Google Drive Final ?'s

Question 1

A home care nurse assesses a client with chronic obstructive pulmonary disease (COPD) who is complaining of increased dyspnea. The client is on home oxygen via a concentrator at 2 liters per minute, and the client’s respiratory rate is 22 breaths per minute. The appropriate nursing action is to:

1. Determine the need to increase the oxygen
2. Conduct further assessment of the client’s respiratory status
3. Call emergency services to take the client to the emergency room
4. Reassure the client that there is no need to worry

Answer 1

2. Conduct further assessment of the client’s respiratory status

Reassuring the client that there is “ no need to worry” is inappropriate.

Calling emergency services is a premature action.

Oxygen is not increased without the approval of the physician, especially because the client with COPD can retain carbon dioxide.

Question 2

A 1000ml intravenous (IV) solution of normal saline 0.9% is prescribed for the client. The nurse understands that this type of IV solution:

1. Is isotonic with the plasma and other body fluids.
2. Is hypertonic with the plasma and other body fluids.
3. Affects the plasma osmolarity.
4. Is the same solution as sodium chloride 0.45%.

Answer 2

1. Is isotonic with the plasma and other body fluids.

Sodium Chloride 0.9% (not sodium chloride 0.45%) is the same solution as normal saline 0.9%.

This solution is isotonic (not hypertonic), and isotonic solutions are frequently used for IV infusion because they do not affect the plasma osmolarity.

Question 3

A client with a burn injury is transferred to the nursing unit and a regular diet has been prescribed. Which dietary items should the nurse encourage the client to eat in order to promote wound healing?

1. Veal, potatoes, Jell-O, orange juice
2. Peanut butter and jelly, cantaloupe, tea
3. Chicken breast, broccoli, strawberries, milk
4. Spaghetti with tomato sauce, garlic bread, ginger ale

Answer 3

3. Chicken breast, broccoli, strawberries, milk

Protein and Vitamin C are necessary for wound healing. Poultry and milk are good sources of protein.

Broccoli and strawberries are good sources of vitamin C.

Peanut butter is a source of niacin.

Jell-O and jelly have no nutrient value.

Spaghetti is a complex carbohydrate.

Question 4

A client has an order for “enemas until clear” before major bowel surgery. After preparing the equipment and solution, the nurse assists the client into which of the following positions to administer the enema?

1. Left-lateral Sims’ position
2. Right-lateral Sims’ position
3. Left side-lying with head of bed elevated 45 degrees
4. Right side-lying with head of bed elevated 45 degrees

Answer 4

1. Left-lateral Sims’ position

When administering an enema, the client is placed in a left Sims’ position so that the enema solution can flow by gravity in the natural direction of the colon. The head of the bed is not elevated in the Sims’ position.

Question 5

An anxious client enters the emergency room seeking treatment for a laceration of the finger that occurred when using a power tool. The client’s vital signs (vs) are: Pulse: 96 bpm, BP: 148/88, R: 24. After cleansing the injury and reassuring the client, the nurse rechecks the VS and notes: HR: 82 bpm BP: 130/80 R: 20. The nurse determines that the change in VS is caused by:

1. Reduced stimulation of the sympathetic nervous system
2. The cooling effects of the cleansing solution
3. The body’s physical adaptation to the air conditioning
4. Possible impending cardiovascular collapse

Answer 5

1. Reduced stimulation of the sympathetic nervous system

Physical or emotional stress triggers a sympathetic nervous system response. Responses that are reflected in the VS include increased pulse, BP, and RR. Stress reduction, then returns these parameters to a baseline.

Question 6

A nurse is inserting an indwelling urinary catheter into a male client. As the nurse inflates the balloon with a syringe, the client complains of discomfort. The nurse:

1. Removes the syringe form the balloon because discomfort is normal and temporary.
2. Aspirates the fluid from the balloon, advances the catheter farther, then re-inflates the balloon.
3. Aspirates the fluid from the balloon, waits until the discomfort subsides, then re-inflates the balloon
4. Aspirates the fluid from the balloon, removes the catheter, and reinserts a new catheter

Answer 6

2. Aspirates the fluid from the balloon, advances the catheter farther, then re-inflates the balloon.

If the balloon is positioned in the urethra, inflating the balloon could produce trauma, and pain will occur. If pain occurs, the fluid should be aspirated, and the catheter inserted a little bit farther in order to provide sufficient space to inflate the balloon. The catheter’s balloon is behind the opening at the catheter insertion tip. Inserting the catheter the extra distance will ensure that the balloon is inflated inside the bladder and not inside the urethra. There is no need to remove the catheter and reinsert a new one. Pain when the balloon is inflated is not normal.

