Basic Physical care (Part 2)

Reviewed by Editorial Team
The ProProfs editorial team is comprised of experienced subject matter experts. They've collectively created over 10,000 quizzes and lessons, serving over 100 million users. Our team includes in-house content moderators and subject matter experts, as well as a global network of rigorously trained contributors. All adhere to our comprehensive editorial guidelines, ensuring the delivery of high-quality content.
Learn about Our Editorial Process
| By Suarezenriquec1
S
Suarezenriquec1
Community Contributor
Quizzes Created: 12 | Total Attempts: 16,792
| Attempts: 629
SettingsSettings
Please wait...
  • 1/114 Questions

    A postoperative client receives a lunch tray with milk, custard, and vanilla ice cream. What is the client's current diet order?

    • American Dietetic Association Exchange diet
    • Full-liquid diet
    • Clear liquid diet
    • BRAT diet
Please wait...
About This Quiz

Physical care is the type of care given to someone who is facing a health problem or issue in order to get him or her back to working condition. The quiz below is the second in the series of tests that to see how equipped you are to offer basic care to your loved ones. Give it a try!

Basic Physical care (Part 2) - Quiz

Quiz Preview

  • 2. 

    A nurse is teaching a group of nursing assistants about infection-control measures. The nurse tells the group that the first line of intervention for preventing the spread of infection is:

    • Wearing gloves.

    • Administering antibiotics.

    • Washing hands.

    • Assigning clients to private rooms.

    Correct Answer
    A. Washing hands.
    Explanation
    RATIONALE: Hand washing is the first line of intervention for preventing the spread of infection. Wearing gloves and assigning private rooms for clients can also decrease the spread of infection and should be implemented according to standard precautions. Antibiotics should be initiated when a causative organism is identified.

    CLIENT NEEDS CATEGORY: Safe, effective care environment
    CLIENT NEEDS SUBCATEGORY: Safety and infection control
    COGNITIVE LEVEL: Application

    REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and Science of Nursing Care, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 708.

    Rate this question:

  • 3. 

    Which statement demonstrates a safe practice for taking telephone orders from a physician?

    • The physician must rewrite the order within 3 days.

    • The physician must cosign the order within 7 days.

    • A nurse must verify the order by reading it back to the physician.

    • Nurses aren't permitted to accept telephone orders.

    Correct Answer
    A. A nurse must verify the order by reading it back to the physician.
    Explanation
    RATIONALE: Nurses may accept telephone orders, but should do so only when absolutely necessary. To verify the information, the nurse must read back the order and clarify any questions about the order. The physician must cosign the order within 24 hours; there's no need for the physician to rewrite the order.

    CLIENT NEEDS CATEGORY: Safe, effective care environment
    CLIENT NEEDS SUBCATEGORY: Management of care
    COGNITIVE LEVEL: Application

    REFERENCE: Craven, R.F., and Hirnle, C.J. Fundamentals of Nursing: Human Health and Function, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 255.

    Rate this question:

  • 4. 

    A client on prolonged bed rest has developed a pressure ulcer. The wound shows no signs of healing even though the client has received skin care and has been turned every 2 hours. Which factor is most likely responsible for the failure to heal?

    • Inadequate vitamin D intake

    • Inadequate protein intake

    • Inadequate massaging of the affected area

    • Low calcium level

    Correct Answer
    A. Inadequate protein intake
    Explanation
    RATIONALE: Clients on bed rest suffer from lack of movement and a negative nitrogen balance. Therefore, inadequate protein intake impairs wound healing. Inadequate vitamin D intake and low calcium levels aren't factors in poor healing for this client. A pressure ulcer should never be massaged.

    CLIENT NEEDS CATEGORY: Physiological integrity
    CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
    COGNITIVE LEVEL: Comprehension

    REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and Science of Nursing Care, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p.1189.

    Rate this question:

  • 5. 

    To evaluate a client for hypoxia, the physician is most likely to order which laboratory test?

    • Red blood cell count

    • Sputum culture

    • Total hemoglobin

    • Arterial blood gas (ABG) analysis

    Correct Answer
    A. Arterial blood gas (ABG) analysis
    Explanation
    RATIONALE: Red blood cell count, sputum culture, total hemoglobin, and ABG analysis all help evaluate a client with respiratory problems. However, ABG analysis is the only test that evaluates gas exchange in the lungs, providing information about the client's oxygenation status.

    CLIENT NEEDS CATEGORY: Physiological integrity
    CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
    COGNITIVE LEVEL: Comprehension

    REFERENCE: Smeltzer, S.C., and Bare, B. Brunner & Suddarth's Textbook of Medical Surgical-Nursing, 11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 334.

    Rate this question:

  • 6. 

    A nurse is assessing a client for the risk of falls. The nurse should obtain:

    • Gait and balance information.

    • The facility's restraint policy.

    • The family's psychosocial history.

    • The client's dietary preferences.

    Correct Answer
    A. Gait and balance information.
    Explanation
    RATIONALE: Assessing the client's gait and balance helps determine his risk of falls. The facility's policy on restraints isn't relevant to a risk assessment for falls. Assessing the family's psychosocial history and the client's dietary preferences are important but not as important as gait and balance in relation to the risk of falls.

    CLIENT NEEDS CATEGORY: Safe, effective care environment
    CLIENT NEEDS SUBCATEGORY: Safety and infection control
    COGNITIVE LEVEL: Analysis

    REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and Science of Nursing Care, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 678.

    Rate this question:

  • 7. 

    A client with terminal breast cancer is being cared for by a long-time friend who's a physician. The client has identified her sister as the agent in her health care power of attorney. The client loses decision-making capacity, and the sister tells the nurse, "A different physician will be caring for my sister now. I've dismissed her friend." In response, the nurse should:

    • Inform the sister that she doesn't have the authority to assign a different physician.

    • Ask the dismissed physician if the client ever stated that she wanted a different physician.

    • Abide by the wishes of the sister who holds the durable power of attorney.

    • Politely ignore the sister's statement and continue to call the dismissed physician for orders.

    Correct Answer
    A. Abide by the wishes of the sister who holds the durable power of attorney.
    Explanation
    RATIONALE: A health care power of attorney transfers an individual's rights regarding health care decisions to the designated agent. It's within the power of the sister to change the physician caring for the terminally ill client. The dismissed physician has no power to interfere with the wishes of the health care power of attorney. It would be inappropriate and unprofessional of the nurse to ignore the wishes of the client's agent.

