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Questions and Correct Answers
A client is rescued from a house fire and arrives at the emergency department 1 hour after the rescue. The client weighs 132 pounds (60 kilograms) and is burned over 35% of the body. The nurse expects that the amount of lactated Ringer solution that will be prescribed to be infused in the next 8 hours is what? a. 2100 mL b. 4200 mL c. 6300 mL d. 8400 mL ---------CORRECT ANSWER-----------------b When assessing an obese client, a nurse observes dehiscence of the abdominal surgical wound with evisceration. The nurse places the client in the low-Fowler position with the knees slightly bent and encourages the client to lie still. What is the next nursing action? a. Obtain vital signs.
b. Notify the healthcare provider. c. Reinsert the protruding organs using aseptic technique. d. Cover the wound with a sterile towel moistened with normal saline. --------- CORRECT ANSWER-----------------d The nurse is caring for a client who is 1 day postoperative for a left hip fracture repair. During the assessment, which finding should the nurse assess further? a. Pain at the surgical site b. Small amount of serosanguinous drainage c. Decreased range of motion to the left extremity d. Sudden shortness of breath ---------CORRECT ANSWER-----------------d The nurse is developing a plan of care for the client who has activity intolerance. In determining the desired client outcomes, what should the nurse do? a. Prioritize psychosocial needs over physical needs.
a. Clamp the tube. b. Consider this an expected event. c. Instill the tube with iced normal saline. d. Notify the surgeon immediately. ---------CORRECT ANSWER-----------------b The nursing manager is preparing a schedule for delegating appropriate tasks to different health care team members. Which health care team member can be delegated the task of administering oral medications? Select all that apply. a. Certified technician b. Patient care associate c. Licensed practical nurse d. Licensed vocational nurse e. Unlicensed nursing personnel ---------CORRECT ANSWER-----------------c, d
A pregnant woman is admitted with a tentative diagnosis of placenta previa. The nurse implements prescriptions to start an intravenous (IV) infusion, administer oxygen, and draw blood for laboratory tests. The client's apprehension is increasing, and she asks the nurse what is happening. The nurse tells her not to worry, that she is going to be alright, and that everything is under control. What is the best interpretation of the nurse's statement? a. Adequate, because the preparations are routine and need no explanation b. Effective, because the client's anxieties would increase if she knew the danger involved c. Questionable, because the client has the right to know what treatment is being given and why d. Incorrect, because only the primary healthcare provider should offer assurances about management of care ---------CORRECT ANSWER-----------------c What is the duty of a nurse while caring for a client? a. The nurse should determine the client's care preferences. b. The nurse should hide serious information from the family. c. The nurse should inform the family after taking the required steps.
b. Inform the client that the child will be cognitively impaired if he is not stimulated. c. Explain the need for the family to hire a mother's helper for the home. d. Initiate a referral to an appropriate agency to assess the need for a home health aide and schedule a family conference. ---------CORRECT ANSWER------------- ----d A visitor from a room adjacent to a client asks the nurse what disease the client has. The nurse responds, "I cannot discuss any client's illness with you." What legal issue supports the nurse's response? a. Libel b. Slander c. Negligence d. Invasion of privacy ---------CORRECT ANSWER-----------------d The nurse manager of the unit comes to work obviously intoxicated. The staff nurse's ethical obligation is to do what?
