2020iHESIiFundamentals

1. A ipolicy irequiring ithe iremoval iofiacrylic inailsiby iall inursing ipersonnel iwasiimplemented i6 imonthsiago. iWhich iassessment imeasure

ibest ideterminesiifithe iintended ioutcome iofithe ipolicy iisibeing iachieved.

a. Numberiofistaffiinduced iinjury

b. Client isatisfaction isurvey

c. iHealth icare-associated iinfectionirate.

d. Rate iofineedle-stick iinjuriesibyinurse.

2. The inurse iisipreparing ito iassist ia inewly iadmitted iclient iwith ipersonal ihygiene imeasures. iThe iclient...the iclient’sigag ireflex. iWhich

iaction ishould ithe inurse iinclude?

A. Offerismallsisipsiofiwaterithrough iaistraw

B. Place itongue iblade ion iback ihalfiofitongue

C. Use ia ipenlight ito iobserve iback iofioral icavity

D. Auscultate ibreath isoundsiaftericlient iswallows

3. The ifatheriofian i11-year-old iboy….

informithe ifatherithat iit iisimost iimportant ito ilet ithe ison ithat inocturnal iemissionsiare inormal

4. The inurse iexplainsito ian iolderiadult imale ithe iprocedure iforicollecting ia i24-houriurine ispecimen iforicreatinineiclearance.

A. Assessithe iclient iforiconfusion iand ireteach ithe iprocedure

B. Check ithe iurine iforicoloriand itexture

C. Empty ithe iurinal icontentsiinto ithe i24-houricollection icontainer

D. Discard ithe icontentsiofithe iurinal

5. A i54-year-old imale iclient iand ihisiwife iwere iinformed ithisimorning ithat ihe ihasiterminal icancer. iWhich inursing iintervention iisilikely

ito ibe imost

A. Ask iherihow ishe iwould ilike ito iparticipate iin ithe iclient’sicare

B. Provide ithe iwife iwith iinformation iabout ihospice

C. Encourage ithe iwife ito ivisit iafteripainful itreatmentsiare icompleted

D. Referiherito isupport igroup iforifamily imembersiofithose idying ioficanceri

6. A iclient iwho ihasia ibody imassiindex i(BMI)iofi30 iisirequesting iinformation ion ithe iinitial iapproach ito ia iweight ilossiplan. iWhich

iaction ishould ithe inurse irecommend?

A. Plan ilow icarbohydrate iand ihigh iproteinimeals

B. Engage iin istrenuousiactivity iforian ihouridaily

C. Keep ia irecord iofifood iand idrinksiconsumed idaily

D. Participated iin ia igroup iexercise iclassi3 itimesia iweek

7. The inurse iassessesia iclient iwho ihasia inasal icannula idelivering ioxygen iat i2 iL/min. iTo iassessiforiskin idamage irelated ito ithe icannula,

iwhich iareasishould ithe inurse iobserve?

A. Topsiofithe iear

B. Bridge iofithe inose

C. Around ithe inostrils

D. Overithe icheeks

E. Acrossithe iforehead

8. The inurse iobservesian iunlicensed iassistive ipersonnel i(UAP)iwho iisiproviding ia itotal ibed ibath iforia iconfused iand ilethargic iclient.

iThe iUAP iisisoaking ithe iclient’sifoot iin ia ibasin iofiwarmiwateriplaced ion ithe ibed. iWhat iaction ishould ithe inurseitake?

a. Remove ithe ibasin iofiwaterifromithe iclient’sibed iimmediately

b. Remind ithe iUAPito idry ibetween ithe iclient’sitoesicompletely i

c. Advise ithe iUAP ithat ithisiprocedure iisidamaging ito ithe iskin

d. Add iskin icreamito ithe ibasin iofiwateriwhile ithe ifoot iisisoaking i

9. The inurse iin ithe iemergency idepartment iobservesia icolleague iviewing ithe ielectronic ihealth irecord i(EHR)iofia iclient iwho iholdsian

ielected iposition iin ithe icommunity. iThe iclient iisinot ia ipart iofithe icolleague’siassignment. iWhich iaction ishould ithe inurseimplement?

