A 92-year-old client is scheduled for a colectomy. Which normal physiological change that ac-companies the aging process increases this client’s risk for surgery? 1. An increased tactile sensation 2. An increased metabolic rate 3. A relaxation of arterial walls 4. Reduced glomerular filtration rate ANSWER ANS: 4 An older adult is likely to have […]
Which of the following responses best reflects an understanding of the purpose of the “related to” phrase attached to the diagnostic label deficient knowledge regarding postoperative routines? 1. “To focus on the cause of the client’s needs” 2. “To identify the etiology of the client’s diagnosis” 3. “To provide for individualization of the nursing interventions” […]
The nurse is assessing a client’s pressure ulcer. To determine the depth of the ulcer, the nurse should take which action? 1. Measure the width. 2. Measure the length. 3. Insert a sterile swab into the deepest part of the wound. 4. Identify where on the face of a clock the ulcer is located. […]
The nurse attempting to use Thompson’s model of ethical decision making will address an ethical problem by implementing the following steps in what order? 1. Interviewing the client regarding details of the problem. 2. Discussing the various results of the identified possible actions to resolve the problem. 3. Determining what, if any, ethical issues exist. […]
Home health nurses experience a variety of challenges in caring for their clients. Unlike the acute care setting, entry into the home is ___________. Fill in the blank with the appropriate word. ANSWER Correct Answer: granted, not assumed Rationale : The home is the family’s territory, and issues in delivering care differ from those […]
Which of the following is likely to result in damage to the client’s skin? (Select all that apply.) 1. Dry shaving a client in preparation for discharge 2. Removing the tape when discontinuing a heparin lock 3. Frequently positioning the client on her favorite right side 4. Applying moisturizing lotion on the heels of a […]
A contractual agreement between a hospital and a corporation to pay the health care expenses of the corporation’s employees is an example of a(n): 1. PPO 2. HMO 3. Private insurance 4. Third-party payment ANSWER ANS: 1 A preferred provider organization (PPO) is characterized by a contractual agreement between a set of providers (e.g., […]
The client is assessed by the nurse as having a high risk for aspiration. The nursing diagnosis identified for the client is feeding self-care deficit related to unilateral weakness. An appropriate technique for the nurse to use when assisting the client with feeding is to: 1. Place food in the unaffected side of the mouth […]
When asked to define the purpose of diagnostic reasoning, the best nursing response is: 1. “Diagnostic reasoning is the foundation of the second step of the nursing process; Nursing Diagnosis.” 2. “The diagnostic reasoning process flows from the assessment process and includes decision-making steps.” 3. “Diagnostic reasoning includes data clustering, identifying client needs and for-mulating […]
A client has received an oil retention enema. The nurse should instruct the client that the enema will take effect within 1. 1 to 3 hours. 2. 10 to 20 minutes. 3. 5 to 10 minutes. 4. 10 to 15 minutes. ANSWER Correct Answer: 1 Rationale 1: Oil retention enemas take effect within 1 […]
