The involvement of the client in planning the change

The involvement of the client in planning the change
9. A nurse is planning to obtain the vital signs of a 2-year-old child who is experiencing diarrhea and
who might have a right ear infection. Which of the following routes should the nurse use to obtain
the temperature?
Temporal
10. A nurse is witnessing a client sign an informed consent form for surgery. Which of the following
describes what the nurse is affirming by this action?

The signature on the preoperative consent form is the client’s
11. A nurse on a medical-surgical unit is admitting a client. Which of the following information should
the nurse document in the client’s record first?
Assessment
12. A nurse on a medical-surgical unit is washing her hands prior to assisting with a surgical procedure.
Which of the following actions by the nurse demonstrates proper surgical hand-washing
techniques?
The nurse washes with her hands held higher than her elbows.
13. A nurse at a screening clinic is assessing a client who reports a history of a heart murmur related to
aortic valve stenosis. At which of the following anatomical areas should the nurse place the
stethoscope to auscultate the aortic valve?
Second intercostal space to the right of the sternum
14. A nurse is measuring vital signs for a client and notices an irregularity in the pulse. Which of the
following actions should the nurse take?
Count the apical pulse rate for 1 full minute, and describe the rhythm in the chart.
15. A nurse is caring for an older adult client who becomes agitated when the nurse requests the
client’s dentures be removed prior to surgery. Which of the following responses should the nurse
make?
“What worries you about being without your teeth?”
16. A nurse is caring for a client who has a terminal illness. The client asks several questions about the
nurse’s religious beliefs related to death and dying. Which of the following actions should the nurse
take?
Encourage the client to express his thoughts about death and dying
17. A nurse is caring for a client who has Type 1 diabetes mellitus and is resistant to learning self-
injection of insulin. Which of the following statements should the nurse make?

“Tell me what I can do to help you overcome your fear of giving yourself injections.”
18. A charge nurse is teaching adult cardiopulmonary resuscitation (CPR) to a group of newly licensed
nurses. Which of the following actions should the charge nurse teach as the first response in CPR?
Confirm unresponsiveness.
19. A community health nurse is preparing a campaign about seasonal influenza. Which of the following
plans should the nurse include as a secondary prevention?
Screening groups of older adults in nursing care facilities for early influenza manifestations
20. A nurse is preparing to provide tracheostomy care for a client. Which of the following actions should
the nurse take first?