Care Management II: Exam 4 Questions With Complete
Solutions
A client admitted for pneumonia has been tachypneic for several
days. When the nurse starts an IV to give fluids, the client
questions this action, saying I have been drinking tons of water.
How am I dehydrated? What response by the nurse is next?
a. breathing so quickly can be dehydrating
b. everyone with pneumonia is dehydrated
c. this is really just to administer your antibiotics
d. why do you think you are so dehydrated? Correct Answers a.
breathing so quickly can be dehydrating
- tachypnea and mouth breathing, both seen in pneumonia,
increase insensible water loss and can lead to a degree of
dehydration
A client had a femoropopliteal bypass graft with a synthetic
graft. What action by the nurse is most important to prevent
wound infection?
a. appropriate hand hygiene before giving care
b. assessing the client's temperature every 4 hours
c. clean technique when changing dressings
d. monitoring the client's daily white blood cell count Correct
Answers a. appropriate hand hygiene before giving care
- hand hygiene best way to prevent infections in hospitalized
clients
,A client had a percutaneous transluminal coronary angioplasty
for peripheral material disease. What assessment finding by the
nurse indicates a priority outcome for this client has been met?
a. pain rated as 2/10 after medication
b. distal pulse on affected extremity 2+/4+
c. remains on bedrest as directed
d. verbalized understanding of procedure Correct Answers b.
distal pulse on affected extremity 2+/4+
- assessing circulation distal to the puncture sire is a critical
nursing action. a pulse of 2+/4+ indicates good perfusion
A client has a deep vein thrombosis (DVT). What comfort
measure does the nurse delegate to the unlicensed assistive
personnel (UAP)?
a. ambulate the client
b. apply a warm moist pack
c. massage the clients leg
d. provide an ice pack Correct Answers b. apply a warm moist
pack
- warm moist packs help with the pain of DVT
A client has a tracheostomy that is 3 days old. Upon assessment,
the nurse notes the client's face is puffy and the eyelids are
swollen. What action by the nurse takes priority?
a. assess the client's oxygen saturation
b. notify the rapid response team
c. oxygenate the client with a bag-valve-mask
d. palpate the skin of the upper chest Correct Answers a. assess
the client's oxygen saturation
,- think ABC (airway, breathing, circulation)
A client has a tracheostomy tube in place. When the nurse
suctions the client, food particles are noted. What action by the
nurse is best?
a. elevate the head of the client's bed
b. measure and compare cuff pressures
c. place the client on NPO status
d. request that the client have a swallow study Correct Answers
b. measure and compare cuff pressures
- constant pressure from the cuff can cause tracheomalacia,
leading to dilation of tracheal passage. can be manifested by
food particles seen in secretion.
A client has been admitted for suspected inhalation anthrax
infection. What question by the nurse is most important?
a. are any family members also ill?
b. have you traveled recently?
c. how long have you been ill?
d. what is your occupation? Correct Answers d. what is your
occupation?
- inhalation anthracites is rare and is an occasional hazard
among people who work with animal wool, bone meal, hides,
and skin, such as taxidermists and veterinarians. inhalation
anthrax in someone without an occupational risk is considered a
bioterrorism event and must be reported to the authorities
immediately
, A client has been bedridden for several days after major
abdominal surgery. What action does the nurse delegate to the
unlicensed assistive personnel (UAP) for DVT prevention?
(Select all that apply)
a. apply compression stockings
b. assist with ambulation
c. encourage coughing and deep breathing
d. offer fluids frequently
e. teach leg exercises Correct Answers a. apply compression
stockings
b. assist with ambulation
d. offer fluids frequently
A client has been diagnosed with a DVT and is to be discharged
on warfarin (Coumadin). The client is adamant about refusing
the drug because it's dangerous. What action by the nurse is
best?
a. assess the reason behind the client's fear
b. remind the client about laboratory monitoring
c. tell the client drugs are safer today than before
d. warn the client about consequences of noncompliance Correct
Answers a. assess the reason behind the client's fear
- may be related to an experience of someone the client knows.
teaching is unsuccessful is nurse cannot address a specific
rationale
A client has been diagnosed with an empyema. What
interventions should the nurse anticipate providing to this client?