    CLIENT NEEDS CATEGORY: Safe, effective care environment
    CLIENT NEEDS SUBCATEGORY: Management of care
    COGNITIVE LEVEL: Application

    REFERENCE: Craven, R.F., and Hirnle, C.J. Fundamentals of Nursing: Human Health and Function, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 92.

    Rate this question:

  • 8. 

    Which situation demonstrates correct principles of confidentiality?

    • An emergency department nurse reports suspected child abuse.

    • Two nurses in an elevator are discussing a client's status.

    • A nurse copies and e-mails client information to a friend.

    • During change-of-shift report, a nurse talks about a client's personal problems.

    Correct Answer
    A. An emergency department nurse reports suspected child abuse.
    Explanation
    RATIONALE: Any health care provider must report suspected child abuse. Sharing this information doesn't violate the client's right to confidentiality. A discussion of confidential information in a public place may be overheard and is a breach of confidentiality. Any client information, whether written or electronic, is considered confidential; e-mailing it to a friend would be considered a breach of confidentiality. Nurses must discuss client's problems during change-of-shift report, but these discussions should be limited to information needed to provide safe care.

    CLIENT NEEDS CATEGORY: Safe, effective care environment
    CLIENT NEEDS SUBCATEGORY: Management of care
    COGNITIVE LEVEL: Application

    REFERENCE: Craven, R.F., and Hirnle, C.J. Fundamentals of Nursing: Human Health and Function, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 256.

    Rate this question:

  • 9. 

    Policy and procedure require hand washing when caring for clients. Which statement about hand washing is true?

    • Frequent hand washing reduces transmission of pathogens from one client to another.

    • Wearing gloves is a substitute for hand washing.

    • Bar soap, which is generally available, should be used for hand washing.

    • Waterless products shouldn't be used in situations in which running water is unavailable.

    Correct Answer
    A. Frequent hand washing reduces transmission of pathogens from one client to another.
    Explanation
    RATIONALE: Even if the nurse wears gloves, she must wash her hands before and after client contact because thorough hand washing reduces the risk of cross-contamination. She shouldn't use bar soap because it's a potential carrier of bacteria. Soap dispensers are preferable, but they must be checked for bacteria. When water is unavailable, the nurse should use a liquid hand sanitizer to wash her hands.

    CLIENT NEEDS CATEGORY: Safe, effective care environment
    CLIENT NEEDS SUBCATEGORY: Safety and infection control
    COGNITIVE LEVEL: Comprehension

    REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and Science of Nursing Care, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 708.

    Rate this question:

  • 10. 

    A client's blood test results are: white blood cell (WBC) count is 1,000/μl; hemoglobin (Hb) level, 14 g/dl; hematocrit (HCT), 42%. Which goal is most important for this client?

    • Promote fluid balance

    • Prevent infection

    • Promote rest

    • Prevent injury

    Correct Answer
    A. Prevent infection
    Explanation
    RATIONALE: The client's dangerously low WBC count puts him at risk for infection. Hb level and HCT are within normal limits; therefore, fluid balance, rest, and prevention of injury are inappropriate.

    CLIENT NEEDS CATEGORY: Health promotion and maintenance
    CLIENT NEEDS SUBCATEGORY: None
    COGNITIVE LEVEL: Application

    REFERENCE: Craven, R.F., and Hirnle, C.J. Fundamentals of Nursing: Human Health and Function, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 1061.

    Rate this question:

  • 11. 

    A client who's a member of Jehovah's Witnesses refuses a blood transfusion based on his religious beliefs and practices. His decision must be followed based on which ethical principle?

    • The right to die

    • Advance directive

    • Autonomy of the client

    • Substituted judgment

    Correct Answer
    A. Autonomy of the client
    Explanation
    RATIONALE: The right to refuse treatment is grounded in the ethical principle of respect for the autonomy of the individual. The client has the right to refuse treatment as long as he's competent and aware of the risks and complications associated with that refusal. The right to die is a difficult decision involving whether to initiate or withhold life-sustaining treatment for a client who is irreversibly comatose, vegetative, or suffering with end-stage terminal illness. The client may have signed an advance directive, making his wishes known. An advance directive is a document that provides guidelines for starting or continuing life-sustaining medical care, generally for a client who has a terminal disease or disability and can't indicate his own wishes. Substituted judgment is an ethical principle used when a nurse makes a decision based on what's best for an incapacitated client.

    CLIENT NEEDS CATEGORY: Safe, effective care environment
    CLIENT NEEDS SUBCATEGORY: Management of care
    COGNITIVE LEVEL: Application

    REFERENCE: Craven, R.F., and Hirnle, C.J. Fundamentals of Nursing: Human Health and Function, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 1396.

    Rate this question:

  • 12. 

    After suctioning a client, a nurse should expect to find:

    • A respiratory rate of 28 breaths/minute.

    • A heart rate of 104 beats/minute.

    • Brisk capillary refill.

    • Clear breath sounds.

    Correct Answer
    A. Clear breath sounds.
    Explanation
    RATIONALE: Clear breath sounds, which indicate that secretions have been removed, indicate effective suctioning. An above-normal respiratory rate, such as a rate of 28 breaths/minute, may indicate that the airway isn't clear of secretions and the client's respiratory rate has increased to compensate. A slightly increased heart rate, such as a rate of 104 beats/minute, may indicate health concerns unrelated to suctioning. Brisk capillary refill indicates adequate cardiovascular function and is unrelated to suctioning.

    CLIENT NEEDS CATEGORY: Physiological integrity
    CLIENT NEEDS SUBCATEGORY: Physiological adaptation
    COGNITIVE LEVEL: Comprehension

    REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and Science of Nursing Care, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1649.

    Rate this question:

  • 13. 

    A client complains of dyspnea. Which action by the nurse is most appropriate?

    • Placing the client in Trendelenburg position

    • Placing the client in Sims' position

    • Placing the client in Fowler's position

    • Placing the client in the supine position

    Correct Answer
    A. Placing the client in Fowler's position
    Explanation
    RATIONALE: Fowler's position — the posture assumed by the client when the head of the bed is elevated 40 to 60 degrees — promotes breathing by allowing the thoracic cavity to expand. The Trendelenburg, Sims', and supine positions wouldn't facilitate breathing.

