Nokea
A nurse is preparing a client for transfer to another unit. Which finding does the nurse include in the transfer report?
- A. Response to pain medication
- B. Review of ongoing discharge plan
- C. Recent physical changes
- D. All of the above
Correct Answer: D
Rationale: All findings are important for ensuring continuity of care in the transfer report.
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A nurse is teaching about measures to promote sleep for a client with insomnia. What statement indicates understanding?
- A. I should reduce my fluid intake to 2 hours before bedtime
- B. I will watch TV in bed before sleeping
- C. I can take long naps during the day
- D. I should exercise right before going to bed
Correct Answer: A
Rationale: Reducing fluid intake to 2-4 hours before sleeping helps prevent interruptions during the night, promoting better sleep.
A nurse is monitoring a client who has been receiving intermittent enteral feedings. What should the nurse identify as an intolerance to the feeding?
- A. Increased appetite
- B. Nausea
- C. Weight gain
- D. Regular bowel movements
Correct Answer: B
Rationale: Nausea is a sign of intolerance to enteral feedings, which may also include vomiting and dumping syndrome.
A nurse is documenting client care. Which of the following entries should the nurse identify as an example of implementation of client care?
- A. Contacted the provider to report client findings
- B. Administered medications as prescribed
- C. Reviewed the client's lab results
- D. Discussed the care plan with the family
Correct Answer: B
Rationale: Documenting that medications were administered as prescribed is an example of the implementation of client care.
A nurse is caring for a client who reports burning around the peripheral IV site. Which finding should the nurse identify as a manifestation of infiltration?
- A. Redness at the site
- B. Warmth around the site
- C. Edema
- D. Pain at the site
Correct Answer: C
Rationale: Edema at the IV site indicates that IV solution has leaked into the extravascular tissue, which is a sign of infiltration.
A nurse is performing a cultural assessment of a group of clients to maintain respect for their value systems and beliefs. Which of the following should the nurse identify as examples of cultural variables?
- A. Eye contact
- B. Personal space
- C. Touch
- D. All of the above
Correct Answer: D
Rationale: Eye contact, personal space, and touch are cultural variables that can affect communication.