select correct answer and explain rationale 1. The nurse is assessing a patient who is bedridden. Fo

select correct answer and explain rationale 1. The nurse is assessing a patient who is bedridden. For which condition would the nurse consider this patient to be at risk?a. Increase in the movement of secretions in the respiratory tractb. Increase in circulating fibrinolysin c. Predisposition to renal calculid. Increased metabolic rate Rationale: 2. A nurse is caring for a client who is immobile. Which of the following actions is the priority for the nurse to include in the client’s plan of care?a. Auscultate breath sounds at least every 2 hr.b. Perform range-of-motion (ROM) exercises at least two to three times daily.c. Make sure the client has an intake of 2,000 to 3,000 mL of fluid per day.d. Apply anti-embolic stockings. Rationale: 3. A nurse is assisting a patient from a bed to a wheelchair. Which nursing action is appropriate?a. The nurse discourages the patient from helping with the transferb. The nurse administers pain medication following the transferc. The nurse grabs and holds the patient by his armsd. The nurse uses assistive devices when lifting more than 35 pounds of patient weight Rationale: 4. A nurse is logrolling a patient who has a spinal injury. Which nursing action follows the recommended guidelines for this procedure?a. Enlist the assistance of two or three other nurses to perform the procedureb. Use a friction-reducing sheet that extends from below shoulder to above hipsc. Have the patient cross his or her arms on the chest and place a pillow over themd. Have two nurses stand on the side of the bed in the direction the patient will be turned Rationale: 5. Which body systems effects would the nurse state as occurring due to immobility? (Select all that apply)a. Increased cardiac workloadb. Increased depth of respirationsc. Increased rate of respirationd. Decreased urinary stasise. Increased risk for renal calculif. Increased risk for electrolyte imbalance Rationale: 6. A nurse is caring for a client who had an amphetamine overdose and has sensory overload. Which of the following interventions should the nurse implement? a. Immediately complete a thorough assessment. b. Put the client in a room with a client who has hearing loss. c. Provide a private room, and limit stimulation. d. Speak at a higher volume to the client, and encourage ambulation.  Rationale: 7. A nurse is reviewing instructions with a client who has hearing loss and has just started wearing hearing aids. Which of the following statements should the nurse identify as an indication that the client understands the instructions? a. “I use a damp cloth to clean the outside of my hearing aids.”b. “I clean the ear molds of the hearing aids with rubbing alcohol.” c. “I keep the volume of my hearing aids turned up so I can hear better.” d. “I take the batteries out of my hearing aids when I take them off at night.”  Rationale: 8. A nurse is assessing a client for conductive hearing loss. When using the Weber Test, which of the following results should the nurse identify as an indication that the client has conductive hearing loss of the left ear?a. air conduction is less than bone conduction in the left earb. air conduction is greater than bond conduction in the left earc. sound is lateralizing to the left eard. there is no lateralization of sound  Rationale: 9. What interview question would be the best choice for the nurse to use to assess for recent changes in a patient’s sleep-wakefulness pattern? a. In what way does the sleep you get each day affect your everyday living? b. How much sleep for you think you need to feel fully rested? c. What do you usually do to help yourself fall asleep? d. Do you usually go to bed and wake up about the same time each day?  Rationale: 10. A nurse on a medical unit is caring for a client who has difficulty sleeping. Which of the following actions should the nurse take to promote the client’s ability to fall asleep?a. Encourage the client to ambulate in the hallway just before bedtimeb. Allow the client to maintain the same bedtime routine as at homec. Keep the room temperature warmd. Offer the client a cup of warm hot chocolate before bedtime. Rationale:    Health ScienceScienceNursing NURS 120 Share QuestionEmailCopy linkComments (0)

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