The nurse is assessing the peripheral vascular status of an older client. Which finding should the nurse consider as being normal for this client? 1. Easy to palpate upper extremity arteries 2. Easy to palpate lower extremity arteries 3. Reduction in the number of varicosities 4. Increase in diastolic blood pressure ANSWER Correct Answer: […]
The nurse is assessing the vital signs of a 5-year-old client. Should the nurse measure this child’s blood pressure? 1. Yes, blood pressure is measured for all children over the age of 3 years. 2. No, blood pressure measurements are not required until age 13. 3. Only if the child complains of headache or has […]
A client who has AIDS tells the nurse, “I don’t know why I should even keep trying. This disease is so horrible and so many people die from it. It will get me, too.” The nurse recognizes this statement as being 1. an indication of hopelessness that should be further evaluated for treatment. 2. a […]
A client’s laceration has been closed with tissue adhesive. What instruction should the nurse provide the client about wound healing? 1. Primary intention 2. Open approximation 3. Secondary healing 4. Delayed closure ANSWER Correct Answer: 1 Rationale 1: The nurse should instruct the client regarding primary intention wound healing. The edges of these wounds […]
A client with a history of sleep apnea has had a same-day surgery procedure that will require the administration of morphine postoperatively to manage pain. This client will be assessed most appropriately by the perioperative nurse for the risk for respira-tory complications by frequently: 1. Listening to breath sounds 2. Monitoring pulse oximetry 3. Evaluating […]
The plan of care offers a number of different types of nursing interventions that may be incorpo-rated in. An example of a nurse implemented specific life-saving measure is: 1. Administering analgesics 2. Restraining a violent client 3. Initiating stress-reduction therapy 4. Teaching the client how to take his/her pulse rate ANSWER ANS: 2 Restraining […]
A nursing student that immediately informs her clinical instructor after she realizes that she has administered the wrong dose of medication to a patient is best described professionally as: 1. Confident 2. Trustworthy 3. Compliant 4. Accountable ANSWER ANS: 4 Accountability refers to the ability to answer for one’s own actions. The goal is […]
A nurse is learning how to operate a new ventilator that the hospital is considering to purchase. Many of the functions available on the old model are also available on the new, and the setup is quite similar between the two machines. In this case, the nurse is utilizing a ___________ order of critical-thinking skill. […]
A client is hospitalized for treatment of a new disorder. While admitted, the client receives no telephone calls or visitors. The nurse should assess which aspect of the client’s sensory-perception function? 1. Risk for sensory overload 2. Social support network 3. Mental status 4. Environment ANSWER Correct Answer: 2 Rationale 1: The lack of […]
One of the benefits of anticipatory grieving to a client or family is that it can: 1. Be done in private 2. Be discussed with others 3. Promote separation of the ill client from the family 4. Help a person progress to a healthier emotional state ANSWER ANS: 4 The benefit of anticipatory grief […]
