Questions and Answers
Which nursing intervention should the nurse include in the care plan?
Which nursing task would be most appropriate to delegate to the unlicensed assistive personnel (UAP) on a postoperative unit?
Which client assessment data are priority for the post-anesthesia care nurse?
The male client in the day surgery unit complains of difficulty urinating postoperatively. Which intervention should the nurse implement?
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The postoperative client complains of hearing a 'popping sound' and feeling 'something opening' when ambulating in the room. Which intervention should the nurse implement first?
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Which client problem would the nurse include in the plan of care for an elderly postoperative client who became confused during the previous shift?
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The client one day postoperative develops an elevated temperature. Which intervention would have priority for the client?
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Which statement made by the client who is postoperative abdominal surgery indicates the discharge teaching has been effective?
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Which interventions should the nurse implement for a client who is two (2) hours postoperative with noted vital signs: T 102.6°F, P 132, R 26, BP 92/46?
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The client comes into the emergency room in severe pain and reports that a pot of boiling hot water accidentally spilled on his lower legs. Which depth of burn should the nurse document?
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The client with full-thickness burns to 40% of the body is being transferred to a burn center. Which measure should be instituted before the transfer?
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After establishing a patent airway in a client with full-thickness burns to 65% of the body, including the chest area, what is the priority collaborative intervention?
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While applying mafenide acetate (Sulfamylon) to a client's lower extremity burn, which assessment data would require immediate attention by the nurse?
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What is a xenograft?
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Which client problem has priority for a client with severe full-thickness and deep partial-thickness burns over half the body?
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Which intervention would be appropriate for the nursing diagnosis 'impaired skin related to open burn wounds'?
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Which nursing intervention should be included for the client who has full-thickness and deep partial-thickness burns to 50% of the body?
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Which assessment data would warrant notifying the health-care provider for a client with deep partial-thickness and full-thickness burns to the chest area?
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Which intervention should the nurse implement for a client with full-thickness and partial-thickness burns to more than 30% of the body concerning nutritional status?
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Which information should the nurse provide to a client who sustained a hot grease burn to the right hand?
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Which strategies should the nurse identify to promote the client's mental health upon discharge after being in the burn unit for six weeks?
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Which intervention should the nurse implement when discussing health promotion activities for a client with a German heritage who leads a sedentary lifestyle?
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The elderly female client of Mexican heritage is upset and tells the nurse the unlicensed assistive personnel (AP) complimented her grandchild's hair. Which intervention should the nurse implement?
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Which intervention should the nurse implement for the home health care visit to an elderly African American female client who talks loudly?
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In visiting a 42-year-old male client with terminal cancer, which behavior would best promote a therapeutic nurse/client relationship?
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When interviewing the client of Hindu heritage, which information should the nurse obtain to plan culturally sensitive care?
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Which rationale should the nurse give the AP for allowing the client to continue to wear the amulet?
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After evaluating the meal tray of a Jewish client, the nurse notices the client ate none of the meal. Which intervention should the nurse implement first?
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Which complementary therapy should the nurse suggest to assist the client's weight-loss program?
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When incorporating complementary therapies in a long-term care facility, which information should the nurse consider when matching the clients with the therapy? (Select all that apply)
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Which form of complementary therapy should the nurse encourage as a relaxation technique for the anxious elderly client admitted for surgery?
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What should the nurse include in the client's pain management plan for a client with a history of drug abuse?
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Which intervention should the circulating nurse implement for the preoperative elderly client who is anxious and diaphoretic?
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Which statement best supports the nurse allowing the male Navajo client to wear the pouch filled with objects around his neck?
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Which statement explains the role of the curandero in Mexican culture?
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The home health nurse is visiting a Jewish client who has a small container on the doorpost of the house. What term best describes this container?
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Which intervention should the nurse implement for a client who requests to keep his religious medal on during surgery?
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Which client would not be able to consent legally to surgery?
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Which intervention should the nurse implement first when preparing a client for surgery?
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The 68-year-old client scheduled for intestinal surgery does not have clear fecal contents after (3) tap water enemas. Which intervention should the nurse implement first?
