Answer to Question 1
D
The nurse evaluates success by observing the client's performance of each expected behaviour. Feedback indicating success in this situation is the client drinking 240 mL of fluid five or six times during the shift. This would total a fluid intake of 1200 to 1440 mL, meeting the objective of at least 1000 mL during the designated period.
Voiding at least 1000 mL during the shift is not the objective. The objective is to have the client drink at least 1000 mL during the designated period.
Verbalizing abdominal comfort without pressure is not an evaluation of the objective regarding specific fluid intake.
Having adequate intake and output is not accurate feedback indicating success. The term ade-quate is not quantified.
Answer to Question 2
A
To assess the client's sleeping problem, the nurse should inquire about predisposing factors, such as by asking, What do you do just before going to bed? Assessment is aimed at understanding the characteristics of any sleep problem and the client's usual sleep habits so that ways for pro-moting sleep can be incorporated into nursing care.
Older adults may prefer to sleep in softly lit rooms.
Napping more during the daytime is often not the best solution. The nurse should first assess the client's sleeping problem.
The client does not always have to eat something before going to bed. The nurse should first as-sess the client's current sleep habits.
The nurse assists the patient in reflecting on his feelings
The nurse can make observations about the patient's general appearance while talking with the p
A client is having an endoscopy performed by a physician who views the upper gastrointestinal intern
To increase pressure using body weight, lean on your client.
Measuring the client’s height with a platform scale
Testing patellar reflex, client in a sitting position