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A nurse is caring for a client who states during a counseling session, "I am sliding off a cliff." Which of the following statements should the nurse make?

"I don't think that is really what is happening to you."

"Don't worry. Everything will be okay."

"How are things going at your job?"

"You must be feeling very frightened right now."

Answer and Explanation

The Correct Answer is D

A. This statement dismisses the client's feelings.

B. Offering false reassurance is not therapeutic.

C. Changing the subject does not address the client's distress.

D. This is the correct answer. Acknowledging the client's feelings is a therapeutic response that encourages further discussion.

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Correct Answer is A

Explanation

A. Heart rate 148/min – Correct. A heart rate of 148/min in a 3-year-old is elevated (tachycardia) and may indicate worsening dehydration or shock.

B. Potassium 3.9 mEq/L – Incorrect. This potassium level is within the normal range (3.5–5.0 mEq/L).

C. Respiratory rate 22/min – Incorrect. This is within the expected range for a 3-year-old.

D. Sodium 142 mEq/L – Incorrect. This sodium level is within the normal range (135–145 mEq/L).

A. Choose the client's dominant arm for IV access whenever possible. B. Initiate IV access on the palmar side of the client's wrist. C. Select a site proximal to previous venipuncture sites. D. Insert a larger gauge IV catheter to prevent phlebitis.

Correct Answer is C

Explanation

A. The non-dominant arm should be used when possible to minimize interference with daily activities.

B. The palmar side of the wrist is highly sensitive and should be avoided due to the risk of discomfort and nerve injury.

C. This is the correct answer. The nurse should select a site proximal to previous venipuncture sites to maintain vein integrity and avoid complications such as infiltration or phlebitis.

D. Using a larger gauge catheter increases the risk of phlebitis rather than preventing it.

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A nurse is caring for a client who states during a counseling session, "I am sliding off a cliff." Which of the following statements should the nurse make?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a 3-year-old toddler who has dehydration. Which of the following findings should the nurse report to the provider?

Correct Answer is A

Explanation

A nurse is inserting a short peripheral IV catheter for a client who requires IV fluids. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

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A nurse is teaching a client how to care for his behind-the-ear hearing aids. Which of the following statements by the client indicates an understanding of the teaching?

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