a. Communicate ithe icolleague’siactionsito ithe iunit icharge inurse

b. Send ian iemail ito ifacility iadministration ireporting ithe iaction

c. Write ian ianonymousicomplaint ito ia iprofessional iwebsite

d. Post ia icomment iabout ithe iaction ion ia istaffidiscussion iboard

10. At i0100 ion ia imale iclient’sisecond ipostoperative inight, ithe iclient istatesihe iisiunstable ito isleep iand iplansito iread iuntil ifeeling isleepy.

iWhat iaction ishould ithe inurse iimplement?

a. Leave ithe iroomiand iclose ithe idoorito ithe iclient’siroom

b. Assessithe iappearance iofithe iclient’sisurgical idressing

c. Bring ithe iclient ia iprescribed iPRNisedative-hypnotic

d. Discussisymptomsiofisleep ideprivation iwith ithe iclient

11. The inursing istaffiin ithe icardiovasculariintensive icare iunit iare icreating ia icontinuousiquality iimprovement iproject ion isocial imedia

ithat iaddressesicoronary iartery idisease i(CAD). iWhich iaction ishould ithe inurse iimplement ito iprotect iclientiprivacy?

a. Remove iidentifying iinformation iofithe iclientsiwho iparticipated

b. Recallithat iauthored icontent imayibe ilegally idiscoverable

c. Share imaterialifromicredible, ipeerireviewed isourcesionly

d. Respect iall icopyright ilawsiwhen iadding iwebsite icontent

12. A imale iclient iwith iunstable iangina ineedsia icardiac icatheterization, iso ithe ihealthcare iprovideriexplainsithe irisksiand ibenefitsiofithe

iprocedure, iand ithen ileavesito iset iup iforithe iprocedure. iWhen ithe inurse ipresentsithe iconsent iformiforisignature, ithe iclient ihesitatesiand

iasksihowithe iwiresiwill ikeep ihisiheart igoing. iWhich iaction ishould ithe inurse itake?

a. Answerithe iclient’sispecific iquestionsiwith ia ishort iunderstandable iexplanation

b. Postpone ithe iprocedure iuntil ithe iclient iunderstandsithe irisksiand ibenefits

c. Call ithe iclient’sinext iofikin iand iask ithemito iprovide iverbal iconsent

d. Page ithe ihealthcare iproviderito ireturn iand iprovide iadditional iexplanation

13. The inurse iisiteaching ia iclient ihowito ido iactive irange iofimotion i(ROM)iexercises. iTo iexercise ithe ihinge ijoints, iwhich iaction

ishould ithe inurse iinstruct ithe iclient ito iperform?

a. Tilt ithe ipelvisiforwardsiand ibackwards

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b. bend ithe iarmiby iflexing ithe iulnarito ithe ihumerusi

c. Turn ithe ihead ito ithe iright iand ileft

d. Extend ithe iarmiat ithe iide iand irotate iin icircles

14. A ipostoperative iclient ihasithree idifferent iPRN ianalgesicsiprescribed iforidifferent ilevelsiofipain. iThe inurse iinadvertently

iadministersia idose ithat iisinot iwithin ithe iprescribed iparameters. iWhat iactionsishould ithe inurse itakeifirst?

a. Accessiforiside ieffectsiofithe imedication.

b. Document ithe iclient’siresponses.

c. complete ia imedication ierrorireport.

d. Determine iifithe ipain iwasirelieved.