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Which interventions should the nurse include in the care plan for a male client undergoing abdominal surgery? (Select all that apply)
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Which behavior indicates the need for further preoperative teaching for a client scheduled for total hip replacement?
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Which intervention should the nurse implement first when a client states they are allergic to codeine?
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Which laboratory result would require immediate intervention by the nurse for the client scheduled for surgery?
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Which information should the nurse report to the anesthesiologist for a surgical client? (Select all that apply)
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Which activities are the circulating nurse's responsibilities in the operating room?
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What should the nurse do when the surgical scrub technician removes a sponge from the edge of the sterile field with a clamp?
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When the circulating nurse and the scrub technician find a discrepancy in the sponge count, what should the circulating nurse take first?
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Which violation of surgical asepsis would require immediate intervention by the circulating nurse?
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Which nursing intervention should the nurse implement for the client who is identified as 'risk for injury related to positioning' in the operating room?
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Which client has the greatest potential for nerve damage during surgery?
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Which situation demonstrates the circulating nurse acting as the client's advocate?
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Which statement is the expected outcome when planning care for an intraoperative client?
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Which nursing intervention has the highest priority when preparing the client for a surgical procedure?
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Which case should the nursing manager assign to the inexperienced nurse?
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The circulating nurse assesses tachycardia and hypotension in the client. Which interventions should the nurse implement?
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Which intervention has the highest priority when planning the care of a surgical client having conscious sedation?
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The PACU nurse is receiving the client from the OR. What should the nurse assess first?
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Which intervention should the nurse implement first?
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Which assessment data indicate the postoperative client who had spinal anesthesia is suffering a complication of the anesthesia?
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After transferring the client from the PACU to the surgical unit, which intervention should the nurse implement first?
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Which client problem should the nurse add to the plan of care for a client who received Narcan?
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Which interventions should the nurse implement for the 26-year-old male client in the PACU? Select all that apply.
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Which data indicate the nursing care has been effective for the client who is one day postoperative surgery?
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Which task can the nurse delegate to the unlicensed nursing assistant?
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Which postoperative client is the most appropriate assignment for the graduate nurse?
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Which statement would be an expected outcome for the postoperative client who had general anesthesia?
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When transferring the postoperative client from the PACU to the surgical floor, which action should the nurse implement first?
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What is the priority client problem for someone who is one day postoperative?
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What intervention would be most appropriate for a first-day postoperative client's vital signs of T 100.8F, P 80, R 24, and B/P 148/80?
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Which intervention should the nurse implement first for a client complaining of left shoulder pain?
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Which intervention should the nurse implement for a client in acute pain as a result of surgery?
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Which situation exemplifies the nurse fulfilling the role of client advocate?
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Which statement would indicate an expected outcome for a client experiencing acute pain?
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Which intervention has the highest priority when administering pain medication to a client experiencing acute pain?
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Which intervention can the nurse delegate to the unlicensed nursing assistant when caring for a client experiencing acute pain?
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Which interventions should the nurse implement to provide for client safety when administering an opioid narcotic? Select all that apply.
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Which technique would be most appropriate for the nurse to implement when assessing a four-year-old client for acute pain?
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Which nursing intervention would be a priority for the client experiencing acute pain?
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While interviewing a 75-year-old client admitted with acute pain, which question would take priority when assisting with pain management?
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What should the nurse implement after discovering that the client has used only a small amount of medication during the shift with the PCA pump?
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Which problem would be most appropriate for the nurse to identify for a client experiencing acute pain?
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Which client would the nurse identify as having the highest risk for developing postoperative complications?
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Which information should the nurse report to the surgeon during the preoperative checklist?
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What explains the nurse's responsibility when obtaining informed consent for the client undergoing surgery?
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Which client outcome should the nurse identify for the preoperative client?
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Which problem would be appropriate for the nurse to identify for a preoperative client having an open reduction and internal fixation of the right ankle?
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Which task would be most appropriate to delegate to unlicensed assistive personnel?
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Which action indicates that preoperative teaching has been effective?
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Which intervention has priority for the nurse in the surgical holding area?
