The nurse is reviewing kidney function with a client experiencing renal failure. Identify the area in the nephron where solutes such as glucose are reabsorbed. What will be an ideal response? ANSWER The nurse is caring for a client with a urinary diversion. For which type of diversion should the nurse plan care for […]
A postpartum client has been unable to void since her delivery of her baby this morning. Which of the following nursing measures would be beneficial for the client initially? 1. Increase fluid intake to 3500 mL. 2. Insert indwelling Foley catheter. 3. Rinse the perineum with warm water. 4. Apply firm pressure over the bladder. […]
The nurse is assessing a 78-year-old female African-American client with dark skin. When as-sessing the skin, the nurse knows to avoid which source of light because it can cast a bluish hue on the skin, making the assessment difficult? 1. Natural sunlight 2. Halogen light 3. Florescent light 4. Incandescent light ANSWER ANS: 3 […]
For a client with a nursing diagnosis of impaired physical mobility related to bilateral arm casts, the nurse should select which of the following methods of nursing intervention? 1. Teaching 2. Counseling 3. Compensating for adverse reactions 4. Assisting with activities of daily living (ADLs) ANSWER ANS: 4 A client with bilateral arm casts […]
The nurse is preparing to assess a client who has a history of falls. Which methods should the nurse use to assess this client’s risk for injury? 1. Cognitive awareness 2. Mobility 3. Nursing history 4. Physical examination 5. Health status ANSWER Correct Answer: 3, 4 Rationale 1: Cognitive awareness, mobility, and health status […]
Because young adults are less likely to experience serious illness, which of the following nursing interventions is most effective in determining risk for illness in this age-group? 1. Health screenings 2. Personal lifestyle assessment 3. Full body systems assessment 4. Cardiopulmonary focal assessment ANSWER ANS: 2 A personal lifestyle assessment (see Chapter 6) helps […]
The nurse is working with a nursing assistive personnel to provide care for a group of clients. The nurse can delegate which of the following activities to the nursing assistive personnel? 1. Assess for medical limitations before beginning the exercise activity. 2. Teach the clients breathing skills to help reduce their anxiety. 3. Obtain preexercise […]
The nurse has completed an assessment on the client and identified the following nursing diag-noses. Which one of the following nursing diagnoses indicates a need to postpone teaching that was planned? 1. Activity intolerance related to pain 2. Ineffective management of treatment regimen 3. Noncompliance with prescribed exercise plan 4. Knowledge deficit regarding impending surgery […]
A client experiencing diabetic ketoacidosis is likely to present with which of the following clini-cal signs? (Select all that apply.) 1. Red, flushed skin 2. Verbally aggressive 3. Complaints of dry mouth 4. Crackles in both lung fields 5. Oral temperature of 102.8° F 6. Requiring frequent linen changes ANSWER ANS: 1, 2, 3, […]
A client is angry about not being permitted to smoke and throws the breakfast tray at the nurse. What should the nurse do in response to this outburst? 1. Call the charge nurse and refuse to take care of this client until he is under control. 2. Apologize to the client for the unit rules, […]