    CLIENT NEEDS CATEGORY: Physiological integrity
    CLIENT NEEDS SUBCATEGORY: Basic care and comfort
    COGNITIVE LEVEL: Application

    REFERENCE: Craven, R.F., and Hirnle, C.J. Fundamentals of Nursing: Human Health and Function, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 870.

    Rate this question:

  • 14. 

    Which nursing action is essential when providing continuous enteral feeding?

    • Elevating the head of the bed

    • Positioning the client on his left side

    • Warming the formula before administering it

    • Adding methylene blue to the enteral feeding to detect aspiration

    Correct Answer
    A. Elevating the head of the bed
    Explanation
    RATIONALE: Elevating the head of the bed during enteral feeding minimizes the risk of aspiration and allows the formula to flow into the client's intestines. When such elevation is contraindicated, the client should be positioned on his right side. The nurse should give enteral feedings at room temperature to minimize GI distress. Because methylene blue can cause adverse effects, it isn't a recommended enteral feeding additive.

    CLIENT NEEDS CATEGORY: Safe, effective care environment
    CLIENT NEEDS SUBCATEGORY: Safety and infection control
    COGNITIVE LEVEL: Application

    REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and Science of Nursing Care, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1452.

    Rate this question:

  • 15. 

    A client twists his right ankle while playing basketball and seeks care for ankle pain and swelling. After the nurse applies ice to the ankle for 30 minutes, which client statement suggests that ice application has been effective?

    • I need something stronger for pain relief.

    • My ankle looks less swollen now.

    • My ankle appears redder now.

    • My ankle feels very warm.

    Correct Answer
    A. My ankle looks less swollen now.
    Explanation
    RATIONALE: Ice application decreases pain and swelling. Continued or increased pain, redness, and increased warmth are signs of inflammation that shouldn't occur after ice application.

    CLIENT NEEDS CATEGORY: Physiological integrity
    CLIENT NEEDS SUBCATEGORY: Physiological adaptation
    COGNITIVE LEVEL: Application

    REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and Science of Nursing Care, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1222.

    Rate this question:

  • 16. 

    A client admitted with anorexia nervosa lost 30 lb (13.6 kg) during the previous 3 months. When planning this client's care, what should a nurse select as a priority intervention?

    • Asking the physician for an order for physical therapy

    • Requesting that a chaplain visit the client

    • Consulting with a dietitian about the client's dietary needs

    • Asking the nursing assistant to shampoo the client's hair

    Correct Answer
    A. Consulting with a dietitian about the client's dietary needs
    Explanation
    RATIONALE: The nurse must first assess and plan interventions for the client's nutrition and other immediate physical needs. The nurse should consult with a dietitian to determine the client's dietary requirements, set nutritional goals, and explore ways to meet those goals. Requesting an order for physical therapy, having a chaplain visit the client, and shampooing the client's hair are also important interventions. However, they don't meet basic physical needs and aren't priority interventions at this time.

    CLIENT NEEDS CATEGORY: Safe, effective care environment
    CLIENT NEEDS SUBCATEGORY: Management of care
    COGNITIVE LEVEL: Analysis

    REFERENCE: Craven, R.F., and Hirnle, C.J. Fundamentals of Nursing: Human Health and Function, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 61.

    Rate this question:

  • 17. 

    Which assessment is most supportive of the nursing diagnosis, Impaired skin integrity related to purulent wound drainage?

    • A heart rate of 88 beats/minute

    • Wound healing by primary intention

    • Oral temperature of 101° F (38.3° C)

    • Dry and intact wound dressing

    Correct Answer
    A. Oral temperature of 101° F (38.3° C)
    Explanation
    RATIONALE: The nursing diagnosis indicates that the client's wound, which has purulent drainage, is infected. In response to the infection, the client's temperature would be elevated. A heart rate of 88 beats/minute, healing by primary intention, and a dry, intact dressing demonstrate normal assessment findings.

    CLIENT NEEDS CATEGORY: Physiological integrity
    CLIENT NEEDS SUBCATEGORY: Physiological adaptation
    COGNITIVE LEVEL: Application

    REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and Science of Nursing Care, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1192.

    Rate this question:

  • 18. 

    An obese, malnourished client has undergone abdominal surgery. While ambulating on the fourth postoperative day, she complains to the nurse that her dressing is saturated with drainage. Before this activity, the dressing was dry and intact. Which is the best initial action for the nurse to take?

    • Splint the abdomen with a pillow and call the surgeon.

    • Apply an abdominal binder.

    • Reinforce the existing dressing with another dressing.

    • Lift the dressing to assess the wound.

    Correct Answer
    A. Lift the dressing to assess the wound.
    Explanation
    RATIONALE: The client probably has a wound evisceration or dehiscence. The first step is to assess the wound; then the nurse can implement appropriate measures. Splinting the abdomen, applying an abdominal binder, or reinforcing the existing dressing would delay treatment.

    CLIENT NEEDS CATEGORY: Physiological integrity
    CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
    COGNITIVE LEVEL: Application

    REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and Science of Nursing Care, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1193.

    Rate this question:

  • 19. 

    A client complains of abdominal discomfort and nausea while receiving tube feedings. Which intervention is most appropriate for this problem?

    • Give the feedings at room temperature.

    • Stop the feedings and check for residual volume.

    • Place the client in semi-Fowler's position while feeding.

    • Change the feeding container daily.

    Correct Answer
    A. Stop the feedings and check for residual volume.
    Explanation
    RATIONALE: Complaints of abdominal discomfort and nausea are common in clients receiving tube feedings. Stopping the feeding and checking for residual volume helps assess the reason for the client's nausea and discomfort. If residual volume is greater than 100 ml, hold the feeding and notify the physician. Feedings are normally given at room temperature to minimize abdominal cramping; however, this action doesn't help assess why nausea and discomfort are occurring. Elevating the head of the client's bed to at least 30 degrees prevents aspiration during feeding. Also, feeding containers are changed daily to prevent bacterial growth.

    CLIENT NEEDS CATEGORY: Physiological integrity
    CLIENT NEEDS SUBCATEGORY: Basic care and comfort
    COGNITIVE LEVEL: Application

    REFERENCE: Craven, R.F., and Hirnle, C.J. Fundamentals of Nursing: Human Health and Function, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 992.

