The nurse is preparing to complete a physical assessment before surgery. Which assessments should the nurse obtain? 1. Mini mental status 2. Assessment of hearing 3. Assessment of the respiratory system 4. Gastrointestinal assessment 5. Maintain NPO status ANSWER Correct Answer: 1, 2, 3, 4 Rationale 1: A brief or “mini” mental status examination […]
Case management is one strategy for coordinating health care services. What best describes this caregiving approach? 1. Continuity of care is the primary concern. 2. This focus of care may be more expensive. 3. The physician is the coordinator of client care. 4. It is designed to provide minimal to moderate levels of care. […]
A client is prescribed 3% sodium chloride, which is a hypertonic solution. The nurse recognizes the primary goal of such intravenous therapy is to: 1. Expand the volume of fluid in the vascular system 2. Pull fluid from the cells 3. Keep protein levels normal 4. Move fluid into the cells ANSWER ANS: 2 […]
The nurse knows that which of the following habits may interfere with a client’s sleep? 1. Listening to classical music 2. Finishing office work 3. Reading novels 4. Drinking warm milk ANSWER ANS: 2 At home a client should not try to finish office work or resolve family problems before bedtime. Noise should be […]
A nurse is caring for a client who has colonized methicillin-resistant Staphylococcus aureus (MRSA). Which of the following statements reflects the best understanding of the client’s con-dition? 1. “This client has the bacteria present but it hasn’t become infected.” 2. “This makes the client’s MRSA very infectious and so a danger to others.” 3. “Just […]
The client tells the nurse that she does not wish to see her mother-in-law during this hospitalization because she does not like her. When the client’s husband and her mother-in-law visit, the client is very cordial and acts happy to see both visitors. The nurse recognizes that this client may be using which defense mechanism? […]
Which of the following assessment findings is most representative of a stage II pressure ulcer? 1. A blister 2. Undermining 3. Nonblanchable redness 4. Visible subcutaneous fat ANSWER ANS: 1 Stage II ulcers have partial-thickness skin loss involving the epidermis, dermis, or both. The ulcer is superficial and presents clinically as an abrasion, blister, […]
When reviewing both the client’s problem list against the various identified nursing diagnoses, both of which included client and family input, the nurse is utilizing of the following processes to minimize diagnostic error? 1. Understanding what is normal vs. what is not normal 2. Verifying 3. Consulting resources 4. Basing diagnoses on patterns ANSWER […]
The nurse caring for a 38-year-old female client with multiple fractures in the trauma intensive care unit knows that this client is at high risk for pulmonary complications such as atelectasis from her immobility. One of the interventions that the nurse can do to help prevent this from occurring is to: 1. Keep the PaO2 […]
The nurse has determined that the assessment data have resulted in a strong inference that the client is suffering from depression. Which of the following client responses to nursing questions best supports the possibility of depression? (Select all that apply.) 1. “My work environment would depress anyone.” 2. “It seems like almost anything can make […]