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What should the nurse say when the client in the surgical holding area expresses fear about the surgery?
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What should the nurse do if overhearing a UAP discussing a problem during one of the surgeries?
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Which laboratory value should the nurse report to the health care provider immediately during the preoperative checklist?
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Which problem is appropriate for the nurse to identify for a client in the intraoperative phase of surgery?
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What nursing intervention should be implemented to decrease a complication from the lithotomy position during surgery?
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What should the circulating nurse do upon observing the surgeon tossing a bloody gauze sponge onto the sterile field?
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What should the circulating nurse do upon noting a discrepancy in the needle count?
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Which interventions should the nurse implement if the client identifies the left arm as the surgical site but the permit designates the right arm? Select all that apply.
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Which assessment data would warrant immediate intervention for a client received from the post-anesthesia care unit?
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What should the nurse be aware of after a client received naloxone (Narcan), an opioid antagonist, in the post-anesthesia care unit?
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Study Notes
Health Promotion and Cultural Sensitivity
- Promote exercise routines for clients with sedentary lifestyles, considering their heritage.
- Address cultural sensitivities, such as the "evil eye" belief in certain communities, when handling personal compliments.
- Understand that loud talking may not indicate anger; cultural factors and communication styles vary among individuals.
Therapeutic Communication and Family Dynamics
- Initial communication with clients should consider addressing the eldest family member first, especially in culturally diverse families.
- Engaging with clients about their cultural practices and preferences (e.g., use of ayurveda) enhances culturally sensitive care.
Complementary and Alternative Therapies
- Hypnotherapy can assist in weight-loss programs by offering alternative approaches.
- Complementary therapies, such as deep breathing and music therapy, may be integrated for anxiety management pre-surgery.
- Encourage discussions on pain management that includes both medications and complementary therapies for clients with drug abuse histories.
Pre- and Postoperative Care
- Performing a preoperative checklist is essential to ensure all aspects of care are addressed before surgery.
- Understanding patients' health status is critical; for instance, notify the surgeon if a client has abnormal lab values like low potassium levels.
- During postoperative care, monitor for respiratory complications, especially following spinal anesthesia.
Patient Consent and Legal Considerations
- Legal competence for surgical consent varies; assess factors such as age and mental orientation.
- Gather detailed allergy histories, focusing on specific reactions to medications like codeine, to ensure safe practices.
Safety Protocols in Surgery
- The responsibilities of the circulating nurse include patient safety and maintaining sterile conditions.
- Interventions for patients at risk of injury during surgery involve taking precautions like padding extremities.
Recognizing and Responding to Emergencies
- Detect vital sign irregularities such as tachycardia and hypotension, which may indicate medical emergencies.
- Quick actions, like elevating the head after transfer from PACU if abnormal signs are noted, are crucial for patient stability.
Cultural Objects and Practices
- Respect and understand the significance of cultural items such as amulets and pouches worn by clients, ensuring they are not removed without understanding their importance.
Dietary Considerations
- Assess dietary restrictions for clients, such as ensuring kosher meals for Jewish patients, to promote adequate nutritional intake.
Emotional and Psychological Support
- Provide emotional support through familiar items, like religious medals, during surgical procedures to alleviate anxiety.
- Be aware of postoperative symptoms indicating complications, including respiratory distress or changes in blood pressure.### Postoperative Nursing Care
- Temperature Monitoring: A postoperative client with T 99.0°F, P 98, R 20, and BP 100/60 indicates effective recovery after surgery.
- Vital Signs Assessment: First action upon transfer from PACU to surgical floor is to assess the client's vital signs.
- Delegation: Unlicensed Nursing Assistants (UAPs) can take vital signs every four hours but cannot check surgical sites or administer medications.
Postoperative Complications
- Potential Hemorrhaging: Recognized as priority complication for clients one day postoperative.
- Monitoring for Infection: Vital signs and drainage from surgical sites must be regularly monitored to prevent infection.
Pain Management
- Acute Pain Interventions: Administer pain medication as soon as the schedule allows; always assess patient's verbal and nonverbal cues for pain.
- Client Education: Clients should understand to report pain adequately and use prescribed pain management techniques (e.g., PCA).