    Rate this question:

  • 20. 

    A nurse is to collect a sputum specimen from a client. The best time to collect this specimen is:

    • Early in the evening.

    • Any time during the day.

    • In the morning, as soon as the client awakens.

    • Before bedtime.

    Correct Answer
    A. In the morning, as soon as the client awakens.
    Explanation
    RATIONALE: Because sputum accumulates in the lungs during sleep, the nurse should collect a sputum specimen in the morning, as soon as the client awakens. This specimen will be concentrated, increasing the likelihood of an accurate culture. Sputum specimens collected at other times during the day aren't concentrated and may not provide an accurate culture.

    CLIENT NEEDS CATEGORY: Safe, effective care environment
    CLIENT NEEDS SUBCATEGORY: Safety and infection control
    COGNITIVE LEVEL: Knowledge

    REFERENCE: Ellis, J.R., and Bentz, P.M. Modules for Basic Nursing Skills, 7th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 288.

    Rate this question:

  • 21. 

    Delegation is the process of transferring work to subordinates. A nurse-manager may appropriately delegate which task?

    • Scheduling staff assignments for the next month

    • Terminating a nursing assistant for insubordination

    • Deciding on salary increases for nurses after they complete orientation

    • Telling a staff nurse to initiate disciplinary action against one of her peers

    Correct Answer
    A. Scheduling staff assignments for the next month
    Explanation
    RATIONALE: Scheduling may be safely and appropriately delegated. Termination, disciplinary action, and salary increases shouldn't be delegated to staff, who don't have the power and authority to take such actions.

    CLIENT NEEDS CATEGORY: Safe, effective care environment
    CLIENT NEEDS SUBCATEGORY: Management of care
    COGNITIVE LEVEL: Analysis

    REFERENCE: Craven, R.F., and Hirnle, C.J. Fundamentals of Nursing: Human Health and Function, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 116.

    Rate this question:

  • 22. 

    A nurse is caring for a client who required chest tube insertion for a pneumothorax. To assess for pneumothorax resolution, the nurse can anticipate that the client will require:

    • Monitoring of arterial oxygen saturation (SaO2).

    • Arterial blood gas (ABG) studies.

    • Chest auscultation.

    • A chest X-ray.

    Correct Answer
    A. A chest X-ray.
    Explanation
    RATIONALE: Chest X-ray confirms diagnosis by revealing air or fluid in the pleural space. SaO2 values may initially decrease with a pneumothorax but typically return to normal within 24 hours. ABG studies may show hypoxemia, possibly with respiratory acidosis and hypercapnia not related to a pneumothorax. Chest auscultation will determine overall lung status, but it's difficult to determine if the chest has reexpanded sufficiently.

    CLIENT NEEDS CATEGORY: Physiological integrity
    CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
    COGNITIVE LEVEL: Analysis

    REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and Science of Nursing Care, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1633.

    Rate this question:

  • 23. 

    When caring for a client with a 3-cm stage I pressure ulcer on the coccyx, which action may the nurse institute independently?

    • Using a povidone-iodine wash on the ulceration three times per day

    • Using normal saline solution to clean the ulcer and applying a protective dressing as necessary

    • Applying an antibiotic cream to the area three times per day

    • Massaging the area with an astringent every 2 hours

    Correct Answer
    A. Using normal saline solution to clean the ulcer and applying a protective dressing as necessary
    Explanation
    RATIONALE: The nurse may wash the area with normal saline solution and apply a protective dressing. These interventions will protect the area and are within the nurse's scope of practice. A nurse must obtain a physician's order to use a povidone-iodine wash or an antibiotic cream. Massaging with an astringent can further damage the skin.

    CLIENT NEEDS CATEGORY: Physiological integrity
    CLIENT NEEDS SUBCATEGORY: Basic care and comfort
    COGNITIVE LEVEL: Application

    REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and Science of Nursing Care, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 315.

    Rate this question:

  • 24. 

    A nurse revises the care plan for a client who has difficulty dealing with a crying neonate. Which strategy should the new care plan implement early in this mother's hospital stay?

    • Anger-management therapy

    • Proper care of a crying infant

    • Proper methods for dealing with stressful situations such as crying infants

    • Assessment of the mother's coping strengths and weaknesses and the presence or absence of support systems

    Correct Answer
    A. Assessment of the mother's coping strengths and weaknesses and the presence or absence of support systems
    Explanation
    RATIONALE: Assessment of the mother's coping strengths and weaknesses and the presence or absence of support systems is an important aspect in the implementation process. Assessment will also help the nurse identify situations that the mother perceives as stressors. Educating the client about alternative ways of expressing feelings and about crisis hotlines and community support systems should also be part of the care plan. The nurse hasn't established that the mother is angry, so anger-management therapy may not be necessary. Proper care of a crying neonate is necessary, and assessing the mother's coping will help provide the basis for teaching the essential skills.

    CLIENT NEEDS CATEGORY: Psychosocial integrity
    CLIENT NEEDS SUBCATEGORY: None
    COGNITIVE LEVEL: Analysis

    REFERENCE: Craven, R.F., and Hirnle, C.J. Fundamentals of Nursing: Human Health and Function, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 198.

    Rate this question:

  • 25. 

    A client with severe chest pain is brought to the emergency department. He tells the nurse, "I just have a little indigestion." Which coping mechanism is the client exhibiting?

    • Anxiety

    • Denial

    • Repression

    • Confusion

    Correct Answer
    A. Denial
    Explanation
    RATIONALE: During a crisis, it's common for a client to use denial, a coping mechanism exhibited by minimizing symptoms or avoiding discussion. Anxiety is typically indicated by restlessness. A client who verbally acknowledges a problem exists isn't confused or repressing the incident.

    CLIENT NEEDS CATEGORY: Psychosocial integrity
    CLIENT NEEDS SUBCATEGORY: None
    COGNITIVE LEVEL: Comprehension

    REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and Science of Nursing Care, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 963.

    Rate this question:

  • 26. 

    Which statement is a guideline to help nurses protect themselves from liability?

    • Follow all physician's orders.

    • Do what the client desires even though the nurse may disagree.

    • Practice within the scope of the state's nurse practice act.

    • Obtain malpractice insurance.