15. When iassessing ia imale iclient, ithe inurse ifindsithat ihe iisifatigue, iand iisiexperiencing imuscle iweakness, ileg icramps, iand

icardiac idysrhythmias. iBased ion ithese ifindings, ithe inurse iplansito icheck ithe iclient’silaboratory ivaluesito ivalidate ithe iexistence

iofiwhich?

a. Hyperphosphatemia

b. Hypocalcemia

c. Hypermagnesemia

d. Hypokalemia i

16. A ifemale iclient’sisignificant iotherihasibeen iat iheribedside iproviding ireassurancesiand isupport iforithe ipast i3days, iasidesired iby ithe

iclient. iThe iclient’siestranged ihusband iarrivesiand idemandsithat ithe isignificant iotherinot ibe iallowed ito ivisit ioribe igiven icondition

iupdates. iWhich iintervention ishould ithe inurse iimplement?

a. Obtain ia iperception ifromithe ihealthcare iprovideriregarding ivisitation iprivileges

b. Request ia iconsultation iwith ithe iethicsicommittee iforiresolution iofithe isituation

c. Encourage ithe iclient ito ispeak iwith iherihusband iregarding ihisidisruptive ibehavior

d. Communicate ithe iclient’siwishesito iall imembersiofithe imultidisciplinaryiteam

17. When imeasuring ivital isigns, ithe inurse iobservesithat ia iclient iisiusing iaccessory ineck imusclesiduring irespirations. iWhat ifollow-up

iaction ishould ithe inurse itake ifirst?

a. Determine ipulse ipressure

b. Auscultate iheart isounds

c. Measure ioxygen isaturation

d. Check iforineck ivein idistention

18. To iavoid inerve iinjury, iwhat ilocation ishould ithe inurse iselect ito iadministeria i3 imLiIMiinjection?

a. Ventrogluteal

b. outeriupperiquadrant iofithe ibuttock

c. Two iinchesibelow ithe iacromion iprocess

d. Vastusilateralis

19. Which iinstruction ishould ithe inurse iinclude iin ithe idischarge iteaching iplan iforian iadult iclient iwithihypernatremia?

a. Monitoridaily iurine ioutput ivolume

b. Drink iplenty iofiwateriwheneverithirsty

c. Use isalt itabletsiforisodiumicontent

d. Review ifood ilabelsiforisodium icontent

20. While ichanging ia iclient’sipost ioperative idressing, ithe inurse iobservesia ired iand iswollen iwound iwith ia imoderate iamount iofiyellow

iand igreen idrainage iand ia ifoul iodor. iGiven ithere iisia ipositive iMRSA, iwhich iisithe imost iimportant iaction iforithe inurse itoitake?

A. Force ioral ifluids

B. Request ia inutritioniconsult

C. Initiate icontactiprecautions

D. Limit ivisitorsito iimmediate ifamily ionly

21. To iprepare ia iclient iforithe ipotentialiside ieffectsiofia inewly iprescribed imedication, iwhatiaction ishould ithe inurse

iimplement?

a. Assessithe iclient iforihealth ialterationsithat imay ibe iimpacted iby ithe ieffectsiofithe imedication

b. Teach ithe iclient ihow ito iadministerithe imedication ito ipromote ithe ibestiabsorption

c. Administeria ihalfidose iand iobserve ithe iclient iforiside ieffectsibefore iadministering ia ifullidosage

d. Encourage ithe iclient ito idrink iplenty iofifluidsito ipromote ieffective idrugidistribution

22. Aiclientiisi2 idaysipost-op ifromia ithoracic isurgery iand iisicomplaining iofiincisional ipain. iThe iclient ilast ireceived ipain imedication i2

ihoursiago. iHe iisirating ihisipain ia i5 ion ia i1-10 iscale. iAftericalling ithe iprovider, iwhat iisithe inurse'sinextiaction?

a. instruct ithe iclient ito iuse iguided iimagery iand islow irhythmic ibreathing

b. Provide iat ileast i20 iminutesiofiback imassage iand igentle ieffleurage

c. Encourage ithe iclient ito iwatch iTV.

d. Place ia ihot iwatericirculation idevice, isuch iasian iAqua iK ipad, ito ioperative isite

23. A iclient iwith icirrhosisiand iascitesiisireceiving ifurosemide i40 img iBID. iThe ipharmacy iprovidesi20 img itablets. iHow imany itablets

ishould ithe iclient ireceive ieach iday? i[Enterinumeric ivalue ionly]

