Self-Assessment Test #21: Mrs.

Yue, a landed immigrant from China, lives with her daughter and son-in law. Mrs. Yue has been in Canada for two years now. She was recently diagnosed with early stage of Alzheimers disease. For the last several weeks she has been noted to speak only Mandarin although she speaks very good English. 1. The nurse who does not speak the patients native language was assigned to assess how Mrs. Yue and her family are coping with the situation. How should the nurse initially collect data about Mrs. Yues situation? a. Ask the patient and her daughter to describe changes on the patient which she has recently experienced. b. Ask the daughter to translate the nurses question and her mothers answers. c. Interview the patients family members to explore their perception of the situation over the past few months. d. Have the daughter describe the changes she has seen in her mother. 2. Mrs. Yues daughter reveals to the nurse that her mother has become increasingly frustrated and angry in the last 2 weeks. Which of the following explanation by the nurse would best assist the family in understanding the behavioral changes on the patient? a. The patient is easily agitated if demands are made. b. Assigning different tasks at the same time boost the patients self-esteem. c. Outbursts are characteristics of the illness and are predictable. d. The patients awareness of her memory problems causes strain and significant changes in the behavior. 4. Mrs. Yue is observed feeling lonely during the day. Which one of the following actions by the nurse would best address this concern? a. Allow unrestricted family visits during the day. b. Encourage Mrs. Yue to join programs in the facility specifically designed for clients with Alzheimers. c. Involve the patient in simple task like folding linens. d. Reassure the patient and her family that this is a part of the patients illness. 5. One morning, at breakfast, the nurse noticed that Mrs. Yue used a plate for her porridge. Mrs. Yue became very upset when the nurse transferred the porridge into a bowl. What should the nurse do? a. The nurse will allow Mrs. Yue to use the plate for the porridge. b. The nurse try to convince Mrs. Yue that the bowl should be used for the porridge. c. The nurse will ignore Mrs. Yues outburst. d. The plate must be removed from Mrs. Yues meal tray. 6. A newly admitted patient says, I just dont know if I should be here. What will my family think? Using the approach of reflection, the nurse may respond most appropriately with which of the following statement?

a. Its hard to be here. Youre concern about your familys reaction. b. What youre family think isnt important. Its you that were concerned about. c. It sounds like your family doesnt understand you. d. You cant always please your family, can you? 7. Mrs. J. Novak is newly admitted to the long-term care facility. While the nurse is helping her unpack her belongings, she suddenly burst out to crying. What is the nurses best response? a. Please dont cry. Everyone is happy here. b. I see that youre upset. It must be very hard for you to be here. c. It is alright to be in the hospital, Mrs. Novak. d. I know how difficult it is for you to be here in the hospital. 8. A colleague was discovered taking cocaine at work. What should the nurse do? a. Notify the police and ask for help from the immediate supervisor. b. Reprimand your colleague to stop taking cocaine or you will report him to the authority. c. Inform her colleague that the incident will be reported to the immediate supervisor. d. Your colleague should not be allowed to provide patient care while under the influence of the drug. 9. The nurse enters Ronalds room for the first time and says, Ronald I am Miss Swan, the nurse. I will help you get settled. Ronald responds, I want another nurse. I dont like you. Youre mean. Before responding to Ronalds initial outburst, the nurse should: a. Make sure she is on a safe distance from the patient. b. Move closer to the patient to show that she is not afraid. c. Assess her own feelings and responses to the patients behavior. d. Recognize that it takes time for relationships to develop and feel hurt. 10. Lee Smith tried to cut a supermarket manager with a piece of broken glass. He said he did this because he was just laid off from his job. He also said his wife recently left him because of his alcoholism and the physical abuse he inflicted on her. He was also recently restrained in the unit for throwing chairs across the room. The nurse records that the patient has a potential for violence directed at others. Which goal is most appropriate for this nursing diagnosis category? a. The patient will verbalize anger rather than physically strike out. b. The patient will be placed in seclusion whenever he threatens anyone verbally or physically. c. The patient will not strike out more than once per day. d. The patient will not verbalize anger or strike out anyone. 11. Mr. Howard Cotter is policeman for 35 years, diagnosed with depression for 3 years and had undergone knee surgery five days ago. Which of the following patients statements suggest that the patient is improving?

a. b. c. d.

I am taking my medication regularly. The pain in my knee disturbs my sleep. I have called my friend to visit me in the hospital. My pain subsides as I walk around the unit.

