require prompt medical attention. Use over-the-counter cough suppressants frequently (Moderate Priority ✅) Coughing helps clear secretions. While occasional use of a suppressant may help with sleep, frequent use can trap mucus in the lungs, leading to complications. Deselect Answer None Using the matrix below, determine whether each factor is a high, moderate, or low priority concern for the client’s wound healing delay and antibiotic therapy complications. A 72-year-old client is recovering from an infected surgical wound and is receiving IV antibiotics. The client has type 2 diabetes, hypertension, and a history of smoking. The nurse is assessing factors that may delay wound healing and monitoring for adverse effects of antibiotics. Risk Factor High Priority Moderate Priority Low Priority Uncontrolled blood glucose levels (Diabetes) Smoking history Hypertension Older age (72 years old) Daily intake of high-protein foods Deselect Answer None A 45-year-old client recently had a spinal cord injury and is now paraplegic. The client expresses frustration, stating, "I don’t know how I’m going to take care of my family now." The nurse assesses the client’s coping mechanisms to determine adaptation to their new role. Which statement by the client indicates positive adaptation to their role change? Deselect Answer "I have been reading about assistive devices that can help me regain some independence." "I don’t want my family to see me like this, so I avoid spending time with them." "There’s nothing I can do. I don’t see the point in trying to be independent anymore." "I don’t need counseling. I just want to be left alone." None A 16-year-old client is admitted to the hospital for chronic asthma management. The client states, "I feel like I can’t do anything fun like my friends because of my asthma. It’s so unfair." The nurse wants to provide a therapeutic response to address the adolescent’s concerns. Which response by the nurse demonstrates therapeutic communication? Deselect Answer "I know how you feel. My younger brother has asthma too." "At least your asthma is manageable. Some people have worse conditions." "It sounds like you’re feeling frustrated. Can you tell me more about what you miss doing?" "You just have to learn to deal with it. Many people live with asthma and are fine." None A 68-year-old client has been on bed rest for five days following hip surgery. The nurse is providing education on preventing complications of immobility before the client is discharged home. Which statement by the client indicates a correct understanding of ways to reduce the adverse effects of immobility? Deselect Answer "I should perform ankle pumps and leg exercises in bed to help with circulation." "I should avoid deep breathing exercises because they could strain my healing hip." "Drinking less water will help prevent swelling in my legs while I’m less active." "I should stay in bed as much as possible to allow my hip to heal completely." None Deselect Answer None Time's up P Proctored Practice Post navigation Previous Previous post: Fund 6Next Next post: Fund 8
