Exam 2 Questions

A nurse is preparing to communicate with an older client who is hearing impaired. Which intervention would be implemented initially?

• Exaggerate lip movements

• Stand in front of the client

• Obtain a sign-language interpreter

• Pantomime and write the client notes

The nurse inspects a pressure injury on a client's sacrum and notes that the site has partial-thickness skin loss and the formation of a blister. The nurse would document the pressure injury as which category?

• Stage I

• Stage II

• Stage III

• Stage IV

The nurse on a behavioral health unit is having a therapeutic discussion with a client and recognizes that which communication techniques would be non-therapeutic? Select all that apply.

• Giving recognition

• Minimizing feelings

• Changing the subject

• Asking "why" questions

Using the SOAP method of documentation, which nursing note belongs in the subjective portion of the patient's chart?

• Patient's blood pressure is 145/90

• Patient currently taking Metoprolol 20 mg/daily

• Patient reports pain of 7 out of 10

• Patient's past surgical history includes hernia repair

A Spanish-speaking client arrives at the triage desk in the emergency department and states to the nurse, "No English, only Spanish." Which action should the nurse take?

• Have one of the client's family members interpret

• Have the Spanish-speaking triage receptionist interpret

• Seek an interpreter from the hospital's interpreter services

• Obtain a Spanish-English dictionary and attempt to triage the client

The nurse is reviewing dental care with a client who is edentulous (lacking teeth) and wears dentures. Which of the following client statements indicated an understanding of proper dental care?

• "Since I have no teeth, I do not need to brush my mouth."

• "I need to use hot water when cleaning my dentures to kill bacteria."

• "I will remove my dentures before bed and keep them in my labeled denture cup covered with water."

• "When I am not wearing my dentures during the day, I can keep them in the denture cup with no water, as they should only be in water at night."

The nurse checks a client's skin turgor and documents that the client exhibits normal fluid balance. Which statement correctly describes what the nurse has documented?

• The skin when pinched remained elevated when released.

• The skin when pinched failed to return to normal when released

• The skin when pinched immediately fell back to normal when released

• The skin when pinched remained tented for several seconds when released.

The nurse is providing directions to the assistive personnel (AP) regarding clients hygiene needs. Based on the client needs, the nurse instructs the AP to bathe which client first?

• A client who is on bed rest after multiple traumas.

• A confused client who is incontinent of stool and urine.

• A client who was admitted for dehydration and failure to thrive.

• A client who is independent with ADLs (activities of daily living).

The nurse is educating an LPN on where to find mucous membranes in the body. The LPN knows that mucous membranes are located (Select all that apply).

• Enamel of the teeth

• Respiratory tract

• Nostrils

• Stomach

A nurse is preparing to delegate tasks to an assistive personnel (AP). The nurse knows that which is not part of the five rights of delegation?

• Righ communication

• Right task

• Right documentation

• Right person

• Right direction/communication