12. A 4-year-old boy is going to have a diagnostic cardiac catheterization tomorrow. The child appears very worried about the upcoming surgical procedure. How can the nurse calm the child down? a. Demonstrate the procedure using a doll. b. Bring the child to the operating room and let him touch the instruments and equipment. c. Explain the procedure clearly to the child. d. Speak to the childs mother and explain to her the purpose of the procedure. 13. Which of the following would be the best management for the childs temper tantrums? a. Give immediate attention to what the child wants. b. Leave the child alone. c. Take the child to a quiet, secluded place to calm down. d. Tell the child to go to her room for half an hour to regain control. 14. Maria died of cancer of the sigmoid of colon. When you entered the patients room you saw the husband lying beside the patient who died just 15 minutes ago. Which of the following would be the best nursing action? a. Leave them alone. b. Tell the husband that he is not allowed to lie beside her. c. Tell the husband to go out of the room. d. Stay in the room and offer comfort to the husband. 15. The nurse phones a mother whose son died of a certain disease. The mother tells her that she thinks she will not be able to overcome the grieving process. What is the nurses best response? a. Tell the mother that grieving is normal and self-limiting. b. Arrange for some possible involvement in a grieving support group. c. Suggest that she calls her doctor for prescription of anti-depressant pills. d. Inform the mother that she should accept reality and move on with life. 16. A 14-year-old female patient has been placed on a suicide watch after ingesting 10 tablets of Valium. Which of the following offers best protection for the patient? a. Ensure that no sharp instrument will be at the patients immediate environment. b. One-on-one watch 24 hours everyday. c. Ensure that doors and windows are properly locked. d. Promote a trusting relationship with the patient.

17. A group of HIV+ men were discussing about the unceasing public homophobic reactions and misconceptions of people with HIV/AIDS i.e. that people with AIDS can easily spread the disease and that they are going to die soon. What would be your best nursing intervention to facilitate good public awareness? a. Ask them to get involved in AIDS awareness activities to facilitate changes into these misconceptions. b. Connect them to support groups and people who are affected by HIV/AIDS. c. Advise them to seek counseling. d. Refer them to the psychologist of a particular AIDS community organization i.e. ACT (AIDS Committee of Toronto). 18. An HIV + patient ask you whom he has to tell of his HIV status. He further asks, and will they accept me? What would be your best response? a. Tell your family, partner and friends when you are ready. b. Inform the people you know with HIV or AIDS. c. Inform the people you work with. d. Tell the sexual partners you had contact with and the people you shared needles with. 19. A group of people is planning to spearhead in organizing and building a hospice for AIDS patients. This group would be considered the hospices: a. Steering committee b. Board of directors c. Standing committee d. People Living with AIDS (PLWAs) and Parents and Families of Lesbians and Gays (PFLAGs) 20. What should be taken into consideration in building a hospice for AIDS patient? a. Demographic data b. Community size c. Availability and accessibility of a local AIDS Committee of the target community or region. d. Important, pertinent and relevant data from another hospice in the community. 21. How will you know if the community needs a hospice for people with AIDS? a. Data showing how many people in the community have HIV and AIDS. b. Assess the different needs of the community. c. Assess the degree of support from the local government in terms of financial and infrastructure support. d. Assess the directories of people with AIDS in the community. 22. The first step to take in building a hospice is to: a. Perform an assessment and feasibility study. b. Develop a preliminary mission statement. c. Decide on a proposed model of service and operation.

d. Do a general population survey regarding the need to build a hospice. 23. Where would this group of people who are planning to build a hospice turn to for financial support? a. Local government b. Local politicians c. Local and national AIDS supporters d. Non-government organizations (NGOs) 24. A young patient with Leukemia decides to stop his chemotherapy. The nurse will ask the client which of the following as an appropriate question? a. Ask him if he realizes the benefits of the therapy. b. Ask him if he is aware of the consequences of quitting the therapy. c. Ask him if he is aware of the side effects of the therapy. d. Ask him if he has discussed his plans with his physician. 25. One of the persons in a group of lactating young mothers in a post-partum class started saying that the only way to have her old jeans she used to wear before pregnancy to fit again is to go back smoking and start dieting. What will the nurse discuss in this group? a. The influences of diet on breastfeeding. b. The influences of smoking and eating habits on breastfeeding. c. The influence of breastfeeding on lactation. d. The effect of exercise on weight loss. 26. In doing a cultural assessment, what are the most important data that the nurse needs to obtain? a. The patients perception of cultural beliefs and values. b. The beliefs and values held by the patients family. c. The beliefs and values inherent in the patients religious group affiliation. d. The beliefs and values of the patients sociocultural group. 27. A patient who continuously checks windows and doors throughout the night says to the nurse, Do you think Im foolish to check so much? Before responding, the nurse needs to understand that the patient is: a. Expressing his concern about the compulsive checking. b. Purposely putting the nurse on the spot. c. Asking for help in stopping the ritualistic behavior. d. Testing to see if the nurse thinks this repetitive behavior is rational. 28. A patient with a diagnosis of Myocardial Infarction voices out, Im very much worried that I cant go back to work anymore. The most appropriate nursing diagnosis would be: a. Powerlessness related to role change. b. Fear related to hospitalization. c. Self-esteem disturbance related to change of level of activity.

