The nurse is reviewing collected data from a client. Which information should the nurse identify as a physiological barrier to defend the client’s body from microorganisms? 1. Heavy smoking 2. Moisturizing the skin 3. Breakdown of skin 4. Voiding quantity sufficient ANSWER Correct Answer: 4 Rationale 1: Heavy smoking does not defend the body […]
A client is admitted to the hospital after vomiting for 3 days. Which arterial blood gas results should the nurse expect to find in this client? 1. pH 7.30; PaCO2 50; HCO3 27 2. pH 7.47; PaCO2 43; HCO3 28 3. pH 7.43; PaCO2 50; HCO3 28 4. pH 7.47; PaCO2 30; HCO3 23 […]
A nurse shows an understanding of practices that are designed to provide legal protections regarding liability for client care when: 1. Checking the client’s name band prior to the administration of a preoperative medication. 2. Asking for help when moving a comatose client because the client can not be safely handled by one nurse. 3. […]
Regarding access to client records, the nursing faculty informs the nursing students to be pre-pared to: 1. Show the unit staff proper student identification 2. Sign a confidentiality agreement when on the unit to preplan 3. Review the medical record only in the presence of unit staff 4. Obtain permission from the client to access […]
In accordance with Erikson’s theory, it is expected by the nurse that a middle-aged adult client will be involved in the process of: 1. Developing a sense of identity 2. Searching for meaning in life 3. Enhancing one’s capability to love others 4. Expanding personal and social involvement ANSWER ANS: 4 In accordance with […]
The client was working in the kitchen and was splashed in the face with a caustic cleaning agent. His eyes were affected, and he was brought to the hospital for treatment. After cleansing and evaluation, his eyes were bandaged. When assisting this client, who has temporary visual loss, to eat the nurse should: 1. Feed […]
The nurse is attempting to ambulate a postoperative client who continues to rate his pain as a 7 on a scale of 0 to 10, with 10 being the most severe. The client is reluctant to walk and consents to move only to the chair, reporting that “it hurts too much to walk.” The nurse’s […]
Which of the following clients is at greatest risk for insensible water loss? 1. A 37-year-old with a superficial burn to the left hand 2. A 15-year-old experiencing an asthmatic attack 3. A 50-year-old with type 2 diabetes 4. A 73-year-old with a history of pneumonia ANSWER ANS: 2 Insensible water loss is continuous […]
The nurse is caring for the stoma of a client who has a colostomy. Which action is the most appropriate? 1. Apply pressure over the stoma. 2. Clean the stoma and pat dry. 3. Dilate the stoma. 4. Scrub the stoma. ANSWER Correct Answer: 2 Rationale 1: Applying pressure over the stoma may damage […]
The nurse, after completion of an assessment in the medical clinic of a client, the nurse docu-ments that the client has dyspareunia based on the client’s experience of: 1. Delay or absence of an orgasm 2. Deficient or absent sexual desire 3. Involuntary constriction of the vagina 4. Recurrent genital pain during intercourse ANSWER […]
