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Questions 149

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Question 1 of 5

The nurse is caring for a client with depression over the recent death of her father from cancer. The client states, 'It's my fault. I should have insisted he get regular checkups instead of letting him put it off.' The nurse responds, 'You feel like it's your fault?' Which therapeutic communication technique is the nurse using?

Correct Answer: B

Rationale: Reflecting mirrors the client’s feelings, encouraging further expression and exploration of emotions.

Question 2 of 5

A client with liver failure and ascites is having a paracentesis to relieve severe dyspnea resulting from abdominal fluid accumulation. Prior to the procedure, the nurse assists the client to urinate. Which of the following is the most important reason to have the patient urinate?

Correct Answer: C

Rationale: Urinating before paracentesis prevents bladder puncture (
C) by emptying the bladder, reducing risk during needle insertion.

Question 3 of 5

The Joint Commission for Accreditation of Hospital Organizations (JCAHO) specifies that two client identifiers are to be used before administering medication. Which method is best for identifying patients using two patient identifiers?

Correct Answer: A

Rationale: Comparing the MAR with the client's armband name and medical number ensures accurate identification using two reliable identifiers.

Question 4 of 5

An 80-year-old man with a decubitus ulcer has just been admitted to the floor. Upon assessment of the wound, the nurse notes that an area of skin under the wound extends and creates another opening in the skin 4 centimeters away. She would chart this as

Correct Answer: A

Rationale: Tunneling is a narrow channel extending from a wound, creating another skin opening, as described. Undermining involves a wider area under intact skin, dehiscence is wound separation, and evisceration is organ protrusion.

Question 5 of 5

The nurse is caring for a client with a small-bowel obstruction. A Salem sump nasogastric tube (NGT) is in place. Which finding by the nurse requires corrective action? Select all that apply.

Correct Answer: A, C

Rationale: A sudden decrease in output may indicate blockage or displacement, requiring assessment. Medium intermittent suction is inappropriate for a Salem sump, which requires low continuous suction. Other actions are correct.

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