FUNDS PROCTORED EXAM LATEST -

FUNDS PROCTORED EXAM LATEST -

EXAM TEST BANK 200 QUESTIONS AND CORRECT

ANSWERS|ALREADY GRADED A+(WEST COAST

UNIVERSITY)

A nurse is preparing to check a client's blood pressure. Which of the following actions should the nurse take?

• Apply the cuff above the clients antecubital fossa.
• Use a cuff with a width that is about 60% of the client's arm circumference.
• Have the clients sit with his arm resting above the level of his heart.
• Release the pressure on the client's arm 5 to 6 mm per second.- - ANSWER- a.

Apply the cuff above the clients antecubital fossa.

Rationale: width of the cuff should be 40% of the arm circumference; arms should rest that the level of the heart; release the pressure no faster than 2-3 mmHg per second; apply cuff 2.5cm (1in) above the antecubital space with the brachial artery in line with the marking on the cuff.

A nurse is preparing to perform nasal tracheal suctioning for a client. Which of the following is an appropriate action for the nurse to take?

• Hold the suction catheter with the clean non-dominant hand.
• Apply suctioning for 20 to 30 seconds.
• Place the catheter in a location that is clean and dry for later use new line.
• Use surgical asepsis when performing the procedure. - ANSWER- d. Use

surgical asepsis when performing the procedure.

Rationale: suction should be no more than 10-15 seconds to avoid hypoxemia;

catheter should never be re-used; use surgical asepsis for all types of suctioning

A nurse is documenting client care. Which of the following abbreviations should the nurse use?

• "SS" for sliding scale
• "BRP" for bathroom privileges
• "OJ" for orange juice
• "SQ" for subcutaneous - ANSWER- b. "BRP" for bathroom privileges 1 / 4

A nurse is caring for a client who has left lower atelectasis. in which of the following positions should the nurse place the client for postural drainage?

• Supine and low-Fowler's position
• Right lateral in Trendelenburg position
• Side lying with the right side of the chest elevated
• Prone with pillows under the extremities - ANSWER- b. Right lateral in

Trendelenburg position

A nurse is receiving the prescription for a client who is experiencing dysphagia following a stroke. Which of the following prescriptions should the nurse clarify?

• Dietitian consult
• Speech therapy referral
• Oral suction at the bedside
• Clear liquids - ANSWER- d. Clear liquids

food levels for dysphagia include pureed, mechanically altered, advanced/mechanically soft, and regular. Liquids must be THICK.. Clear liquids can cause aspiration

A nurse is administering a large volume enema to a client. Identify the sequence of steps the nurse should follow after preparation and lubricating the enema set.(ati funds video enema)

• Administer the enema solution.
• Remove the enema tube from the clients rectum.
• Wrap the end of the enema tube with a disposable tissue.
• Insert the enema tube into the client's rectum.
• Clamp the enema tube. - ANSWER- 4, 1, 5, 2, 3

A nurse is teaching a group of newly licensed nurses about the Braden Scale.Which of the following responses by the newly licensed nurse indicates an understanding of the teaching?

• "The client's age is part of the measurement."
• "The scale measures six elements."
• "The higher the score, the higher the pressure ulcer risk." 2 / 4

• "Each element has a range from 1 to 5 points." - ANSWER- b. "The scale

measures six elements."

Rationale: It measures the six elements: Sensory perception, moisture, activity, mobility, nutrition, friction & shear.

The higher the score the less risk.Each element is ranged from 1-4 points

A nurse is documenting in a client's medical record . Which of the following entries should the nurse record?

• "Incision without redness or drainage."
• "Drink adequate amounts of fluid with meals."
• "Oral temperature slightly elevated at 0800."
• "Administered pain medication." - ANSWER- d. "Administered pain

medication."

any action and change to the client's condition should be recorded

A nurse is caring for a client who refuses to follow the providers prescription for bed rest. The nurse over hears the AP tell the client that if she does not remain in bed he will place her in restraints. The nurse should identify that the AP is committing which of the following torts?

-Libel -Defamation of character -Assault -Battery - ANSWER- -Assault

A nurse is preparing to insert an IV catheter for a client following a r. mastectomy.Which of the following veins should the nurse select when initiating an IV therapy?

-the radial vein on the left wrist -the cephalic vein in the left distal forearm -the basilic vein in the right antecubital fossa -the cephalic vein on the back of the right hand - ANSWER- -the cephalic vein on the back of the right hand

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A nurse is teaching an older adult client who has type 2 diabetes mellitus about how to care for corns and calluses toes. Which of the following statements by the client indicates an understanding of the teaching?

• I can apply lotion to soften the calluses as long as I don't put lotion between my

toes

• I can place an oval corn pad over toes that have corns as longs as remove the pad

weekly

• I should soak my feet in warm water daily to soften corns and calluses
• I should use an over the counter liquid medication to remove corns - ANSWER-
• I can apply lotion to soften the calluses as long as I don't put lotion between my

toes

A nurse is caring for a client who has wrists restraints after an episode of violent behavior. Which of the following actions should the nurse take?

-Tie the restraints to the side rail -Secure restraints with a square knot -Remove one restraint at a time -Remove the restraints every 3 hours - ANSWER- -Remove one restraint at a time

A nurse is planning care for a client who has a latex allergy and is scheduled for surgery. Which of the following actions is appropriate to include in the client's plan of care?

-Schedule the client as the first surgical procedure of the day -Cleanse the stoppers with primidone iodine for withdrawing medication -Remove the stop stocks from iv tubing -Ensure the gloves in the surgical suite are powdered gloves - ANSWER- - Schedule the client as the first surgical procedure of the day

A nurse is providing discharge teaching to a client who does not speak the same language as the nurse. Which of the following action should the nurse take?

-Offer written instructions in the client language -Request that an AP interpret instructions for the client -Use proper medical terms giving instructions to the client -Direct verbal discharge instructions to the interpreter - ANSWER- -Direct verbal discharge instructions to the interpreter

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