    Correct Answer
    A. Practice within the scope of the state's nurse practice act.
    Explanation
    RATIONALE: The nurse practice act outlines acceptable standards for nursing for a particular state. Practicing within those guidelines will protect the nurse from liability. The nurse shouldn't follow all physician's orders because physicians may not be aware of guidelines for nurses and may delegate inappropriate treatment or practice for the nurse. The client doesn't know standards of care and isn't responsible for the nurse's actions. Insurance won't prevent a liability suit, it will only assist the nurse if a suit should be filed.

    CLIENT NEEDS CATEGORY: Safe, effective care environment
    CLIENT NEEDS SUBCATEGORY: Management of care
    COGNITIVE LEVEL: Knowledge

    REFERENCE: Craven, R.F., and Hirnle, C.J. Fundamentals of Nursing: Human Health and Function, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 99.

    Rate this question:

  • 27. 

    A nurse-manager notes that a staff nurse isn't working to full potential. Which strategy by the nurse-manager would best benefit the staff nurse?

    • Assigning the staff nurse several clients with multiple physical problems

    • Allowing the staff nurse to select her own assignments

    • Discussing the staff nurse's performance and ways she can improve

    • Assigning the staff nurse fewer patients than her coworkers

    Correct Answer
    A. Discussing the staff nurse's performance and ways she can improve
    Explanation
    RATIONALE: The nurse-manager should meet with the staff nurse to discuss her performance and ways she can improve. Assigning the staff nurse several clients with multiple physical problems would be overwhelming, counterproductive, and unsafe because she has yet to demonstrate the priority-setting and decision-making leadership skills that this client load would require. Letting her select her own assignments or giving her fewer patients could impair the morale of other staff nurses.

    CLIENT NEEDS CATEGORY: Safe, effective care environment
    CLIENT NEEDS SUBCATEGORY: Management of care
    COGNITIVE LEVEL: Application

    REFERENCE: Craven, R.F., and Hirnle, C.J. Fundamentals of Nursing: Human Health and Function, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 115.

    Rate this question:

  • 28. 

    Which is a nurse's role in a situation involving domestic abuse?

    • Documenting the situation and providing support for the victim

    • Protecting the client's privacy by not documenting the abusing

    • Counseling the person committing the abuse

    • Counseling the victim

    Correct Answer
    A. Documenting the situation and providing support for the victim
    Explanation
    RATIONALE: The nurse must carefully and adequately document her assessment of the abused victim. The documentation must include statements from the victim, physical and psychological assessment findings, and observations relative to the abuse situation. The nurse should give the victim information about community resources, social agencies, and legal services to prevent recurrence of physical abuse. A professional nurse isn't qualified to counsel the abuser or the victim. She should refer the abuser and the victim to a professional counselor trained in dealing with domestic violence.

    CLIENT NEEDS CATEGORY: Psychosocial integrity
    CLIENT NEEDS SUBCATEGORY: None
    COGNITIVE LEVEL: Analysis

    REFERENCE: Weber J., and Kelley, J. Health Assessment in Nursing, 3rd ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 898.

    Rate this question:

  • 29. 

    A nurse is teaching the parents of a child with cystic fibrosis about proper nutrition. Which instruction should the nurse include?

    • Encourage a high-calorie, high-protein diet.

    • Restrict fluids to 1,500 ml per day.

    • Limit salt intake to 2 g per day.

    • Encourage foods high in vitamin B.

    Correct Answer
    A. Encourage a high-calorie, high-protein diet.
    Explanation
    RATIONALE: The child should be encouraged to eat a high-calorie, high-protein diet. In cystic fibrosis, the pancreatic enzymes (lipase, trypsin, and amylase) become so thick that they plug the ducts. In the absence of these enzymes, the duodenum can't digest fat, protein, and some sugars; therefore, the child can become malnourished. A child with cystic fibrosis needs to drink plenty of fluid and take salt supplements, especially on warm days or when exercising, to help maintain hydration and adequate sodium levels. Water-soluble forms of the fat-soluble vitamins (A, D, E, and K) are essential.

    CLIENT NEEDS CATEGORY: Physiological integrity
    CLIENT NEEDS SUBCATEGORY: Basic care and comfort
    COGNITIVE LEVEL: Application

    REFERENCE: Pillitteri, A. Maternal & Child Health Nursing: Care of the Childbearing and Childrearing Family, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 1271.

    Rate this question:

  • 30. 

    In planning a presentation that advocates decreasing the client-to-nurse ratio from 8:1 to 6:1, a nurse should emphasize the effect on:

    • Institutional resources.

    • Standards of practice.

    • Client-care quality.

    • Nursing recruitment.

    Correct Answer
    A. Client-care quality.
    Explanation
    RATIONALE: Client-care quality should always be the first consideration when proposing a change in care provision. Institutional resources, standards of practice, and nursing recruitment will all influence the decision but none should be as influential as client-care quality.

    CLIENT NEEDS CATEGORY: Safe, effective care environment
    CLIENT NEEDS SUBCATEGORY: Management of care
    COGNITIVE LEVEL: Knowledge

    REFERENCE: Craven, R.F., and Hirnle, C.J. Fundamentals of Nursing: Human Health and Function, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 27.

    Rate this question:

  • 31. 

    As a nurse-manager of a medical-surgical unit reviews the month's risk-management data, she notices that a number of incident reports were completed because 6 p.m. medications were administered late. Dinner is served between 5:30 p.m. and 6 p.m. Staff take their dinner breaks between 5 p.m. and 6:30 p.m. Based on this information, which is the most appropriate action for the nurse-manager to take?

    • Terminate the nurses responsible for failing to administer medications on time.

    • Decide that the staff must postpone dinner breaks until at least 7 p.m.

    • Decide that the kitchen staff must change the time they deliver supper trays.

    • Investigate when medications are given, staff and client dinner times, the number of medications that must be given at 6 p.m., and staff availability between 5 p.m. and 6 p.m.

    Correct Answer
    A. Investigate when medications are given, staff and client dinner times, the number of medications that must be given at 6 p.m., and staff availability between 5 p.m. and 6 p.m.
    Explanation
    RATIONALE: An effective nurse-manager knows that to accurately evaluate risk-management findings, she must look at the entire process and the circumstances surrounding each incident. Terminating staff without such evaluation doesn't resolve all the problem's contributing factors. She shouldn't change dinner breaks or kitchen delivery times unless she has evaluated how these factors influence medication administration.