4 itablets

24. An iolderiadult imale iclient iisiadmitted ito ithe imedical iunit ifollowing ia ifall iat ihome. iWhen iundressing ihim, ithe inurse inotesithat

ihe iisiwearing ian iadult idiaperiand iskin ibreakdown iisiobviousioverihisisacral iarea. iWhat iaction ishould ithe inurse iimplement ifirst?

a. Establish ia itoileting ischedule ito idecrease iepisodesiofiincontinence

b. Complete iaifunctionaliassessmentiofithe iclient’siself-care iabilities

c. Apply ia ibarrieriointment ito iintact iareasithat imay ibe iexposed ito imoisture

d. Determine ithe isize iand idepth iofiskin ibreakdown ioverithe isacral iarea

25. While iinterviewing ia iclient, ithe inurse irecordsithe iassessment iin ithe ielectronic ihealth irecord. iWhich istatement iisimost iaccurate

iregarding ielectronic idocumentation iduring ian iinterview?

a. The iclient’sicomfort ilevel iisiincreased iwhen ithe inurse ibreaksieye icontact ito itype inotesiinto itheirecord

b. The iinterviewiprocessiisienhanced iwith ielectronic idocumentation iand iallowsithe iclientito ispeak iat

ia inormal ipace

c. The inurse ihasilimited iability ito iobserve inonverbal icommunication iwhile ientering ithe

iassessment ielectronically

d. Completing ithe ielectronic irecord iduring ian iinterview iisia ilegal iobligation iofithe iexamininginurse

26. A ifemale iclient iwith ichronic iback ipain ihasibeen itaking imuscle irelaxantsiand ianalgesicsito imanage ithe idiscomfort, ibut iisinow

iexperiencing ian iacute iepisode iofipain ithat iisinot irelieved iby ithisimedication iregime. iThe iclientitellsithe inurse ithat ishe idoesinot iwant ito

ihave

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back isurgery iforia iherniated iintervertebral idisk, iand ireportsithat ishe ihasifound iacupuncture ieffective iin iresolving ipast iacute iepisodes.

iWhich iresponse iisibest iforithe inurse ito iprovide?

a. Surgery iremovesithe idisk iand iisithe ionly itreatment ithat ican itotally iresolve itheipain

b. The imedication iregimen iyou ipreviously iused ishould ibe ire-evaluated iforidoseiadjustment

c. Massage iand ihot ipack itreatmentsiare ilessiinvasive iand ican iprovide itemporary irelief

d. Acupuncture iisia icomplementary itherapy ithat iisioften ieffective iforimanagement iofipain

27. The inurse iis iproviding iwound icare ito ia iclient iwith istage i3 ipressure iulcer ithat ihas ia ilarge iamount iof ieschar. iThe iwound icare

iprescription istatesi“clean ithe iwound iand ithen iapply icollagenase.” icollagenase iisia idebriding iagent. iThe iprescription idoes inot ispecify ia

icleaning imethod. iWhich itechnique ishould ithe inurse icleanse ithe ipressure iulcer?

a. Lightly icoat ithe iwound iwith ipovidone-iodine isolution

b. Irrigate ithe iwound iwith isterile inormal isaline

c. Flush ithe iwound iwith isterile ihydrogen iperoxide

d. Remove ithe ieschariwith ia iwet-to-dry idressing

28. A iclient iisiadmitted iwith ia ifeveriofiunknown iorigin. iTo iassessifeveripatterns, iwhich iintervention ishould ithe inurseimplement?

a. Document ithe iclient’sicircadian irhythms

b. Assessiforiflushed, iwarmiskin iregularly

c. Measure itemperature iat iregularintervals

d. Vary isitesiforitemperatureimeasurement

29. When iperforming iblood ipressure imeasurement ito iassessiforiorthostatic ihypotension, iwhich iaction ishould ithe inurse iimplementifirst?

