The nurse has identified the following nursing diagnoses for his assigned clients. Of the follow-ing diagnoses, which one indicates the greatest potential need to plan for the client’s spiritual needs? 1. Altered health maintenance 2. Ineffective individual coping 3. Impaired long-term memory 4. Decreased adaptive capacity ANSWER ANS: 2 Ineffective individual coping is a […]
A client who is on postoperative day 1 after abdominal surgery is requesting a back rub. The nurse realizes this care should be provided by 1. the registered nurse. 2. unlicensed assistive personnel. 3. no one, because the client cannot assume the prone position. 4. the physician. ANSWER Correct Answer: 1 Rationale 1: Because […]
The nurse will be starting a new intravenous infusion and needs to select the site for the insertion. In selection of a site, the nurse should: 1. Start with the most proximal site 2. Look for hard, cordlike veins 3. Use the dominant arm 4. Avoid sites on the extremity away from a dialysis graft […]
The home care nurse notes that a 67-year-old female diabetic client’s blood glucose level has been elevated since she strained her back the previous week. The client states that she cannot understand why her blood glucose level is elevated. The nurse suspects the most likely cause for the elevated blood sugar is: 1. The decreased […]
Which of the following responses observed in a client recently diagnosed with lung cancer is most directly addressed by the Neuman System Model? 1. The client asks for a consult with the hospital clergy. 2. The client is observed crying after his family has left for the day. 3. The client asks for pictures of […]
Which return demonstration by a client indicates that teaching about performing a blood glucose monitoring test has been effective? 1. The client punctures the fingertip. 2. The client puts on gloves. 3. The client smears the blood on the reagent strip. 4. The client washes the hands. ANSWER Correct Answer: 4 Rationale 1: Once […]
Which of the following questions asked by the nurse best assesses for the signs of pregnancy most likely observed in the second trimester? 1. “Have you had any problems climbing steps?” 2. “Have you noticed any cramping in your abdomen?” 3. “Have you experienced any nausea in the morning?” 4. “Have you had any problems […]
A client has been prescribed bed rest for a prolonged time. To specifically promote the use of re-sistive isometric exercise for the client, the nurse will initiate: 1. Quadriceps setting 2. Gluteal muscle contraction 3. Moving the arms and legs in circles 4. Pushing against a footboard ANSWER ANS: 4 Resistive isometric exercises are […]
The nurse provides an oral opiate to a client with pain. In how many hours should the nurse expect the client to need another dose of the medication? 1. 2 hours 2. 4 hours 3. 6 hours 4. 8 hours ANSWER Correct Answer: 2 Rationale: The duration of action for most opiates is 4 […]
The nurse is caring for a 35-year-old father of three young children who has experienced a com-pound fractured femur as a result of a work-related incident. He has expressed great concern over both his physical recovery and his long-term ability to work again. This has affected both his emotional status and his sleeping patterns. The […]