d. Powerlessness related to lack of information regarding disease entity. 29. Group members were not able to come up with a decision over the appropriate course of action regarding the AIDS Hospice. Which action made by the nurse would best assist members to resolve their conflict? a. Suggest that members should vote on the appropriate course of action. b. Suggest that members with the same opinions must stick together and support each other. c. Suggest that members should discuss their own views in greater detail. d. Encourage members to examine the values underlying the various positions. 30. Which of the following information will be most useful as the group continue to plan for the Hospice and the programs to be offered? a. The members and the people diagnosed with HIV in the community. b. Demographic information in the community about individuals with HIVAIDS. c. Financial support available for Health services and programs offered in other communities. d. The nature of the disease and how it is treated. 31. Mr. Harris is a 38 y/o single, male who work full time for a community police force, was admitted with a diagnosis of bipolar effective disorder type 2. He has a history of severe depressive episode as well as hypomanic episode. He has been taking antidepressant medication daily and his bipolar disorder is stable at present. He develops drainage from the surgical site and is referred to a home care nurse. Although the doctor has stated that Mr. Harris may bear full weight on his knee, Mr. Harris tells the nurse that his knee gets very tired and sore if he walks for too long. Which of the following actions taken by the nurse best address the patients concern? a. Refer him to the physiotherapist. b. Suggest that he limit his activities and elevate his knee on a pillow. c. Reassure him that his knee will improve. d. Suggest he call his supervisor about returning to limited duty. 32. The home care nurse is not comfortable about the details of care on a client with bipolar disorder. The most appropriate first step in planning care for this client would include? a. Consult a nurse specialist in mental health. b. Check with Mr. Harris if he is taking his antidepressant as prescribed. c. Consult Mr. Harris psychiatrist for assistance. d. Contact the Mental Health Association 33. Based on the nursing assessment, which behavior indicates that the patient is no longer depressed? a. The patient is taking his anti-depressant medications as prescribed. b. The patient was able to perform his activities of daily living.

c. He complains that he couldnt sleep well at night due to the pain in his knee. d. He maintains regular social contact with his friends. 34. Mr. Harris complains that his antidepressant is causing dry mouth and periodic bouts of diarrhea. What initial suggestion should the nurse make to the client? a. Take anti-emetic. b. Eat low fiber diet. c. Drink extra fluids and chew sugarless gum. d. Suggest to take Immodium and hard candies. 35. Mr. Harris father died suddenly. Shortly after the funeral, the nurse visits Mr. Harris. He tells her that he doesnt want to see anybody, feels no enjoyment in anything and feels hopeless and useless. Which of the following questions asked by the nurse is most relevant to the patients condition? a. Is it your fathers death that is affecting you? b. Do you feel alright in spite of your problems? c. Have you thought of harming yourself? d. May I know whats bothering you? 36. Mr. Collins, 66 years old is scheduled to have a bowel resection for colon cancer. He is admitted to the hospital. The morning of his surgery, Mr. Collins tells his admitting nurse that he is worried that he will wake up with a colostomy. What is the nurses best response to this concern? a. Colostomy is not indicated to the type of your surgery. b. What did the surgeon tell you about your surgery? c. Let me call your doctor for further clarification? d. Your fear is understandable. What would you like to know about colostomies? 37. On the morning of his first operative day, Mr. Collins has been receiving O2 by nasal cannula at a rate of 4 L/min. He is alert and his temperature is 38 at 0800 hrs. His arterial blood gas reports show the following: VALUES CLIENT RESULT NORMAL VALUES pH 7.34 7.35 7.45 PaO2 76 mmHg 80 mmHg PaCO2 50 mmHg 35 45 mmHg a. Increase the flow rate of O2 through his nasal cannula to 8 L/min. b. Give the patient tepid sponge bath and cover him with one bed sheet only. c. Help the patient to perform deep breathing exercises and help him use his incentive spirometer at least q 1 hr. d. Notify the physician immediately with the client status. 38. Mr. Collins is receiving morphine via patient controlled analgesia (PCA) pump on a