- Nurse Advocacy: Nurses should contact health care providers when pain relief is not achieved.
Preoperative Considerations
- Informed Consent: Nurses must ensure clients voluntarily consent to surgery without coercion or misunderstanding.
- Assessment of Risks: Report any significant findings (e.g. herbal supplement use) to the surgeon before surgery.
Surgical Preparedness
- Preoperative Checklist: Must confirm details such as site marking and surgical permits before procedures.
- Patient Teaching: Effective teaching includes demonstrating the use of an incentive spirometer and discussing postoperative care.
Post-Anesthesia Care Unit (PACU) Focus
- Vital Signs Priority: Continuous monitoring of vital signs is essential for identifying complications after surgery.
- Respiratory Monitoring: After administering naloxone for opioid reversal, monitor respiratory rate frequently (every 15 to 30 minutes).
Emergency Situations
- Postoperative Complications: Immediate intervention is required for clients with abnormal vital signs, such as vomiting, altered consciousness, or severe pain.
Discharge Readiness
- Effective Discharge Education: Clients should verbalize understanding of medication regimes, particularly the importance of completing antibiotics.
Special Considerations in Surgical Patients
- Elderly Clients: Increased vigilance for confusion and fall risks in older adults postoperatively; consider "risk for injury" in care plans.
- Pain Assessment Techniques: Use age-appropriate methods for pain evaluation, such as the pain scale for children or non-verbal cues for elderly clients.
Acknowledging Non-Compliance
- Medication Adherence: Emphasize the necessity of completing prescribed medications to prevent complications; clients should not assume they will have no further pain control needs post-surgery.
Potential Complications of Positioning
- Lithotomy Positioning: Lowering one leg at a time can help decrease complications associated with prolonged surgical positioning, such as circulatory issues.
Nursing Responsibilities During Surgery
- Surgical Counts: Ensure all instruments and supplies' counts are accurate and report any discrepancies immediately to maintain patient safety.### Burn Classification and Assessment
- Blistered, mottled red skin with edema suggests deep partial thickness burn.
- Full-thickness burns covering significant areas (e.g., 40% body including legs) necessitate interventions before transfer to a burn center, ensuring adequate peripheral circulation.
- In cases of full-thickness burns (e.g., 65% body), immediate emphasis on replacing fluids and electrolytes is prioritized after airway stabilization.
Medication Administration and Patient Monitoring
- Mafenide acetate (Sulfamylon) may cause pain upon application; however, abnormal ABG results (e.g., pH 7.34, low HCO3) require immediate nursing intervention.
- Knowledge of xenografts is essential; they involve grafts sourced from animals, often pigs.
Nursing Priorities and Care Plans
- High risk for infection is the primary concern in burn patients with extensive injuries (e.g., full-thickness and deep partial-thickness over 50% body).
- Daily wound cleansing is vital in managing open burn wounds and preventing infection.
Infection Control Measures
- Strict hygiene practices are crucial; thorough hand hygiene, sterile gloves for wound care, and wearing gowns/masks during procedures are essential.
- Administer prescribed antibiotics to combat infection risk in severe burn cases.
Patient Assessment and Health Provider Notification
- Urinary output of 50 mL in 2 hours raises concern and should prompt healthcare provider notification.
- Signs of severe pain and vital sign changes (e.g., fever) also warrant close monitoring.
Nutritional Support
- Family involvement in nutritional care is beneficial; encouraging familiarity and preference in food can aid recovery.
- Weight monitoring should be consistent for accurate assessment of nutritional status.
First Aid and Initial Treatment
- For hot grease burns, immediate action involves placing the affected area in cool water rather than applying ice packs, which can cause further damage.
Mental Health Strategies Post-Discharge
- Encouraging realistic expectations regarding lifestyle changes is important for mental well-being post-discharge.
- Promoting social interaction and community engagement is preferable to isolation.
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Test your knowledge on health promotion interventions for clients with diverse backgrounds in this Med Surg Success Q & A quiz. This quiz focuses on implementing effective strategies for clients, especially those from a German heritage living a sedentary lifestyle.