a. Position ithe iclient isupine iforia ifew iminutes

b. Assist ithe iclient ito istand iat itheibedside

c. Apply ithe iblood ipressure icuffisecurely

d. Record ithe iclient’sipulse irate iand irhythm

30. The inurse iretrievesihydromorphone i4mg/mLifromithe iPyxisiMedStation, ian iautomated idispensing isystem, iforia iclient iwho iis

ireceiving ihydromorphone i3 img iIM i6 ihoursiPRN isevere ipain. iHow imany imLishould ithe inurse iadministerito ithe iclient? i(Enterithe

inumerical ivalue ionly. iIfirounding iisirequired i, iround ito ithe inearest itenth)iAns:i0.8

31. The iunlicensed iassistive ipersonnel i(UAP)idescribesithe iappearance iofithe ibowel imovement iofiseveral iclients. iWhich

idescription iwarrantsiadditional ifollow iup iby ithe inurse? i(select iall ithat iapplies).

a. iSolid iwith ired istreaks.

ib. iBrown iliquid.

c. Multiple ihard ipellets.

d. Formed ibut isoft.

ie. iTarry

iappearance.

32. A ifemale iUAP iisiassigned ito itake ithe ivital isignsiofia iclient iwith ipertussisiforiwhomidroplet iprecautionsihave ibeen iimplemented.

iThe iUAPirequestsia ichange iin iassignment...she ihasinot iyet ibeen ifitted iforia iparticulate ifilterimask.Which iaction ishould ithe inurse

itake?

a. Advise ithe iUAPito iwearia istandard iface imask ito itake ivitalisigns, iand ithen iget ifitted iforia ifilterimask

ibefore iproviding ipersonal icare

b. Send ithe iUAP ito ibe ifitted iforia iparticulate ifilterimask iimmediately iso ishe ican iprovide icare ito ithisiclient

c. Instruct ithe iUAP ithat ia istandard imask iisisufficient iforithe iprovision ioficare iforithe iassignediclient

d. Before ichanging iassignments, idetermine iwhich istaffimembersihave ifitted iparticulate ifilterimasks

33. In-home ihospice icare iisiarranged iforia iclient iwith istage i4 ilung icancer. iWhile ithe ipalliative inurse iisiarranging iforidischarge, ithe

iclient iverbalizesiconcernsiabout ipain. iWhat iaction ishould ithe inurse iimplement?

a. Explain ithe irespiratory iproblemsithat ican ioccuriwith imorphine iuse.

b. Teach ifamily ihowito ievaluate ithe ieffectivenessiofianalgesics.

c. Recommend iasking ithe ihealthcare iprofessional iforia ipatient-controlled ianalgesic i(PCA)ipump.

d. Provide iclient iwith ia ischedule iofiaround-the-clock iprescribed ianalgesic iuse.

34. What iassessment ifinding iplacesia iclient iat irisk iforiproblemsiassociated iwith iimpaired iskin iintegrity?

a. Scattered imacula iofithe iface

b. Capillary irefill i5 iseconds

c. Smooth inail itexture

d. Absence iofiskin itenting

35. When ievaluating ithe ieffectivenessiofia iclient’sinursing icare, ithe inurse ifirst ireviewsithe iexpected ioutcomesiidentified iin ithe iplan iof

icare. iWhat iaction ishould ithe inurse itake inext?

a. Determine iifithe iexpected ioutcomesiwere irealistic

b. Obtain icurrent iclient idata ito icompare iwith iexpected ioutcomes

c. Modify ithe inursing iinterventionsito iachieve ithe iclient’sigoals

d. Review irelated iprofessional istandardsioficare

36. The inurse iattachesia ipulse ioximeterito ia iclient’sifingersiand iobtainsian ioxygen isaturation ireading iofi91%. iWhich iassessment

ifinding imost ilikely icontributesito ithisireading?

