Page 2584 - Saunders Comprehensive Review For NCLEX-RN

running in.”
927. A client experiencing a great deal of stress and anxiety is being taught to use
self-control therapy. Which statement by the client indicates a need for
further teaching about the therapy?
1. “This form of therapy can be applied to new situations.”
2. “An advantage of this technique is that change is likely to last.”
3. “Talking to oneself is a basic component of this form of therapy.”
4. “This form of therapy provides a negative reinforcement when the
stimulus is produced.”
928. The nurse is preparing a list of home care instructions regarding stoma and
laryngectomy care for a client with laryngeal cancer who had a
laryngectomy. Which instructions should be included in the list? Select all
that apply.
1. Restrict fluid intake.

2. Obtain a MedicAlert bracelet.

3. Keep the humidity in the home low.

4. Prevent debris from entering the stoma.

5. Avoid exposure to people with infections.
6. Avoid swimming and use care when showering.

929. The primary health care provider prescribes 2000 mL of 5% dextrose and
half-normal saline to infuse over 24 hours. The drop factor is 15 drops
(gtt)/mL. The nurse should set the flow rate at how many drops per minute?
Fill in the blank. Record your answer to the nearest whole number.
Answer: _____ gtt/minute
930. A client is returned to the nursing unit after thoracic surgery with chest tubes
in place. During the first few hours postoperatively, what type of drainage
should the nurse expect?
1. Serous
2. Bloody
3. Serosanguineous
4. Bloody, with frequent small clots
931. A client has had radical neck dissection and begins to hemorrhage at the
incision site. The nurse should take which actions in this situation? Select all
that apply.
1. Monitor vital signs.

2. Monitor the client’s airway.

3. Apply manual pressure over the site.

4. Lower the head of the bed to a flat position.

5. Call the primary health care provider (PHCP) immediately.
932. A sexually active young adult client has developed viral hepatitis. Which
client statement indicates the need for further teaching?
1. “I should avoid drinking alcohol.”

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