demand dosage schedule. Mrs. Collins tells the nurse that she is concerned that her husband will overdose himself. Which of the following is the best response by the nurse? a. If you prefer, the nurse could administer this medication. b. It would be helpful if you record the frequency of his morphine use. c. There is not enough morphine in the pump to cause serious harm. d. The pump is programmed to prevent morphine overdose. 39. Mr. Plett, 63 y/o, has been admitted to the hospital with a diagnosis of transient ischemic attack (TIA). Which one of the following findings is commonly seen in clients experiencing TIA? a. Prolonged prothrombin time. b. Motor paralysis of the lower extremities. c. Decrease hematocrit value. d. Drooping of the facial muscles on one side of the face. 40. Mr. Pletts symptoms become more pronounce and his diagnosis is changed to R hemispheric CVA. At 9:00, the nurse assesses his BP to be 190/120. He is drowsy, begins coughing and is unable to swallow his medication. What action should the nurse take? a. Place Mr. Plett in High-Fowlers position and re-administer his medication. b. Hold Mr. Pletts medication until he is more awake. c. Request a stat ECG for Mr. Plett. d. Notify the physician on the change of Mr. Pletts condition. 41. Mr. Ulster, 50 yr/o is hospitalized following the perforation of gastric ulcer. He informs the nurse that he refuses to have blood transfusion because of his religious beliefs. What should the nurse do in this circumstance? a. Tell him that he may refuse and take the steps to ensure that he is fully informed. b. Suggest blood products as substitute. c. Ask the hospital chaplain to speak with the client. d. Discuss the matter with the physician and ask the physician to convince the client to agree to blood transfusion. 42. Mrs. Victor, 81 yrs old, lives alone and receives home care. One month ago, the physiotherapist prescribed a walker after noticing that Mrs. Victor was having increasing difficulty in moving around. During the home visit, the nurse notices that Mrs. Victor never obtained the walker. Which hypothesis should the nurse explore first with Mrs. Victor? a. Mrs. Victor does not appear concerned in his safety. b. Mrs. Victor does not seem to have fully understood the purpose of physiotherapist visit. c. Mrs. Victor may not have the social supports referred to obtain the walker. d. Mrs. Victor must have another alternative to using the walker.

43. Mr. Singh, 70 y/o, is hospitalized for cholelithiasis and is scheduled for laparoscopic cholecystectomy tomorrow. Mr. Singh states he never had surgery and feels anxious. His family is with him. Which of the following preoperative care activities should the nurse perform? a. Give Mr. Singh an anxiolytic to help him rest and teach him post-operative breathing and mobilization exercise. b. Give Mr. Singh a pamphlet for clients having surgery, invite him to ask question if something is not clear, and provide him with information about post-operative exercise. c. Allow Mr. Singh to express his fears and ask questions and teach him the post-op breathing and mobilization exercise. d. Ensure that the consent form has been completed, take Mr. Singh vital signs and pulse and record them on the chart. 44. Mr. Sharp, 66 y/o has AIDS and is hospitalized with pneumonia. He has just arrived on the respiratory unit. Should Mr. Sharps nurse take special precautionary measures? a. No, standard (universal) precautions are sufficient. b. Yes, gown, mask and gloves should be worn at all times. c. Yes, it is important to wear a mask because of pneumonia. d. No, since the risk and transmission of this disease is limited. 45. Which one of the following must provide the nurse when providing nursing care? a. Medical orders. b. Priorities determined by the nurse. c. Clients needs. d. The nurse skills based on the health situation. 46. Mrs. Doreen, 75 y/o lost sight in her L eye as a result of poorly controlled glaucoma. What must the nurse include in Mrs. Doreens plan of care? a. Place the bedside table and personal effects close to Mrs. Dorhen. b. Approach Mrs. Doreen from the R side as much as possible. c. Maintain subdued lighting on the R side of the room. d. Position Mrs. Doreen on her L side. 47. A nurse on the psychiatric unit admits a client in the acute manic phase of bipolar disorder in addition another client must be watch for high suicide risk. The nurse has many medications to administer, including 2 injections for the person admitted. He asks a colleague to help him perform his duties, but the colleague says that she cannot help at the moment. What should the nurse do? a. Delay distribution of some medication until the situation stabilizes. b. Ask the health care aide to watch the client in the private room. c. Place the newly admitted client in the private room. d. Review the care priorities and once again ask for the colleagues help. 48. The nurse notices that a colleague made a mistake when administering narcotics. The

