A client tells the nurse about passing out after following a fasting diet for 5 days. Which acid–base imbalance should the nurse expect to assess in this client? 1. Respiratory acidosis 2. Respiratory alkalosis 3. Metabolic acidosis 4. Metabolic alkalosis ANSWER Correct Answer: 3 Rationale 1: Starvation would not result in respiratory acidosis. Rationale […]
A client who is ambulatory is able to get out of bed for morning care. What should the nurse assess before assisting the client out of the bed to change the linen? 1. Pulse 2. Respirations 3. Urine output 4. Blood pressure 5. Mobility status ANSWER Correct Answer: 1, 2, 4, 5 Rationale 1: […]
A nurse and client are engaged in imagery training. The nurse shows the best understanding of the importance of selecting an appropriate focus when stating: 1. “Let’s discuss how to select today’s focus.” 2. “Today’s focus will be auditory rather than visual.” 3. “What do you find to be most effective as your focus?” 4. […]
Upon assessment, the nurse notes that a client has dyspnea, crackles in both lung bases, and tires easily upon exertion. Which nursing diagnosis is best supported by these assessment details? 1. Ineffective Breathing Pattern 2. Anxiety 3. Ineffective Airway Clearance 4. Impaired Gas Exchange ANSWER Correct Answer: 3 Rationale 1: There are no data […]
Which statement made by an older adult would reflect the best understanding of the nutritional guidelines for this age-group? 1. “I can prepare grilled chicken at least 10 different, delicious ways.” 2. “When I entertain, I serve healthy foods like veggies and low-fat dip.” 3. “I know I need to eat nutritiously, and I have […]
Nursing documentation should fulfill which of the following criteria? (Select all that apply.) 1. Accurate 2. Inclusive 3. Well organized 4. Show continuity of care 5. Record nursing opinion 5. Record nursing opinion 6. Identify client outcomes ANSWER ANS: 1, 2, 3, 4, 6 Nursing documentation must be accurate, comprehensive, and flexible enough to […]
The faculty member is reviewing a process recording with the student nurse. The student has been working with a client who has had an amputation of the lower left leg and is emotionally fragile. The student receives positive feedback from the faculty member for the following response made to the client: 1. “Why are you […]
Research currently identifies which of the following as the primary reason nurses do not use complementary therapies? 1. Workloads prevent routine implementation 2. Client reluctance to participate appropriately 3. General bias regarding effects of the therapies 4. Lack of education regarding their appropriate uses ANSWER ANS: 4 Nurses’ lack of education about how to […]
The nurse should realize that the most important aspect of knowing the client involves: 1. Establishing a relationship 2. Gathering assessment data 3. Treating discomforts quickly 4. Assuming the client’s emotional needs ANSWER ANS: 1 Nurses must focus on building a relationship that allows them to learn what is important to their clients. Gathering […]
A client hospitalized for a myocardial infarction in a cardiac critical care unit (CCU) is most like-ly to experience sleep deprivation as a result of: 1. A drug-disrupted circadian sleep pattern 2. Generally diminished cardiac output 3. Unfamiliar environmental stimuli 4. Increased emotional stressors ANSWER ANS: 3 Hospitalization, especially in intensive care units, makes […]
