Question

A nurse is assessing the visual acuity of a client who wears glasses using a Snellen chart. Which of the following actions should the nurse take?

Answer 1

Correct Answers:

Begin by testing the client while they are wearing glasses

Rationale :

When assessing visual acuity, the nurse should first test the client while they are wearing their glasses or corrective lenses. This approach evaluates how well the client can see with their usual correction, which is essential for determining any changes in vision or the need for an updated prescription. If the client is unable to read the required lines even with their glasses, it may indicate a more significant vision problem.

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Answer 2

Correct Answers:

Crackles in the lungs

Rationale :

Fluid overload, also known as hypervolemia, occurs when there is excessive fluid in the bloodstream, leading to increased hydrostatic pressure. One of the key signs of fluid overload is the presence of crackles in the lungs, which results from fluid accumulation in the alveoli. This can cause dyspnea, tachypnea, and decreased oxygen saturation, potentially progressing to pulmonary edema if not addressed.

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Answer 3

Correct Answers:

The client's telephone number

Rationale :

The Joint Commission's National Patient Safety Goals require healthcare providers to use at least two patient identifiers before administering medications. Acceptable identifiers include the client’s full name, date of birth, medical record number, or telephone number. These ensure accuracy and prevent medication errors.

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Answer 4

Correct Answers:

Arrange for a video conference with an interpreter who speaks the client's language-

Rationale :

When providing discharge instructions to a client who does not speak the same language, the nurse must ensure clear, accurate, and culturally appropriate communication. Using a professional interpreter, whether in person, via telephone, or through a video conference, is the best practice. This approach ensures that medical terminology is translated correctly and that the client fully understands the instructions, reducing the risk of miscommunication and potential harm.

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Answer 5

Correct Answers:

Assist the client with a bowel cleansing.

Rationale :

An intravenous pyelogram (IVP) is a diagnostic imaging test used to evaluate the urinary tract, including the kidneys, ureters, and bladder. It involves the injection of iodine-based contrast dye into a vein, followed by X-ray imaging. Bowel cleansing is essential before the procedure because excess stool and gas in the intestines can obstruct the view of the urinary structures, leading to poor imaging results. Bowel preparation may include a laxative, enema, or dietary restrictions as prescribed by the healthcare provider.

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Answer 6

Correct Answers:

"l will place the suppository as far inside my vagina as I can reach."

Rationale :

Clotrimazole vaginal suppositories are used to treat yeast infections (candidiasis). Proper administration involves inserting the suppository as far into the vagina as comfortably possible to ensure that the medication is distributed effectively. This helps the antifungal agent reach the affected area and dissolve properly, providing optimal treatment. Suppositories are best inserted while lying on the back with knees bent or in a squatting position.

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Answer 7

Correct Answers:

Ask a second nurse to record her signature when wasting any unused portion of the controlled substance.

Rationale :

When wasting any unused portion of a controlled substance, a second nurse must witness and co-sign the waste documentation. This policy helps prevent drug diversion, medication errors, and unauthorized use. The witnessing nurse confirms that the medication is properly disposed of and not misused. The disposal method varies by facility policy but typically involves discarding liquid medications in a designated disposal container or rendering tablets unusable before disposal.

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Answer 8

Correct Answers:

A client who requires teaching prior to discharge.

Rationale :

Providing written materials in the client’s primary language is crucial when giving discharge teaching, as this information will help guide the client’s self-care after leaving the hospital. Written instructions serve as a reference for medication schedules, wound care, activity restrictions, and follow-up appointments, reducing the risk of misunderstandings and readmissions. This aligns with health literacy and patient safety standards, ensuring clients can manage their care effectively at home.

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Answer 9

Correct Answers:

Prepare the client for a central venous line.

Rationale :

Parenteral nutrition (PN) with 20% dextrose has a high osmolarity, which can damage smaller peripheral veins. Because of this, a central venous catheter (CVC) is required to safely administer the solution. A peripherally inserted central catheter (PICC) or a central line (such as a subclavian or internal jugular catheter) is commonly used. This ensures the solution is diluted properly in the bloodstream, reducing the risk of phlebitis, thrombosis, or vein irritation.

