The nurse realizes that which of the following stated client needs has the highest priority? 1. A client’s reaction to facial scarring after an automobile accident 2. A client who is crying hysterically upon hearing of her son’s death 3. A homeless client’s fear that his belongings will be stolen while he is hospitalized 4. […]
Which of the following statements best reflects a goal based on a clinical standard of practice? 1. Client will lose 10 pounds in 90 days. 2. Client will walk 30 feet with minimal assistance. 3. Client’s peripheral intravenous site will be free of redness. 4. Client’s chronic pain will be managed with oral medication by […]
The nurse is completing the preoperative checklist for an adult client who is scheduled for an op-erative procedure later in the morning. Which of the following preoperative assessment findings for this client indicates a need to con-tact the anesthesiologist? 1. Temperature is 100° F. 2. Pulse is 90 beats per minute. 3. Respiratory rate is […]
While assessing an older Vietnamese client, the nurse notes several oval-shaped reddened areas on her back and arms. The client’s daughter explains them to be the result of a traditional healing practice called “cupping.” The nurse’s immediate reaction should be to: 1. Report the finding to the authorities to rule out physical abuse 2. Ask […]
The nurse is caring for the family of a terminally ill client. The family members have been tearful and sad since the diagnosis was given. What is the best nursing diagnosis problem statement for this family? 1. Anticipatory Grieving 2. Dysfunctional Grieving 3. Hopelessness 4. Caregiver Role Strain ANSWER Correct Answer: 1 Rationale 1: […]
The ANA’s proposal for entry level for professional practice initiated debate among nurses. Which of the following would be most at risk if the ANA proposal were implemented? 1. An RN with an associate degree who has a head nurse position 2. An RN with a BSN who is a staff nurse 3. An RN […]
A spouse assists the nurse evaluating the measurement of the client’s blood pressure. The nurse feels additional teaching is required if the spouse is observed: 1. Deflating the cuff at 2 mm Hg/second 2. Having the client sit down for the measurement 3. Using the same time each day for the measurement 4. Taking the […]
Which of the following fits within the occupational safety and health categories? 1. Noise exposure 2. Firearms’ safety 3. Swimming lessons 4. Motorcycle helmets ANSWER ANS: 1 Exposure to environmental hazards within the workplace, such as noise exposure, is one aspect of occupational safety and health. Firearms do not fit within the occupational safety […]
A client experiencing respiratory alkalosis as a result of asthma is likely to present with which of the following clinical signs? (Select all that apply.) 1. A respiratory rate of 36 breaths per minute 2. Complaints of numbness in fingers and toes 3. Dizziness when attempting to sit upright 4. Difficulty holding a cup because […]
A client tells the nurse that bathing is done at the sink in the bathroom at home because it is difficult to physically lift the legs to get into the shower. The nurse identifies which factor as influencing this client’s hygienic practice? 1. Religion 2. Personal preference 3. Culture 4. Health and energy ANSWER […]