    CLIENT NEEDS CATEGORY: Safe, effective care environment
    CLIENT NEEDS SUBCATEGORY: Management of care
    COGNITIVE LEVEL: Analysis

    REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and Science of Nursing Care, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 321.

    Rate this question:

  • 32. 

    A hospitalized client who has a living will is being fed through a nasogastric (NG) tube. During a bolus feeding, the client vomits and begins choking. Which action should the nurse take?

    • Clear the client's airway.

    • Make the client comfortable as specified in the client's living will.

    • Start cardiopulmonary resuscitation.

    • Stop the feeding and remove the NG tube as specified in the client's living will.

    Correct Answer
    A. Clear the client's airway.
    Explanation
    RATIONALE: A living will gives information about what the client wants if he is in a terminal or permanently unconscious state. A living will doesn't apply to nonterminal events such as choking on an enteral feeding device. In this situation, the nurse should clear the client's airway. Making the client comfortable ignores the life-threatening event. Cardiopulmonary resuscitation isn't indicated. Removing the NG tube would exacerbate the situation.

    CLIENT NEEDS CATEGORY: Physiological integrity
    CLIENT NEEDS SUBCATEGORY: Physiological adaptation
    COGNITIVE LEVEL: Application

    REFERENCE: Craven, R.F., and Hirnle, C.J. Fundamentals of Nursing: Human Health and Function, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 92.

    Rate this question:

  • 33. 

    Standard precautions include which measure?

    • Wearing gloves when changing a dressing

    • Disposing of needles in a puncture-resistant container

    • Wearing eye protection during tracheal suctioning

    • All of the above

    Correct Answer
    A. All of the above
    Explanation
    RATIONALE: To follow standard precautions, caregivers must wear gloves when there is the potential for contact with a client's body fluids; place used, uncapped needles and syringes in a puncture-resistant container; and wear goggles during procedures that are likely to generate splashes of blood or body fluids.

    CLIENT NEEDS CATEGORY: Safe, effective care environment
    CLIENT NEEDS SUBCATEGORY: Safety and infection control
    COGNITIVE LEVEL: Comprehension

    REFERENCE: Craven, R.F., and Hirnle, C.J. Fundamentals of Nursing: Human Health and Function, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 531.

    Rate this question:

  • 34. 

    A client in a long-term care facility refuses to take his oral medications. The nurse threatens that she will apply restraints and inject the medication if he doesn't take it orally. The nurse's statement constitutes which legal tort?

    • Assault

    • Battery

    • Negligence

    • Right to refuse care

    Correct Answer
    A. Assault
    Explanation
    RATIONALE: Assault occurs when a person puts another person in fear of harmful or threatening contact. Battery is offensive contact with another's body. If the nurse actually carried out the threat, battery would also apply. Negligence involves actions that don't meet the standard of care. The client has the legal right to refuse care. In this situation, the nurse should try to calm the client, allow him time to talk, and then determine if he will take the medications. If the client still won't take the medications, the nurse should document his refusal, note the medications involved, and notify the physician and nursing supervisor. The nurse should follow the facility's policy related to clients refusing care.

    CLIENT NEEDS CATEGORY: Safe, effective care environment
    CLIENT NEEDS SUBCATEGORY: Management of care
    COGNITIVE LEVEL: Comprehension

    REFERENCE:Craven, R.F., and Hirnle, C.J. Fundamentals of Nursing: Human Health and Function, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 101.

    Rate this question:

  • 35. 

    According to Elizabeth Kübler-Ross, which stages of grief do a client or family member experience?

    • Acceptance, depression, anger, bargaining, and denial

    • Denial, anger, decreased interaction, depression, and mourning

    • Acceptance, anger, denial, and bargaining

    • Denial, anger, bargaining, depression, and acceptance

    Correct Answer
    A. Denial, anger, bargaining, depression, and acceptance
    Explanation
    RATIONALE: Denial, the avoidance of death's inevitability, is the first step of the grieving process. Anger, the most intense grief reaction, arises when people realize that a family member will die or has died. Bargaining occurs when family members attempt to stall or manipulate the outcome or death. Depression is a response to loss expressed as profound sadness or deep suffering. Acceptance, the final stage of grief, is the ability to overcome the emotion and accept what has happened.

    CLIENT NEEDS CATEGORY: Psychosocial integrity
    CLIENT NEEDS SUBCATEGORY: None
    COGNITIVE LEVEL: Knowledge

    REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and Science of Nursing Care, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 987.

    Rate this question:

  • 36. 

    When planning and prioritizing care and teaching needs for the family of a client with a new feeding tube, a nurse should consider the client's probable length of stay and remember that:

    • Client and family teaching should take place just before discharge.

    • Client and family teaching begins the day of admission.

    • Clients may stay in the hospital as long as they choose.

    • A physician will provide all client and family teaching.

    Correct Answer
    A. Client and family teaching begins the day of admission.
    Explanation
    RATIONALE: Duration of hospital stays is decreasing, and discharged clients go home with more complex needs than in the past. Teaching should begin on the day of admission. This allows time for adequate teaching and for the client and caregivers to become comfortable with any new procedures they will need to perform. Trying to teach the caregiver immediately before discharge wouldn't allow time for practice and return demonstrations. Most insurance reimbursements don't allow for lengthy hospital stays. The main responsibility for teaching clients and family members falls to the nurse, not the physician.

    CLIENT NEEDS CATEGORY: Safe, effective care environment
    CLIENT NEEDS SUBCATEGORY: Management of care
    COGNITIVE LEVEL: Analysis

    REFERENCE: Craven, R.F., and Hirnle, C.J. Fundamentals of Nursing: Human Health and Function, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 29.

    Rate this question:

  • 37. 

    An elderly client has been admitted to the medical-surgical unit from the postanesthesia care unit. While the nurse is off the floor, the client falls out of bed and fractures his right leg and right wrist. The nurse finding him states, "The side rails were down and the bed was in the high position." The client's family files legal charges against the nurse and the hospital. Which charge most accurately reflects the nurse's actions?

    • Collective liability

    • Comparative negligence

    • Battery

    • Negligence

    Correct Answer
    A. Negligence
    Explanation
    RATIONALE: The position of the client's bed indicates negligence, a general term that denotes conduct lacking in due care. Collective liability stems from cooperation by several manufacturers in a wrongful activity. Comparative negligence holds the injured parties accountable for their fault in the injury. Battery involves harmful or unwarranted contact with the client.