colleague refuses to fill-out an incident report claiming that the clients condition is unchanged. What should the nurse do? a. Fill out the incident report for the colleague. b. Notify the immediate supervisor of the situation. c. Discuss the situation with the members of the health acre team. d. Ask the colleague to review the hospital policy. 49. Which approach should the nurse, who is starting in a geriatric unit, adopts when providing care with elderly clients? a. Pay special attention to these clients because they are more vulnerable from younger clients and are therefore more dependent on health care personnel. b. Encourage clients to participate in decision-making and social activities to promote their independence. c. Consider each client as unique with their own personalities and their own daily hobbies that they do not wish to change. d. Pay special attention to these clients because they are often ill and have complex health problem that must be monitored very carefully. 50. Mrs. Cooper, 69 y/o is hospitalized following a CVA. She has weakness in her left leg. When preparing her for discharge, what should be the nurses priority? a. Allow her to rest as she is reluctant to ambulate without a family member present. b. Assess her strength and her mobility when she is transferring out of bed and ambulating. c. Request that the rehabilitation department delivers a walker for her. d. Arrange for a home care nurse to visit following discharge. 51. Mr. OConnor, 83 y/o, recently widowed and unable to live on his own. He was admitted 3 months ago to a long term care facility for the elderly. He says he feels depressed and reluctant to leave the room. Which of the following would be the most effective intervention in promoting social interaction for Mr. OConnor? a. Notify his family and suggest that they telephone him daily. b. Allow him some time alone and encourage him to go to dining room for his medication. c. Schedule him for participation in the facilitys recreational activities. d. Confers with his physician and recommend an antidepressant medication. 52. Susan, 16 y/o was diagnosed 3 months ago with type one diabetes (IDDM) and has been attending the teen diabetic clinic. Which of the following behaviors indicates to the nurse that Susan is adapting well to the diabetes? a. She states that she probably will be able to include all fast foods into her diet. b. She acknowledges that she will have to cancel her planned canoe trip with her friends. c. She says that she has been sharing her 12 y/o brother how to do glucometer reading.

d. She says she feels that she knows enough now about diabetes.

53. A mother tells the nurse that she has not had her child immunized because the disease no longer exists in Canada. Which of the following responses by the nurse is appropriate? a. People coming from other countries bring these diseases with them so you should have your child vaccinated. b. Protection against these diseases is important because the microorganisms that cause them cannot be eliminated completely. c. Public Health Department made immunization mandatory to all children. d. Immunization offers best protection against infectious diseases. 54. Mr. Jack, 72 y/o, has a history of COPD. He tells the nurse that lately he has been feeling very tired and short of breath. He has been eating less than usual and can only sleep in a chair. His O2 saturation is 82% and PR 24/min. On auscultation of the chest, the nurse has difficulty hearing air entry but does not notice any adventitious sounds. How should the nurse best interpret this information? a. Mr. Jack is displaying signs of respiratory depression. b. Mr. Jack requires a referral for home oxygen. c. Mr. Jack is experiencing an exacerbation of mild obstructive pulmonary disease. d. Mr. Jack has adequate respiratory functions given his history of obstructive pulmonary disease. 55. Laryn Parker, 48 y/o, has been hospitalized with an eating disorder. Which one of the following nursing action would most benefit Laryn upon discharge? a. Arrange a doctors appointment for follow up. b. Tell her that she must adhere to the prescribe diet. c. Discuss with her parent the need to monitor her weight. d. Encourage her to join a local eating disorder support group. 56. A 3-y/o- boy is seen in the emergency room for symptoms of head injury. His mother states the boy fell down several stairs two days ago and was not himself that day but seems fine until this arm. The child was admitted for a broken arm six months ago. After treatment has been provided, the most important nursing action would be: a. Admit the child to pediatric unit for further assessment. b. Report possible child abuse incident to appropriate authority. c. Provide information on accident prevention in children prior to discharge. d. Explore, through the child, what had happened in both incidents. 57. The school nurse is teaching a group of young women about osteoporosis, which of the following health teaching would be most appropriate? a. Discuss the important of bone density screening.