a. Call the security guard. b. Tell the nurse manager to go home. c. Have the supervisor validate the observation. d. Offer the nurse manager a large cup of coffee. Offer the nurse manager a large cup of coffee. ---------CORRECT ANSWER------------ -----c A nurse's coworker approaches the nurse to inquire about the test results of a friend who is being cared for by the nurse. How should the nurse respond? a. Answer the questions softly so other people will not hear. b. Decline to discuss the friend's medical condition. c. Give the coworker the name of the client's primary healthcare provider, so the coworker can contact the provider instead. d. To provide reassurance, tell the coworker of the friend's test results that are within normal limits. ---------CORRECT ANSWER-----------------b
d. Utilitarianism ---------CORRECT ANSWER-----------------c A visitor says to the nurse, "Can I read my client's progress record? I am the sponsor from an alcohol recovery program." How should the nurse respond? a. Allow the visitor to review the record; sponsors have access to privileged information. b. Ask the primary healthcare provider about granting permission to the sponsor. c. Do not allow the sponsor to review the record. d. Allow the visitor to review the record; clients with alcoholism need reassurance from sponsors. ---------CORRECT ANSWER-----------------c The nurse is providing postprocedure care to a client who had a cardiac catheterization. The client begins to manifest signs and symptoms associated with embolization. Which action should the nurse take? a. Notify the primary healthcare provider immediately b. Apply a warm, moist compress to the incision site c. Increase the intravenous fluid rate by 20 mL/hr
d. Monitor vital signs more frequently ---------CORRECT ANSWER-----------------a A nurse observes a window washer falling 25 feet (7.6 m) to the ground. The nurse rushes to the scene and determines that the person is in cardiopulmonary arrest. What should the nurse do first? a. Feel for a pulse b. Begin chest compressions c. Leave to call for assistance d. Perform the abdominal thrust maneuver ---------CORRECT ANSWER----------------- b A client reports left-sided chest pain after playing racquetball. The client is hospitalized and diagnosed with left pneumothorax. When assessing the client's left chest area, the nurse expects to identify which finding? a. Dull sound on percussion b. Vocal fremitus on palpation
c. Hypokalemia and hypernatremia d. Hyperkalemia and hypernatremia ---------CORRECT ANSWER-----------------b A nurse is assessing a client's ECG reading. The client's atrial and ventricular heart rates are equal at 88 beats per min. The PR interval is 0.14 seconds, and the QRS width is 0.10 seconds. Rhythm is regular with normal P waves and QRS complexes. How will the nurse interpret this rhythm? a. Normal sinus rhythm b. Sinus tachycardia c. Sinus bradycardia d. Sinus arrhythmia ---------CORRECT ANSWER-----------------a The nurse is caring for a client with a diagnosis of necrotizing fasciitis. Which is the priority concern of the nurse when caring for this client? a. Fluid volume b. Skin integrity
c. Physical mobility d. Urinary elimination ---------CORRECT ANSWER-----------------b A client who had extensive pelvic surgery 24 hours ago becomes cyanotic, is gasping for breath, and reports right-sided chest pain. What should the nurse do first? a. Obtain vital signs b. Initiate a cardiac arrest code c. Administer oxygen using a face mask d. Encourage the use of an incentive spirometer ---------CORRECT ANSWER---------- -------c A nurse is caring for a client with severe burns. The nurse determines that this client is at risk for hypovolemic shock. Which physiologic finding supports the nurse's conclusion? a. Decreased rate of glomerular filtration
a. Equal b. Unrelated c. Inversely related d. Directly proportional ---------CORRECT ANSWER-----------------d A burn client is receiving the open method for wound treatment. Which information will the nurse explain to the client? a. Bathing will not be permitted. b. Dressings will be changed daily. c. Personal protective equipment will be worn by staff. d. Room temperature will be kept below 72° F (22.2° C). ---------CORRECT ANSWER-----------------c A client presents to the emergency department with weakness and dizziness. The blood pressure is 90/60 mm Hg, pulse is 92 and weak, and body weight reflects a
3 - pound (1.4 kilogram) loss in two days. The weather has been hot. Which condition should the nurse conclude is the priority for this client? a. Deficient fluid volume b. Impaired skin integrity c. Inadequate nutritional intake d. Decreased participation in activities ---------CORRECT ANSWER-----------------a A client is admitted with severe burns. The nurse is caring for the client 36 hours after the client's admission and identifies the client's potassium level of 6.0 mEq/L (6.0 mmol/L). Which drink will the nurse recommend be included in the client's diet? a. Milk b. Tea c. Orange juice d. Tomato juice ---------CORRECT ANSWER-----------------b
While receiving a blood transfusion, the client suddenly shouts, "I feel like someone is lowering a heavy weight on my chest. I feel like I'm going to die!" Which actions are priority? a. Administer nitroglycerin and aspirin b. Slow the rate and monitor the vital signs c. Stop the transfusion and administer normal saline through new IV tubing d. Ask the client to further describe the feeling and rate the pain ---------CORRECT ANSWER-----------------c A client who was hospitalized with partial- and full-thickness burns over 30% of the total body surface area is to be discharged. The client asks the nurse, "How will my spouse be able to care for me at home?" How should the nurse interpret this statement? a. Readiness to discuss the client's deformities b. Indication of a change in family relations c. Need for more time to think about the future
d. Beginning realization of implications for the future ---------CORRECT ANSWER---- -------------d A nurse is assessing a client with a cast to the extremity. Which assessment finding is the priority? a. Warmth b. Numbness c. Skin desquamation d. Generalized discomfort ---------CORRECT ANSWER-----------------b Which color of cerebrospinal fluid (CSF) may indicate subarachnoid hemorrhage in the client? a. Hazy b. Yellow c. Brown
