The nurse is using a manual cuff to assess the blood pressure of a client experiencing hyperten-sion. To best ensure accommodation for a possible auscultatory gap, the nurse should use which of the following as a guide for inflating the cuff appropriately? 1. Review the client’s chart for his last blood pressure reading. 2. Ask […]
The nurse plans to apply a theory that focused on stress reduction. A theory proposed by which one of the following individuals should be selected? 1. Parse 2. Peplau 3. Neuman 4. Orlando ANSWER ANS: 3 Stress reduction is the goal of the systems model of nursing practice according to Neuman’s the-ory. Parse’s theory […]
Which of the following situations is the best example of a nurse using intellectual standards as a critical thinking tool? 1. Performing a head-to-toe assessment on a new admission 2. Placing a client experiencing shortness of breath on oxygen 3. Arbitrating a complaint between roommates over the television 4. Notifying a provider of a client’s […]
The nurse is providing ancillary personnel with instructions regarding the performance of passive range-of-motion (ROM) exercises for a client experiencing paralysis from the waist down (para-plegia) as a result of an automobile accident. Which of the following statements made by the ancillary personnel reflects the greatest insight regarding the frequency with which the intervention should […]
The nurse is caring for a 73-year-old female client who is 3 days postoperative for a bowel ob-struction. The nurse knows that the stress response of surgery causes fluid-balance changes in the second to fifth postoperative day, when aldosterone, glucocorticoids, and antidiuretic hormone (ADH) are increasingly secreted, causing sodium and chloride retention and potassium excretion. […]
The nurse is working with a client who has recently had a colostomy and is having difficulty us-ing the provided supplies. The nurse works with the client to see which alternative supplies are easier for the client to use. This is an example of the critical thinking strategy of: 1. Inference 2. Management 3. Problem-solving […]
A client has not had uninterrupted sleep for several nights, and is irritable. What other assessment findings should the nurse associate with the client’s lack of REM sleep? 1. Depression 2. Confusion 3. Disorientation 4. Impaired memory 5. Muscle weakness ANSWER Correct Answer: 1, 2, 3, 4 Rationale 1: In a sleep-deprived client, the […]
The nurse decides to administer tablets of Tylenol instead of the intramuscular Demerol she has previously been providing her orthopedic client. Which step of the nursing process does this ad-dress? 1. Assessment 2. Nursing diagnosis 3. Planning 4. Implementation ANSWER ANS: 4 Taking appropriate action demonstrates the implementation step of the nursing process. Assess-ment […]
While the nurse is taking the client’s blood pressure, the client asks if the reading is high. In ac-cordance with the newest guidelines, the nurse informs the client that a blood pressure measure-ment that is consistent with hypertension is: 1. 120/70 mm Hg 2. 130/84 mm Hg 3. 120/78 mm Hg 4. 118/80 mm Hg […]
The nurse is completing a physical examination for a client who is anemic. In assessing the cli-ent’s eyes, a sign assessed by the nurse that is consistent with the diagnosis is: 1. Xanthelasma 2. Petechiae 3. Corneal arcus 4. Pale conjunctiva ANSWER ANS: 4 Pale conjunctiva is an assessment finding consistent with the diagnosis […]
