A 61-year-old client with diabetes mellitus has physician’s orders for meticulous foot care. Which of the following is the best rationale for the order? 1. The aging process causes increased skin breakdown. 2. There is increased neuropathy with this pathology that places the client at risk. 3. The client probably has a history of poor […]
What should the nurse instruct a client for obtaining a clean voided urine specimen? 1. Collect at least 5 mL of urine. 2. Collect the first voided specimen in the morning. 3. Keep the specimen on ice. 4. Void in a sterile cup. ANSWER Correct Answer: 2 Rationale 1: At least 10 mL of […]
A client is receiving a continuous intravenous infusion. What should the nurse document in the medical record about this infusion? 1. Latest body temperature 2. Type of solution and flow rate 3. Total intravenous intake for the shift 4. Status of the intravenous catheter site 5. Results of blood pressure measurement ANSWER Correct Answer: […]
Within transcultural nursing, sensitivity to social organization is the recognition of the client’s: 1. Language usage 2. Status and expected role in the family 3. Definition of health and health practices 4. Psychological characteristics and coping mechanisms ANSWER ANS: 2 Cultural groups consist of units of social organization delineated by kinship, status hierarchy, and […]
The nurse is very busy and needs to delegate some tasks to the nursing assistive personnel (NAP). Which of the following would be the most appropriate task to delegate? 1. Postoperative client teaching 2. Demonstrating postoperative exercises 3. Transporting the preoperative client from the unit to the holding area 4. Reviewing the preoperative assessment to […]
A 76-year-old client has just been admitted to the nursing unit with terminal cancer of the liver. The nurse is assessing the client’s spiritual needs and responds best by saying: 1. “I notice you have a Bible; is that a source of spiritual strength to you?” 2. “What do you believe will happen to your […]
A home health client has multiple sclerosis. In the last 6 months, his condition has deteriorated significantly. The home health nurse is concerned about the possibility of the spouse experiencing caregiver role strain. Which of the following, if present, would the nurse expect to see or hear if this were the situation? 1. The home […]
While the nurse realizes that the definition of health is unique to the client, the most universal factor is that health is: 1. Dynamic and ever-changing 2. Affected and managed by the nurse 3. Determined by internal and external forces 4. Perceived and defined by the individual ANSWER ANS: 1 Health has different meanings […]
The nurse has completed the admission assessment for a client admitted to the hospital’s sub-acute care unit. Of the following nursing diagnoses identified by the nurse, the one that takes the highest priority is: 1. Social isolation 2. Risk for injury 3. Risk-prone health behavior 4. Impaired verbal communication ANSWER ANS: 2 Safety is […]
Which of the following clients is at greatest risk for developing a renal infection? 1. A 27-year-old male 2. A 16-year-old male 3. A 9-year-old female 4. A 45-year-old female ANSWER ANS: 3 The short length of the urethra predisposes women and girls to infection. It is easy for bacteria to enter the urethra […]