(Select all that apply)
a. assisting with chest tube insertion
Solutions
A client admitted for pneumonia has been tachypneic for several
days. When the nurse starts an IV to give fluids, the client
questions this action, saying I have been drinking tons of water.
How am I dehydrated? What response by the nurse is next?
a. breathing so quickly can be dehydrating
b. everyone with pneumonia is dehydrated
c. this is really just to administer your antibiotics
d. why do you think you are so dehydrated? Correct Answers a.
breathing so quickly can be dehydrating
- tachypnea and mouth breathing, both seen in pneumonia,
increase insensible water loss and can lead to a degree of
dehydration
A client had a femoropopliteal bypass graft with a synthetic
graft. What action by the nurse is most important to prevent
wound infection?
a. appropriate hand hygiene before giving care
b. assessing the client's temperature every 4 hours
c. clean technique when changing dressings
d. monitoring the client's daily white blood cell count Correct
Answers a. appropriate hand hygiene before giving care
- hand hygiene best way to prevent infections in hospitalized
clients
,A client had a percutaneous transluminal coronary angioplasty
for peripheral material disease. What assessment finding by the
nurse indicates a priority outcome for this client has been met?
a. pain rated as 2/10 after medication
b. distal pulse on affected extremity 2+/4+
c. remains on bedrest as directed
d. verbalized understanding of procedure Correct Answers b.
distal pulse on affected extremity 2+/4+
- assessing circulation distal to the puncture sire is a critical
nursing action. a pulse of 2+/4+ indicates good perfusion
A client has a deep vein thrombosis (DVT). What comfort
measure does the nurse delegate to the unlicensed assistive
personnel (UAP)?
a. ambulate the client
b. apply a warm moist pack
c. massage the clients leg
d. provide an ice pack Correct Answers b. apply a warm moist
pack
- warm moist packs help with the pain of DVT
A client has a tracheostomy that is 3 days old. Upon assessment,
the nurse notes the client's face is puffy and the eyelids are
swollen. What action by the nurse takes priority?
a. assess the client's oxygen saturation
b. notify the rapid response team
c. oxygenate the client with a bag-valve-mask
d. palpate the skin of the upper chest Correct Answers a. assess
the client's oxygen saturation
,- think ABC (airway, breathing, circulation)
A client has a tracheostomy tube in place. When the nurse
suctions the client, food particles are noted. What action by the
nurse is best?
a. elevate the head of the client's bed
b. measure and compare cuff pressures
c. place the client on NPO status
d. request that the client have a swallow study Correct Answers
b. measure and compare cuff pressures
- constant pressure from the cuff can cause tracheomalacia,
leading to dilation of tracheal passage. can be manifested by
food particles seen in secretion.
A client has been admitted for suspected inhalation anthrax
infection. What question by the nurse is most important?
a. are any family members also ill?
b. have you traveled recently?
c. how long have you been ill?
d. what is your occupation? Correct Answers d. what is your
occupation?
- inhalation anthracites is rare and is an occasional hazard
among people who work with animal wool, bone meal, hides,
and skin, such as taxidermists and veterinarians. inhalation
anthrax in someone without an occupational risk is considered a
bioterrorism event and must be reported to the authorities
immediately
, A client has been bedridden for several days after major
abdominal surgery. What action does the nurse delegate to the
unlicensed assistive personnel (UAP) for DVT prevention?
(Select all that apply)
a. apply compression stockings
b. assist with ambulation
c. encourage coughing and deep breathing
d. offer fluids frequently
e. teach leg exercises Correct Answers a. apply compression
stockings
b. assist with ambulation
d. offer fluids frequently
A client has been diagnosed with a DVT and is to be discharged
on warfarin (Coumadin). The client is adamant about refusing
the drug because it's dangerous. What action by the nurse is
best?
a. assess the reason behind the client's fear
b. remind the client about laboratory monitoring
c. tell the client drugs are safer today than before
d. warn the client about consequences of noncompliance Correct
Answers a. assess the reason behind the client's fear
- may be related to an experience of someone the client knows.
teaching is unsuccessful is nurse cannot address a specific
rationale
A client has been diagnosed with an empyema. What
interventions should the nurse anticipate providing to this client?
(Select all that apply)
a. assisting with chest tube insertion