a. BP i142/88 immHg

b. 2+ iedema iofifingersiand ihands

c. Radial ipulse ivolume iisi+3

d. Capillary irefill itime iisi2 iseconds

37. The inurse iisicaring iforia ihospitalized iclient iwho iwasiplaced iin irestraintsidue ito iconfusion. iThe ifamily iremovesithe irestraintsiwhile

ithey iare iwith ithe iclient. iWhen ithe ifamily ileaves, iwhat iaction ishould ithe inurse itake ifirst?

a. Apply ithe irestraintsito imaintain ithe iclient’sisafety.

b. Reassessithe iclient ito idetermine ithe ineed iforicontinuing irestraints.

c. Document ithe itime ithe ifamily ileft iand icontinue ito imonitorithe iclient.

d. Call ithe ihealthcare iprovideriforia inew iprescription.

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38. The inurse iisidischarging ian iadult iwoman iwho iwasihospitalized ifori6 idaysiforitreatment iofipneumonia. iWhile ithe inurse iis

ireviewing ithe iprescribed imedications, ithe iclient iappearsianxious. iWhat iaction iisimost iimportant iforithe inurse itoiimplement?

a. Instruct ithe iclient ito irepeat ithe imedication iplan

b. Encourage iclient ito itake ia iPRN iantianxiety idrug

c. Provide iwritten iinstructionsithat iare ieasy ito ifollow

d. Include ia ifamily imemberiin ithe iteaching isession

39. What iinstruction ishould ithe inurse iprovide iforian iUAP icaring iforia iclient iwith iMRSA iwho ihasia iprescription iforicontactiprecautions?

a. Do inot iallow ivisitorsiuntil iprecautionsiare idiscontinued

b. Wearisterile iglovesiwhen ihandling ithe iclient’sibody ifluid

c. Have ithe iclient iwearia imask iwheneverisomeone ientersithe iroom

d. Don ia igown iand iglovesiwhen ientering ithe ireturn

40. While isuctioning ia iclient’sinasopharynx ithe inurse iobservesithat ithe iclient’sioxygen isaturation iremainsiati94%iwhich iisithe isame

ireading iobtained ipriorito istarting ithe iprocedure. iWhat iaction ishould ithe inurse itake iin iresponse ito ithisifinding?

a. iComplete ithe iintermittent isuction iofithe inasopharynx.

b. Reposition ithe ipulse ioximetericlip ito iobtain ia inewireading.

c. Stop isuctioning iuntil ithe ipulse ioximeterireading iisiabove i95%.

d. Apply ian ioxygen imask ioverithe iclient’sinose iand imouth

41. UAP ihasilowered ithe ihead iofithe ibed ito ichange ithe ilinesiforia iclient iwho iisibedless. iWhich iobservation...most iimmediate

iintervention iby ithe inurse?

a. A ifeeding iisiinfusing iat i40 imL/hrithrough ian ienteral ifeeding itube

b. The iurine imeteriattached ito ithe iurinary idrainage ibag iisicompletely ifull

c. There iisia ilarge idependent iloop iin ithe iclient’siurinary idrainage itubing

d. Purulent idrainage iisipresent iaround ithe iinsertion isite iofithe ifeeding itube

42. A imale iclient ipresentsito ithe iclinicsistating ithat ihe ihasia ihigh istressijob iand iisihaving idifficulty ifalling iasleep iat inight. i.The iclient

ireportsihaving ia iconstant iheadache iand iisiseeking imedication ito ihelp ithe isleep. iWhich iintervention ishould ithe inurseimplement?

a. Determine ithe iclient’sisleep iand iactivity ipattern

b. Obtain iprescription iforiclient ito itake iwhen istressed

c. Refericlient iforia isleep istudy iand ineurological ifollow-up

d. Teach icoping istrategiesito iuse iwhen ifeeling istressed

43. The inurse iisiteaching ia iclient iabout iuse iofithe isyringesiand ineedlesiforihome iadministration iofimedications. iWhich iaction iby ithe

iclient iindicatesian iunderstanding iofistandard iprecaution?