Question 7

A nurse is evaluating the patency of a peripheral intravenous (IV) site and suspects an infiltration. The nurse does which of the following to determine if the IV has infiltrated.?

1. Gently palpates the surrounding tissue for edema and coolness
2. Strips the tubing quickly while assessing for a rapid blood return
3. Increases the IV flow rate and observes the site for immediate tightening of tissue
4. Checks the area around the IV site for discomfort, redness, and warmth

Answer 7

1. Gently palpates the surrounding tissue for edema and coolness

When assessing an IV for signs and symptoms of infiltration, it is important to assess the site for edema and coolness, signifying leakage of the IV fluid into the surrounding tissues. Stripping the tubing will not cause a blood return but will force IV fluid inot the vein or surrounding tissues, which could cause more tissue damage. Increasing the IV flow rate can further damage the tissues if the IV has infiltrated. The IV site will feel cool if the IV fluid ahs infiltrated into the surrounding tissues. Redness and warmth may indicate phlebitis.

Question 8

A home care nurse is assessing an older client’s functional abilities and ability to perform activities of daily living (ADLs). The nurse focuses the assessment on:

1. Self-care needs, such as toileting, feeding, and ambulating
2. The normal everyday routine in the home
3. Ability to do light housework, heavy housework, and pay the bills
4. Ability to drive a care

Answer 8

1. Self-care needs, such as toileting, feeding, and ambulating

ADLs refer to the client’s ability to bath, toilet, ambulate, dress, and feed oneself. These functional abilities are always assessed by the home care nurse. The normal routine in the home is not a component of the functional assessment. The ability to do housework and drive a car relates to instrumental activities of daily living.

Question 9

After reviewing a client’s serum electrolytes, the physician states that the client would benefit most from an isotonic intravenous solution. The nurse plans care, anticipating that the order will indicate that which of the following solutions should be administered?

1. 0.45% normal saline
2. 5% dextrose in water
3. 10% dextrose in water
4. 5% dextrose in 0.9% normal saline

Answer 9

2. 5% dextrose in water

5% dextrose in water is an isotonic solution.

Another example of an isotonic solution is 0.9% normal saline.

0.45% NS is hypotonic solution.

10% dextrose in water and 5% dextrose in 0.9% NS are hypertonic solutions.

Question 10

In what way does culture affect sensory functioning?

1. Physiological changes related to sensation are different from culture to culture
2. Stress levels are different depending upon the culture
3. Different cultures have different types of sensory illnesses
4. Culture determines the amount of sensory stimulation that a person considers usual or normal

Answer 10

4. Culture determines the amount of sensory stimulation that a person considers usual or normal

Physiological changes related to sensation are usually due to developmental changes.

Cultural does not determine the levels of stress; however, it does affect how one deals with stress.

The occurrence of illnesses related to sensory functioning does not depend upon the culture of the individual.

Culture determines the amount of sensory stimulation that a person considers usual or normal, so different cultures have different behaviors to deal with the stimulation.

Question 11

A multidisciplinary team has been working with the spouse of a home care client who has end-stage liver failure and has been teaching the spouse interventions for pain management. Which statement by the spouse indicates the need for further teaching?

1. “If the pain increases, I must let the nurse know immediately.”
2. “I should have my husband try the breathing exercises to control pain.”
3. “This narcotic will cause very deep sleep, which is what my husband needs.”
4. “If constipation is a problem, increased fluids will help.”

Answer 11

3. “This narcotic will cause very deep sleep, which is what my husband needs.”

Question 12

A hospitalized client occasionally becomes disoriented. The appropriate nursing action to ensure safety for this client would be to:

1. Raise the head of the be 45 degrees
2. Keep the side rails on the bed in the up position and the call light within reach
3. Keep the over-the-bed light in the clients room on
4. Request that only two visitors visit at a time

Answer 12

2. Keep the side rails on the bed in the up position and the call light within reach

Question 13

An elderly client presents to the emergency room confused and without family members. The nurse knows that the immediate primary goal of nursing care should be focused on maintaining (Choose all that apply)

1. Safety
2. Nutrition
3. Communication
4. Body mechanics

Answer 13

1. Safety

3. Communication

Normal changes of aging vary with the individual but may include hearing, vision, smell, taste, and touch deficits. When the client is confused or has dementia, the goals of nursing care should be focused on maintaining safety and communication.