    CLIENT NEEDS CATEGORY: Safe, effective care environment
    CLIENT NEEDS SUBCATEGORY: Safety and infection control
    COGNITIVE LEVEL: Analysis

    REFERENCE: Craven, R.F., and Hirnle, C.J. Fundamentals of Nursing: Human Health and Function, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 101.

    Rate this question:

  • 38. 

    A nurse is using the computer when a client calls for pain medication. Which action by the nurse helps maintain computer security?

    • Staying logged on, leaving the terminal on, and administering the medication immediately

    • Informing the client that he'll have to wait 15 minutes while she completes the entry

    • Asking a coworker to log out for her and administering the medicine right away

    • Logging out of the computer, then administering the pain medication

    Correct Answer
    A. Logging out of the computer, then administering the pain medication
    Explanation
    RATIONALE: A nurse should meet a client's request for pain medication as quickly as possible after she logs out of the computer. A nurse shouldn't ask a client to wait for as long as 15 minutes for requested pain medication. If the nurse leaves the terminal without logging out, others may view confidential information or use her password. Asking a coworker to log her out isn't safe computer practice.

    CLIENT NEEDS CATEGORY: Safe, effective care environment
    CLIENT NEEDS SUBCATEGORY: Management of care
    COGNITIVE LEVEL: Application

    Rate this question:

  • 39. 

    A nurse is monitoring a client who is receiving moderate sedation during a breast biopsy. Which symptom should the nurse assess first?

    • Lower back pain

    • Coarse crackles in both upper lobes

    • Heart rate of 84 beats/minute

    • Mild bleeding at the surgical site

    Correct Answer
    A. Coarse crackles in both upper lobes
    Explanation
    RATIONALE: Coarse crackles may indicate aspiration — a potentially life-threatening complication of conscious sedation. A heart rate of 84 beats/minute is within the normal range. Mild bleeding is expected at the surgical site. Poor positioning during surgery commonly causes lower back pain. Although the nurse should ultimately assess this pain, it isn't her first priority.

    CLIENT NEEDS CATEGORY: Physiological integrity
    CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
    COGNITIVE LEVEL: Analysis

    REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and Science of Nursing Care, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 828.

    Rate this question:

  • 40. 

    A nurse should question an order for a heating pad for a client who has:

    • Active bleeding.

    • A reddened abscess.

    • An edematous lower leg.

    • Purulent wound drainage.

    Correct Answer
    A. Active bleeding.
    Explanation
    RATIONALE: Heat application increases blood flow and therefore is contraindicated in active bleeding. For the same reason, however, applying heat to a reddened abscess, an edematous lower leg, or a wound with purulent drainage promotes healing.

    CLIENT NEEDS CATEGORY: Safe, effective care environment
    CLIENT NEEDS SUBCATEGORY: Safety and infection control
    COGNITIVE LEVEL: Analysis

    REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and Science of Nursing Care, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1223.

    Rate this question:

  • 41. 

    To collect a clean-catch midstream urine specimen from a female client, the nurse instructs her to clean the area at the external urinary meatus with an antiseptic. How should the client clean the area?

    • By swabbing the labia minora from front to back

    • By cleaning the labia minora from back to front

    • By cleaning the labia majora from back to front

    • By swabbing the entire perineal area

    Correct Answer
    A. By swabbing the labia minora from front to back
    Explanation
    RATIONALE: The client should swab the labia minora from front to back, using one swab for each wipe. This technique cleans from the area of least contamination to the area of greatest contamination. The labia minora shouldn't be cleaned from back to front because doing so increases the risk of contamination. The labia majora should be cleaned with soap and water from front to back — not back to front. Before swabbing the labia minora with an antiseptic, the client should wash the perineal area with soap and water.

    CLIENT NEEDS CATEGORY: Safe, effective care environment
    CLIENT NEEDS SUBCATEGORY: Safety and infection control
    COGNITIVE LEVEL: Comprehension

    REFERENCE: Ellis, J.R., and Bentz, P.M. Modules for Basic Nursing Skills, 7th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 286.

    Rate this question:

  • 42. 

    A physician orders hourly urine output measurement for a postoperative client with an indwelling catheter. The nurse records the following amounts of output for 2 consecutive hours: 8 a.m.: 50 ml; 9 a.m.: 60 ml. Based on these amounts, which action should the nurse take?

    • Continue to monitor and record hourly urine output.

    • Notify the physician.

    • Irrigate the indwelling urinary catheter.

    • Increase the I.V. fluid infusion rate.

    Correct Answer
    A. Continue to monitor and record hourly urine output.
    Explanation
    RATIONALE: Normal urine output for an adult with an indwelling catheter is at least 30 ml/hour. Therefore, this client's output is normal. Beyond continued evaluation, no nursing action is warranted.

    CLIENT NEEDS CATEGORY: Physiological integrity
    CLIENT NEEDS SUBCATEGORY: Basic care and comfort
    COGNITIVE LEVEL: Analysis

    REFERENCE: Craven, R.F., and Hirnle, C.J. Fundamentals of Nursing: Human Health and Function, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p.1079.

    Rate this question:

  • 43. 

    Which client would qualify for hospice care?

    • A client with late-stage acquired immunodeficiency syndrome (AIDS)

    • A client with left-sided paralysis resulting from a stroke

    • A client who's undergoing treatment for heroin addiction

    • A client who had coronary artery bypass surgery 2 weeks earlier

    Correct Answer
    A. A client with late-stage acquired immunodeficiency syndrome (AIDS)
    Explanation
    RATIONALE: Hospices provide supportive, palliative care to terminally ill clients, such as those with late-stage AIDS, as well as their families. Hospice services wouldn't be appropriate for a client with left-sided paralysis resulting from a stroke, a client who's undergoing treatment for heroin addiction, or one who recently had coronary artery bypass surgery because these health problems aren't necessarily terminal.

    CLIENT NEEDS CATEGORY: Health promotion and maintenance
    CLIENT NEEDS SUBCATEGORY: None
    COGNITIVE LEVEL: Comprehension

    REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and Science of Nursing Care, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 159.

    Rate this question:

  • 44. 