a. Remove ineedle ibefore idiscarding iused isyringes

b. Weariglovesito idispose iofithe ineedle iand isyringe

c. Done ia iface imask ibefore iadministering ithe imedication

d. Washesihandsibefore ihandling ithe ineedle iand isyringe i

44. The inurse iobservesian iUAP ipositioning ia inewly iadmitted iclient iwho ihasia iseizure idisorder. iThe iclient iisisupine iand ithe iUAP iis

iplacing isoft ipillowsialong ithe iside irails. iWhich iaction ishould ithe inurse iimplement?

a. Instruct ithe iUAP ito iobtain isoft iblanketsito isecure ito ithe iside irailsiinstead iofipillows

b. Ensure ithat ithe iUAP ihasiplaced ipillowsieffectively ito iprotect ithe iclient

c. Ask ithe iUAP ito iuse isome ipillowsito iprop ithe iclient iin ia iside-lying iposition

d. Assume iresponsibility iforiplacing ithe ipillowsiwhile ithe iUAP icomplete ianotheritask i

45. A icerebrovasculariaccident iisiplaced ion ia iventilator. iThe iclient’sidaughteriarrivesiwith ia idurable ipower iofiattorney, iand ia iliving iwill

ithat iindicatesithe...extraordinary ilife isaving imeasures. iWhat iaction ishould ithe inurse itake?

a. Referito ithe irisk imanager

b. Notify ithe ihealthcare iprovider

c. Discontinue ithe iventilator

d. Review ithe imedical irecord

46. Earlierithisimorning, ian ielderly iHispanic ifemale iwasidischarged ito ia iLTCifacility. iThe ifamily imembersiare inow igathered iin ithe

ihallway ioutside iheriroom. iWhat iisithe ibest iaction?

a. Ask ithe ifamily ito iwait iin ithe icafeteria iwhen ithe inext iofikin imakesithe inecessaryiarrangements

b. Provide ispace iand iprivacy iforithe ifamily ito ishare itheiriconcernsiabout ithe iclient’sidischarge

c. Ask ithe isocial iworkerito iencourage ithe ifamily ito iclearithe ihallway

d. Explain ito ithe ifamily ithe iclient’sineed iforiprivacy iso ithat ishe ican imake iindependentidecisions

47. Aiclientiwith irheumatoid iarthritisiisiexperiencing ichronic ipain iin iboth ihandsiand iwrists. iWhich iinformation iaboutithe iclient iis

imost iimportant iforithe inurse ito iobtain iwhen iplanning icare?

a. Amount iofisupport iprovided iby ifamily imembers

b. Measurement iofipain iusing ia iscale iofi0 ito i10

c. The iability ito iperformiADLs

d. Nonverbal ibehaviorsiexhibited iwhen ipain ioccurs

48. A imale iNative iAmerican ipresents ito ithe iclinic iwith icomplaints iof ifrequent iabdominal icramping iand inausea. iHe istates ithat ithe

ichronic iconstipation iand ihad inot ihad ia ibowel imovement iin ifive idays, idespite itrying iseveral ihome iremedies. iWhich iintervention iis

imost iimportant iforithe inurse ito iimplement?

a. Evaluate ithe istool isamplesiforipresence iofiblood

b. Assessiforithe ipresence iofian iimpaction

c. Determine iwhat ihome iremediesiwereiused

d. Obtain ilist iofiprescribed ihomeimedication

49. Which iassessment idata ireflectsithe ineed iforithe inursesito iinclude ithe iproblem, i“Risk iforifalls” iin ia iclient’siplan ioficare?

a. Recent iserumihemoglobin ilevel iofi16g/dL

b. Opioid ianalgesic ireceived ione ihouriago

c. Stooped iposture iwith ia isteady igait

d. Expressed ifeelingsiofidepression

50. The inurse ireceivesia ireport ithat ia iclient iwith ian iindwelling iurinary icatheterihasian ioutput iofi150 imL, iforithe ipreviousi6 ihour

ishift. iWhich iintervention ishould ithe inurse iimplement ifirst?

a. Check ithe idrainage itubing iforiaikink

b. Review ithe iintake iand ioutputirecord

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