The nurse provides care for a client recovering from a motor vehicle crash. For which sign of ﬂuid volume overload does the nurse measure the client's intake and output? (Select all that apply)

Productive cough

Heart rate 112 beats/min

Blood pressure 96/52 mm Hg

Weight gain of 2 kg (4.4 lb)

Edema +2 of bilateral ankles and feet

Answer and Explanation

Correct Answer : A,D,E

These are all signs of ﬂuid volume overload. Measuring the client's intake and output can help the nurse monitor the client's ﬂuid balance and detect any imbalances. A productive cough may indicate ﬂuid accumulation in the lungs.

Weight gain and edema are also signs of ﬂuid retention.

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Correct Answer is C

Explanation

This is because successful communication requires the eﬀorts of all people involved in a conversation. Even when the person with hearing loss utilizes hearing aids and active listening strategies, it is crucial that others involved in the communication process consistently use good communication strategies. One of these strategies is to face the hearing-impaired person directly, on the same level and in good light whenever possible. Position yourself so that the light is shining on the speaker's face, not in the eyes of the listener ¹.

A. Measures the size of the wound B. Cleans from bottom to top C. Works outward from the incision D. Wipes from clean area to less clean area E. Removes exudate with hydrogen peroxide

Correct Answer is ["A","C","D"]

Explanation

These are all important steps in rendering prescribed wound care for a child with an abdominal wound. Measuring the size of the wound helps to track healing progress. Working outward from the incision and wiping from a clean area to a less clean area helps to prevent infection.

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The nurse provides care for a client recovering from a motor vehicle crash. For which sign of ﬂuid volume overload does the nurse measure the client's intake and output? (Select all that apply)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client diagnosed with a bilateral hearing impairment seeks medical attention for an acute health problem. Which approach does the nurse use to enhance communication with this client?

Correct Answer is C

Explanation

The nurse provides care for a child with an abdominal wound. The wound edges are approximated. Which does the nurse include when rendering the prescribed wound care to this child? (Select all that apply)

Correct Answer is ["A","C","D"]

Explanation

A bed-bound chart has a prescription for routine urinalysis. In which way does the nurse obtain the urine sample for the laboratory?

A young adult client has a partner and no children. The client has a hysterectomy because of endometrial cancer. The client has an IV and an indwelling urinary catheter. The client is crying asking for their partner. Which action does the nurse take first?

The nurse omits to document an assessment finding that resulted in a significant client injury. For which legal issue does the nurse need to prepare?

The nurse evaluates a client's plan of care. The client has an outcome of 'Client will learn self-glucose testing before discharge'. When evidence best allows the nurse to meet the outcome of the plan?

The nurse delegated vital signs for a group of patients to the unlicensed assistive personnel (UAP). Which client condition would prohibit having a rectal temperature taken by the UAP?

The nurse provides care for a patient with an infected surgical wound. The nurse assesses the wound and changes the dressing. Which does the nurse include in the documentation? Select all that apply.

The nurse plans care for a client who reports avoiding people because of having scabies and difficulty walking. Which statement does the nurse document as the client's greatest concern?

The nurse provides care for a client diagnosed with pneumonia. The client is unable to expectorate respiratory secretions. The nurse suctions the client's nasopharyngeal airway. When is suctioning technique correct?