    A nurse is recording a client's complaint of painful urination. When documenting this symptom, the nurse should use which term?A nurse is recording a client's complaint of painful urination. When documenting this symptom, the nurse should use which term?

    • Oliguria

    • Anuria

    • Pyuria

    • Dysuria

    Correct Answer
    A. Dysuria
    Explanation
    RATIONALE: The nurse should document painful urination as dysuria. Oliguria refers to a decrease in the amount of urine excreted; anuria, to a urine output below 50 ml/day; and pyuria, to pus in the urine.

    CLIENT NEEDS CATEGORY: Physiological integrity
    CLIENT NEEDS SUBCATEGORY: Basic care and comfort
    COGNITIVE LEVEL: Knowledge

    REFERENCE: Craven, R.F., and Hirnle, C.J. Fundamentals of Nursing: Human Health and Function, 5th ed.Philadelphia: Lippincott Williams & Wilkins, 2007, p. 1084.

    Rate this question:

  • 45. 

    A physician has ordered a heating pad for an elderly client's lower back pain. Which item would be most important for a nurse to assess before applying the heating pad?

    • Client's risk for falls

    • Client's vital signs and breath sounds

    • Client's nutritional status

    • Client's level of consciousness

    Correct Answer
    A. Client's level of consciousness
    Explanation
    RATIONALE: A client who has impaired consciousness or altered mental status is at increased risk for injury from a heating pad. When administering a heat treatment, a nurse should always check the temperature of the heating unit and examine the client's skin for redness or irritation. Risk for falls, vital signs, and nutrition level are also important assessment areas, but they aren't the priority assessment for a client using a heating pad.

    CLIENT NEEDS CATEGORY: Safe, effective care environment
    CLIENT NEEDS SUBCATEGORY: Safety and infection control
    COGNITIVE LEVEL: Application

    REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and Science of Nursing Care, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1223.

    Rate this question:

  • 46. 

    A nurse is reviewing a client's laboratory test results. Which electrolyte is the major cation controlling a client's extracellular fluid (ECF) osmolality?

    • Potassium

    • Sodium

    • Chloride

    • Calcium

    Correct Answer
    A. Sodium
    Explanation
    RATIONALE: Sodium, the major ECF cation, maintains ECF osmolality. Potassium is the major cation in intracellular fluid. Chloride is the major anion in the ECF. Calcium, found primarily in the intravascular fluid compartment of ECF, is the major cation involved in the structure and function of the teeth and bones.

    CLIENT NEEDS CATEGORY: Physiological integrity
    CLIENT NEEDS SUBCATEGORY: Physiological adaptation
    COGNITIVE LEVEL: Knowledge

    REFERENCE: Craven, R.F., and Hirnle, C.J. Fundamentals of Nursing: Human Health and Function, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 920.

    Rate this question:

  • 47. 

    A nurse-manager works for a nonprofit health care corporation whose revenues have significantly exceeded annual expenses. The nurse-manager has been told to anticipate which action?

    • Receiving a portion of the revenue to improve client services on the unit

    • Identifying revenue as profit

    • Dividing revenue among stockholders as dividends

    • Reducing operating expenses to help the organization pay taxes on the revenue

    Correct Answer
    A. Receiving a portion of the revenue to improve client services on the unit
    Explanation
    RATIONALE: In a nonprofit organization, revenue exceeding expenses is tax-exempt and is usually reinvested in the organization and used to improve services. A for-profit organization calls revenue in excess of expenses a profit and divides it as a dividend among stockholders or reinvests it in the organization.

    CLIENT NEEDS CATEGORY: Safe, effective care environment
    CLIENT NEEDS SUBCATEGORY: Management of care
    COGNITIVE LEVEL: Application

    REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and Science of Nursing Care, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 155.

    Rate this question:

  • 48. 

    A client has a blood pressure of 152/86 mm Hg. The nurse should document the client's pulse pressure as:

    • 66 mm Hg.

    • 238 mm Hg.

    • 86 mm Hg.

    • 152 mm Hg.

    Correct Answer
    A. 66 mm Hg.
    Explanation
    RATIONALE: Pulse pressure is the difference between the systolic and diastolic pressures — in this case, 66 mm Hg.

    CLIENT NEEDS CATEGORY: Physiological integrity
    CLIENT NEEDS SUBCATEGORY: Basic care and comfort
    COGNITIVE LEVEL: Comprehension

    REFERENCE: Weber, J., and Kelley, J. Health Assessment in Nursing, 3rd ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 102.

    Rate this question:

  • 49. 

    When preparing a client for a diagnostic study of the colon, the nurse teaches the client how to self-administer a prepackaged enema. Which statement by the client indicates effective teaching?

    • I will administer the enema while sitting on the toilet.

    • I will administer the enema while lying on my left side with my right knee flexed.

    • I will administer the enema while lying on my right side with my left knee flexed.

    • I will administer the enema while lying on my back with both knees flexed.

    Correct Answer
    A. I will administer the enema while lying on my left side with my right knee flexed.
    Explanation
    RATIONALE: Lying on the left side allows the enema solution to flow downward by gravity into the rectum and sigmoid colon. The other options don't accomplish this goal and, therefore, are less effective in evacuating the lower bowel.

    CLIENT NEEDS CATEGORY: Safe, effective care environment
    CLIENT NEEDS SUBCATEGORY: Safety and infection control
    COGNITIVE LEVEL: Comprehension

    REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and Science of Nursing Care, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1588.

    Rate this question:

Quiz Review Timeline (Updated): Mar 22, 2023 +

Our quizzes are rigorously reviewed, monitored and continuously updated by our expert board to maintain accuracy, relevance, and timeliness.

  • Current Version
  • Mar 22, 2023
    Quiz Edited by
    ProProfs Editorial Team
  • Nov 12, 2015
    Quiz Created by
    Suarezenriquec1

Recent Quizzes

How Special of a Caretaker Are You for Your Cat? How Special of a Caretaker Are You for Your Cat?
How good pet parent are you ? How good pet parent are you ?
How to treat your dog? How to treat your dog?
Health and Social Care - QP2 Health and Social Care - QP2
Selection and Care of Equipment Selection and Care of Equipment
Are You Ready For Your First Horse? Are You Ready For Your First Horse?
Back to Top Back to top
Advertisement
×

Wait!
Here's an interesting quiz for you.

We have other quizzes matching your interest.