Question

38.a nurse is caring for client who is postoperative and asks the nurse .when will I get to go home ?iam not sure what happens next which of the following actions should the nurse take?

A: Tell cleint about the provider will discharge turn when she feels he is ready to leave

B:Explain that the client should trust the provider because she has an excellent reputation

C:inform the provider that the client is requesting information about his treatment

D: Assure the client that the provider will come to talk to him when she gets the chance

39: A nurse is caring for client who has an NG tube and has repeatedly pulled it out .The nurse should identify which of the following findings indicates a need for restraints?

A The cleint gets out of bed to use the bathroom frequantly

B The cleint becomes confused at knight

C The cleint is assigned a room near the nurses station

D The client family is unable to stay with client

37: A nurse is caring for client who is receiving a warm ,moist compares to reliever lower back pain which of the following findings should indicate to the nurse that the compares has been effective ?

A The client states that he is able to concentrate while reading

B The cleint is laughing at the television show

C The cleint skin on the lower back is intact with out redness

D The clients vital signs are with in the expected reference range

44: A nurse is assessing the skin of a client who has worked outdoors for the past 20 years which of the following is the prioprity

A skin tages noted in the neck region

B A trophic wart on the left index finger

C A change in appearance of a mole on the shoulder

D A flat non palpable discolored area of skin on the trunk

49: A nurse is preparing to administer several medications Via NG tube to a client who is receiving a continuous tube feeding which of the following actions should the nurse take ?

A Flush the NG with 5ML of sterile water prior to adminsitatrion

B Combine the medications with the formula in the feeding bag

C Dilute each crushed medication with sterile water

D mix the medication together in a single syringe

Answer 1

ANSWERS :-

38)  

(C) Inform the provider that the client is requesting information about his treatment -

* Here the client expresses that "I am not sure what happens next" indicating he/she is not aware of the post operative care and treatment, and how many days it is expected to be in the hospital for recovery and when is the discharge planned for him/ her. So it is appropriate to inform the provider to explain the treatment plan to the client , so that the client will be aware of the treatment and comfortable during hospital stay.

39) A nurse is caring for a client who has an NG tube and has repeatedly pulled it out.The nurse should identify which of the following finding indicates a need for restraints -

(B) The client becomes confused at night

* When the client is confused,and not aware of the need of the tube, he/ she pull out the NG tube which is causing irritation, So a restraint can help to prevent pulling the NG tube.

* If the patient is conscious and oriented, and the NGtube is fixed properly, the client may not pull it out when ever getting out of bed to use bathroom, and keeping the client in a room near to nurses station and family members staying with patient also cannot prevent patient pulling the NG tube when he/she is confused.

37) The finding that indicate to the nurse that the compress has been effective

(A) The client states that he is able to concentrates while reading.- pain can distract attention and concentration, here the client is able to concentrate because the pain is relieved.

* Watching a TV show is a diversion therapy which can also help sometimes to divert mind from pain for sometimes and make him laugh, back massage is always good to keep the skin intact and not necessary that vital signs vary in pain always, it will be normal.

44)The priority skin assessment finding is

(C) A change in appearance of a mole on the shoulder - It is a warning sign of cancer, it may be due to a skin cancer called melanoma due to continuous exposure to ultraviolet rays from sun.

49)

(A) Flush the NG tube with 5 ml of sterile watet prior to administration to clear the tube

* Each medication should be given separately to avoid drug interactions and flush the tube with sterile water after administering medication. Never combine medications with feeds and never combine medications together in one syringe for administration.