The nurse has diagnosed the client’s problem as altered elimination. From the database the nurse identifies all the following as appropriate etiologies for this diagnosis except: 1. Poor fiber intake 2. Limited fluid intake 3. Total hip replacement 4. Lower abdominal discomfort ANSWER ANS: 3 Total hip replacement because the medical diagnosis requires medical […]
The nurse is removing personal protective equipment. Which nursing action demonstrates the appropriate technique for removing a mask? 1. Bend the strip at the top of the mask. 2. Loop the ties over the ears. 3. Tie the strings in a bow. 4. Touch the mask by the strings only. ANSWER Correct Answer: 4 […]
A client with a chest tube in place is being transported via stretcher to another room closer to the nurses’ station. During the transport the collection unit bangs against the wall and breaks open. The nurse immediately: 1. Clamps the tube 2. Tells the client to hyperventilate 3. Raises the tubing above the client’s chest […]
A condom catheter is to be used for an adult male client in the extended care facility. In the ap-plication of the condom catheter, the nurse employs appropriate technique when: 1. Using sterile gloves 2. Wrapping the adhesive tape securely around the base of the penis 3. Leaving a 1- to 2-inch space between the […]
To facilitate change within a community, the nurse working as an effective change agent should: 1. Inform community members how to effectively manage their health needs 2. Work with clients and groups to select alternative health care sites and treatments 3. Formulate decisions for individual clients regarding their health care options 4. Provide instruction in […]
An adolescent client with acne should be taught by the nurse to: 1. Apply moisturizing lotions or creams 2. Wash the face and hair daily with very warm water and soap 3. Use a depilatory to remove excess hair 4. Add moisture to the air with the use of a humidifier ANSWER ANS: 2 […]
Which of the following is the single most negative factor affecting a nurse’s credibility? 1. Deficient technical skills 2. Unethical or illegal behavior 3. Lack of caring and empathy 4. Poor nurse-client communication ANSWER ANS: 4 Breakdown in communication is a top contributor to errors in the workplace and threatens pro-fessional credibility. The remaining […]
Upon auscultation of the client’s abdomen, the nurse hears hyperactive bowel sounds (greater than 35 per minute). The nurse knows that this can indicate which of the following? 1. Paralytic ileus 2. Fecal impaction 3. Small intestine obstruction 4. Abdominal tumor ANSWER ANS: 3 Absent (no auscultated bowel sounds) or hypoactive sounds (less than […]
The nurse is admitting a client to the medical-surgical unit following a cholecystectomy. Which assessment should the nurse perform first? 1. Level of consciousness 2. Dressing 3. Drains 4. Skin color ANSWER Correct Answer: 1 Rationale 1: The nurse should assess the client’s level of consciousness first. Rationale 2: The operative dressing is not […]
Which of the following are factors that affect the blood’s capacity to carry sufficient oxygen to the various body organs? (Select all that apply.) 1. The size of the individual 2. The age of the individual 3. The gender of the individual 4. The amount of oxygen present in the blood 5. The amount of […]
