Answer to Question 1
ANS: 4
The nurse evaluates success by observing the client's performance of each expected behavior. Feedback indicating success in this situation is the client drinking 240 mL of fluid five or six times during the shift. This would be a fluid intake of 1200-1440 mL, meeting the objective of at least 1000 mL during the designated time period. Voiding at least 1000 mL is not the objective. The objective is to have the client drink at least 1000 mL. Verbalizing abdominal comfort with-out 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 adequate is not quanti-fied.
Answer to Question 2
ANS: 4
The number of persons being taught, the need for privacy, the room temperature, the room light-ing, noise, the room ventilation, and the room furniture are important factors when choosing the setting. The ideal setting helps the client focus on the learning task. Knowing the specific ages of all the people involved is not as important as providing an environment conducive to learning. It is not necessary to know the names of employees who are married to teach individuals how to take their blood pressure. Whether an employee has high blood pressure should not be as im-portant to the teacher as providing an environment conducive to learning. Having high blood pressure may be a motivating factor for employees to learn how to take their blood pressure, be-cause of its personal relevance.
In the communication technique of collaborating, the nurse sends the message that the nurse and pati
The nurse applies a pulse oximeter sensor on the client’s finger.
Weber test: Place the base of the tuning fork on top of the client’s head.
To check pupillary reflexes the nurse first holds the penlight
The nurse begins the general survey
Testing patellar reflex, client in a supine position