A client who has type 2 diabetes is scheduled for the removal of a skin lesion on his right shoul-der at an ambulatory surgery unit. The nursing diagnosis the client is at greatest risk for postoper-atively is: 1. Risk for injury 2. Risk for infection 3. Impaired wound healing 4. Imbalanced nutrition: less than body […]
Wounds that are contaminated or infected heal by: 1. Secondary intention 2. Tertiary intention 3. Primary intention 4. Open intention ANSWER ANS: 2 Wounds that are contaminated and require observation for signs of inflammation are left open for several days. When wound edges are approximated; this is tertiary intention healing.
A client experiencing pain has been prescribed a coanalgesic. The nurse should prepare to administer what medications to the client? 1. Nortriptyline 2. Amitriptyline 3. Tramadol 4. Meloxicam 5. Gabapentin ANSWER Correct Answer: 1, 2, 5 Rationale 1: Nortriptyline is a tricyclic antidepressant used as a coanalgesic to treat pain. Rationale 2: Amitriptyline a […]
The student nurse is seeking to learn skills associated with priority setting. In discussing different priorities of care, an example of a second-order priority is: 1. The need to urinate 2. An obstructed airway 3. The side effects of a medication 4. Activities of daily living in the home environment ANSWER ANS: 1 Second-order […]
A nurse seeks to organize the data obtained from the client in a logical manner. The organization-al method that identifies relationships between factors and symptoms in the database is known as: 1. Clustering data 2. Validating data 3. Peer reviewing 4. Problem statement ANSWER ANS: 1 Clustering data means the nurse organizes the information […]
The middle adult couple is most likely to experience a change in their sexual intimacy when: 1. The changes of normal aging occur 2. One or both retire from the work force 3. Chronic illness affects sexual performance 4. The children no longer reside full time in the home ANSWER ANS: 4 Children leaving […]
A 4 1/2-year-old child is crying from pain related to her fractured leg. Which of the following is the most appropriate nursing response to her alteration in comfort? 1. “Please try to not move your leg and that will make it feel better.” 2. “I’ll give you a shot of medicine that will help take […]
The nurse is assessing a cognitively impaired older adult client and observes a leaking of liquid stool from the rectum. The nurse’s initial intervention for this client is to: 1. Determine if the client has been eating sufficiently, especially fiber-rich foods 2. Determine how long it has been since the client had a normal-size, formed […]
The nurse working in the labor and delivery area is aware that special care is provided for the umbilical cord after the child’s birth for the clients who are: 1. Catholic 2. Navajo 3. Shinto 4. Hindu ANSWER ANS: 2 After a Navajo child’s delivery, the umbilical cord is taken from the newborn, dried, […]
A client is having severe, continuous discomfort from kidney stones. Based on the client’s expe-rience, the nurse anticipates which of the following findings in the client’s assessment? 1. Tachycardia 2. Diaphoresis 3. Pupil dilation 4. Nausea and vomiting ANSWER ANS: 4 Acute severe or deep pain, as with kidney stones, will cause a parasympathetic […]