b. Recommend 1 hour of vigorous exercise each day. c. Advise moderation in caffeine and alcohol consumption. d. Recommend the use of calcium supplements. 58. Mrs. Murphy plans to breastfeed her newborn daughter. Which health practice related to nutrition should the nurse promote? a. Mrs. Murphy should have a well balance diet containing an extra 200 to 500 calories per day. b. Mrs. Murphy should increase her fluid intake to 8 cups of milk everyday. c. Mrs. Murphy should consume high calories snack prior to breastfeeding. d. Mrs. Murphy should consume appropriate quantities of food for appropriate for an active non-pregnant women. 59. Mr. Green, 80 years old, had a right hemicolectomy for carcinoma of cecum yesterday. He has a close portable wound suction drainage device on the right side of his abdomen. What should the nurse do when managing Mr. Greens wound drainage system? a. Irrigates the drainage tube with sterile water if it is becomes blocked. b. Cleans the drainage port daily with antiseptic. c. Wears gloves when emptying the drainage and reactivating the suction. d. Empties and measure the drainage every 24 hours. 60. The nurse arrives at work and discovers that there is staff shortage for the shift. She notes the nursing students are assigned to the unit today. The nurse is assigned to 4 post-operative and 3 pre-operative orthopedic clients. There are several intravenous medications to give and 2 clients have type 1 DM. In addition several dressings require changing and staples need to be removed. In evaluating the situation, which of the following actions should the nurse take? a. Leaves the dressing change for the next shift of staff. b. Offers to assign the pre-operative teaching to student nurses. c. Reports the situation to the unit manager. d. Re-prioritizes nursing care to manage the work lead effectively. 61. Jessica Thorton, 25 years old has just been diagnosed with chlamydia. Jessica asks who has to know about this? What would be the nurses best response? a. Dont worry I will keep it confidencial. b. Because of your age I am required to tell your parents. c. I am required to report this communicable diseases to the public health authority. d. I am not allowed to make any promises about keeping your diagnosis confidential. 62. Mrs. Lee has an osteoporosis and atherosclerosis, which luncheon menu is most appropriate for her? a. Cottage cheese with orange slices on lettuce leaves muffin with margarine.

b. Pasta, salad with carrots and red pepper and strawberry yogurt. c. Canned salmon, spinach salad and skim milk. d. Cheese omelet, whole-wheat roll, apple juice. 63. Mrs. O Reilly must place her 70-year-old mother in along term care facility since she is unable to continue caring for her at home. During this admission interview Mrs. O Reilly begins to cry and says, I never thought that one day I would have to care for my mother like a child. She was the one who took care of me. What should the nurse do initially? a. Leave Mrs. O Reilly alone and reassure her that her mother will be cared for just as well as if she were at home. b. Let. Mrs. O Reilly cries and reassures her that her mother will be cared for just as well as if she were at home. c. Allow Mrs. O Reilly to cry and encourage her to talk about her feeling of placing her mother in a long-term facility. d. Leave Mrs. O Reilly alone and ask her if she would prefer to continue the interview when she feels better. 64. Ms. Bryson, 65 years old, is post-operative client who suddenly develops hematemesis. She is pale, diaphoretic and says she feels faint. The nurse asks the student nurse to take Ms. Bryson vitals sign when she calls the physician. On returning to the client rooms, the student nurse reports that the vital signs have not changed since earlier in the shift. What should the nurse do? a. Places the client in trendelenburg position. b. Instructs the student nurse to recheck the vital signs in 10 minutes. c. Rechecks the vital signs. d. Administers a bolus of 200 ml of normal saline. 65. The nurse asks the 75 years old client who wears a hearing aid about her diet. The nurse receives unrelated answer. Which of the following action should the nurse take initially? a. Assesses the client level of orientation. b. Repeats the question with a slower and lower pitched voice. c. Repeats the question increasing the volume and pitched of her voice. d. Rephrases the question in very simple way. 66. Darren Clare, 10 years old, with asthma has just received a schedule dose of salbutamol. Which of the action should the nurse do first following the administration of the medication? a. Record Darrens vital signs. b. Document the administration of the drug. c. Record the presence of adventitious breath sound. d. Document the effectiveness of the medication.