Question 14

A client admitted to the intensive care unit complains of excessive fatigue and racing thoughts and is moderately anxious. In addition, the client is unable to follow instructions. This client has clinical signs of:

1. Sensory overload
2. Sensory deficit
3. Sensory deprivation
4. Sensory misperception

Answer 14

1. Sensory overload

Question 15

A client complaining of pain is constantly rubbing around the incision area, crying, and restless. The nurse notes that the client is diaphoretic and breathing rapidly. What type of pain is this client experiencing?

1. Deep somatic pain.
2. Visceral pain.
3. Chronic nonmalignant pain.
4. Acute pain

Answer 15

4. Acute pain

Question 16

A client is being discharged from the hospital and will receive oxygen therapy at home. The nurse is teaching the client and family about oxygen safety measures. Which statement by the client indicates the need for further teaching?

1. “I realize that I should check the oxygen level of the portable tank on a consistent basis.”
2. “It is all right to burn my scented candles as long as they are a few feet away from my tank”
3. “I will not sit in front of my wood burning fireplace with my oxygen on.
4. “I will call the physician if I experience any shortness of breath.

Answer 16

2. “It is all right to burn my scented candles as long as they are a few feet away from my tank”

Question 17

When assisting a caregiver to turn a client, the nurse notices that the skin on the dependent side has a bright red flush. After an hour, the nurse returns to check on the client’s skin and notices that the redness has disappeared. What is the best interpretation of this finding?

1. There is no tissue damage anticipated
2. There is localized ischemia
3. Tissue damage has occurred
4. The small blood vessels have been damaged.

Answer 17

1. There is no tissue damage anticipated

Question 18

While doing a dressing change, the nurse notices that there is partial rupturing of the sutured abdominal wound. What is the most appropriate initial intervention?

1. Notify the surgeon and prepare the client for surgery
2. Place a large moist sterile dressing on the wound and notify the physician.
3. Apply large sterile dressings soaked in normal saline to the wound, have the client in supine position with knees flexed, and then notify the surgeon
4. Have the client do deep breathing exercises to alleviate anxiety, apply moist dressings, and call the surgeon.

Answer 18

3. Apply large sterile dressings soaked in normal saline to the wound, have the client in supine position with knees flexed, and then notify the surgeon

Large sterile dressings soaked in normal saline should be applied to the wound. Have the client in supine position with the knees flexed to avoid pulling on the incision, and then notify the surgeon. It is imperative that the initial action deals with the client’s condition before calling the surgeon. Sterile dressings have to be soaked in normal saline. Deep breathing may alleviate anxiety, but it is not the most appropriate initial action.

Question 19

A nurse prepares to assist a postoperative client to progress from a lying to a sitting position to prepare for ambulation. Which nursing action is appropriate to maintain the safety of the client?

1. Assist the client to move quickly from the lying position to the sitting position.
2. Asses the client for signs of dizziness and hypotension.
3. Elevate the head of the bed quickly to assist the client to a sitting position.
4. Allow the client to rise from the bed to a standing position unassisted.

Answer 19

2. Asses the client for signs of dizziness and hypotension.

Early ambulation should not exceed the clients tolerance. The client should be assessed before sitting. The client is assisted to rise from the lying position to the sitting position gradually until any evidence of dizziness, if present, has subsided. This position can be achieved by raising the dead of the bed slowly. After sitting, the client may be assisted to a standing position. The nurse should be at the clients side to provide physical support and encouragement.

Question 20

A client displays signs of anxiety when the nurse explains that the IV will need to be discontinued due to infiltration. The nurse makes which appropriate statement to the client?

1. This will be a totally painless experience. It is nothing to worry about.
2. I’m sure it will be a real relief for you just as soon as I discontinue this IV for good.
3. Just relax and take a deep breath. This procedure will not take a long and will be over soon.
4. I can see that you are anxious. Removal of the IV should not be painful, but the IV will need to be restarted in another location.

Answer 20

4. I can see that you are anxious. Removal of the IV should not be painful, but the IV will need to be restarted in another location.

Question 21

A client with diabetes mellitus is told that amputation of the leg is necessary to sustain life. This client is very upset and states to the nurse: Its all the doctors fault! I have done everything the doctor has asked me to do! The nurse interprets the clients statement as:

1. an expected coping mechanism.
2. a need to notify the hospital lawyer.
3. expression of guilt on the part of the client.
4. an ineffective coping mechanism.

Answer 21

1. an expected coping mechanism.

The expression of anger is normal with an impending loss. And the expression of anger may be directed at self, God or spiritual being, or the caregivers.

The nurse needs to be aware of the effective and ineffective coping mechanisms that can occur in a client when loss is anticipated.

Notifying the hospital lawyer is inappropriate. Guilt may or may not be a component of the clients feelings, and the data in the question does not provide the indication that guilt is present.