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Answer 10

Correct Answers:

"l will tighten my abdominal muscles prior to moving.'

Rationale :

Tightening the abdominal muscles before repositioning a client helps stabilize the spine and lower back, reducing the risk of strain or injury. Engaging the core muscles distributes the workload more evenly and provides better support when lifting or moving a client. This technique is essential for safe body mechanics and is widely recommended for caregivers and healthcare workers.

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QLexNursing

1 : A nurse is assessing the visual acuity of a client who wears glasses using a Snellen chart. Which of the following actions should the nurse take?

2 : A nurse is assessing a client who is receiving continuous IV fluids through a peripheral IV. Which of the following findings indicates to the nurse that the client is experiencing fluid overload?

3 : A nurse is preparing to administer several medications to a client.

Which of the following data should the nurse plan to use to confirm the client's identity?

4 : A nurse is planning to provide discharge instructions to a client who does not speak the same language as the nurse. Which of the following actions should the nurse take?

5 : A nurse is planning care for a client who is scheduled for an intravenous pyelogram. Which of the following actions is appropriate for the nurse to include?

6 : A nurse is providing teaching to a client about the administration of clotrimazole vaginal suppositories.

Which of the following statements by the client indicates an understanding of the teaching?

7 : A nurse is preparing to administer a controlled substance to a client for pain management. Which of the following actions should the nurse take?

8 : A nurse is caring for a group of clients whose primary languages are different from the nurse's. For which of the following clients should the nurse provide written materials in the client's primary language?

9 : A nurse is planning care for a client who has a new prescription for parenteral nutrition (PN) in 20% dextrose and fat emulsions.

Which of the following is an appropriate action to include in the plan of care?

10 : A nurse is providing teaching about preventing back strain to the caregiver of a client who is immobile and requires assistance to reposition in bed. Which of the following statements by the caregiver indicates an understanding of the teaching?

QLexNursing

1 : A nurse is assessing the visual acuity of a client who wears glasses using a Snellen chart. Which of the following actions should the nurse take?

2 : A nurse is assessing a client who is receiving continuous IV fluids through a peripheral IV. Which of the following findings indicates to the nurse that the client is experiencing fluid overload?

3 : A nurse is preparing to administer several medications to a client.Which of the following data should the nurse plan to use to confirm the client's identity?

4 : A nurse is planning to provide discharge instructions to a client who does not speak the same language as the nurse. Which of the following actions should the nurse take?

5 : A nurse is planning care for a client who is scheduled for an intravenous pyelogram. Which of the following actions is appropriate for the nurse to include?

6 : A nurse is providing teaching to a client about the administration of clotrimazole vaginal suppositories.Which of the following statements by the client indicates an understanding of the teaching?

7 : A nurse is preparing to administer a controlled substance to a client for pain management. Which of the following actions should the nurse take?

8 : A nurse is caring for a group of clients whose primary languages are different from the nurse's. For which of the following clients should the nurse provide written materials in the client's primary language?

9 : A nurse is planning care for a client who has a new prescription for parenteral nutrition (PN) in 20% dextrose and fat emulsions.Which of the following is an appropriate action to include in the plan of care?

10 : A nurse is providing teaching about preventing back strain to the caregiver of a client who is immobile and requires assistance to reposition in bed. Which of the following statements by the caregiver indicates an understanding of the teaching?

3 : A nurse is preparing to administer several medications to a client.

Which of the following data should the nurse plan to use to confirm the client's identity?

6 : A nurse is providing teaching to a client about the administration of clotrimazole vaginal suppositories.

Which of the following statements by the client indicates an understanding of the teaching?

9 : A nurse is planning care for a client who has a new prescription for parenteral nutrition (PN) in 20% dextrose and fat emulsions.

Which of the following is an appropriate action to include in the plan of care?