108 EXAM 3 QUESTIONS AND ALL
CORRECT ANSWERS.
An oncology client has just returned from the post anesthesia care unit after an open
hemicolectomy. This client's plan of nursing care should prioritize which of the following? -
Answer Assess the client's wound for dehiscence every 4 hours.
A gerontologic nurse practitioner provides primary care for older adults who are living with
various forms of cardiovascular disease. This nurse is well aware that heart disease is the
leading cause of death in the aged. What is an age-related physiologic change that contributes
to this trend? - Answer Heart muscle and arteries lose their elasticity.
A nurse is planning care for a nephrology client with a new nursing graduate. The nurse states,
"A client in kidney disease partially loses the ability to regulate changes in pH." What is the
cause of this partial inability? - Answer The kidneys regenerate and reabsorb bicarbonate to
maintain a stable pH.
A client comes into the emergency department (ED) by ambulance after slipping on a small
carpet in his home. The client fell on his hip with a resultant fracture. He is alert and oriented;
his pupils are equal and reactive to light and accommodation. His heart rate is elevated, he is
anxious and thirsty, a Foley catheter is placed, and 40 mL of urine is present. What is the nurse's
most likely explanation for the low urine output? - Answer The man is having a sympathetic
reaction, which has stimulated the renin-angiotensin-aldosterone system that results in
diminished urine output.
The nurse is providing care for an 82-year-old man whose signs and symptoms of Parkinson
disease have worsened over the past several months. The man states that he can no longer do
as many things for himself as he used to be able to. What factor should the nurse recognize as
impacting the client's life most significantly? - Answer Loss of independence
The nurse is caring for a client with metastatic bone cancer. The client asks the nurse why he has
had to keep getting larger doses of his pain medication, although they do not seem to affect
him. What is the nurse's best response? - Answer "Over time you become more tolerant of
the drug."
An oncology client has begun to experience skin reactions to radiation therapy, prompting the
nurse to make the diagnosis Impaired Skin Integrity: erythematous reaction to radiation
therapy. What intervention best addresses this nursing diagnosis? - Answer Avoid rubbing or
scratching the affected area
An immunocompromised older adult has developed a urinary tract infection and the care team
recognizes the need to prevent an exacerbation of the client's infection that could result in
, urosepsis and septic shock. What action should the nurse perform to reduce the client's risk of
septic shock? - Answer Remove invasive devices as soon as they are no longer needed
An elderly female client who is bedridden is admitted to the unit because of a pressure ulcer
that can no longer be treated in a community setting. During assessment, the nurse finds that
the ulcer extends into the muscle and bone. At what stage should the nurse document this
ulcer? - Answer IV
An elderly client has come in to the clinic for her twice-yearly physical. The client tells the nurse
that she is generally enjoying good health, but that she has been having occasional episodes of
constipation over the past 6 months. What intervention should the nurse first suggest? - Answer
Increase daily intake of water.
An oncology nurse is contributing to the care of a client who has failed to respond appreciably
to conventional cancer treatments. As a result, the care team is considering the possible use of
biologic response modifiers (BRMs). The nurse should know that these achieve a therapeutic
effect by what means? - Answer Altering the immunologic relationship between the tumor
and the client
The nurse is caring for a female client who developed a pressure ulcer as a result of decreased
mobility. The nurse on the previous shift has provided client teaching about pressure ulcers and
healing promotion. The nurse determines that the client has understood the teaching by
observing the client: - Answer avoid placing her body weight on the healing site.
The mother of a client with cancer comes to the nurse concerned with her daughter's safety.
She states that the dose of morphine that her daughter requires to control her pain is getting
"higher and higher." As a result, the mother is afraid that her daughter will overdose. The nurse
should educate the mother about what aspect of her pain management? - Answer There is
no absolute maximum opioid dose and her daughter is becoming more tolerant to the drug.
The critical care nurse is preparing to initiate an infusion of a vasoactive medication to a client in
shock. What goal of this treatment should the nurse identify? - Answer Maintenance of
adequate mean arterial pressure
The community health nurse is performing a home visit to an older client recovering from hip
surgery. The nurse notes that the client seems uncharacteristically confused and has dry
mucous membranes. When asked about fluid intake, the client states, "I stop drinking water
early in the day because it is just too difficult to get up during the night to go to the bathroom."
What would be the nurse's best response? - Answer "Limiting your fluids can create
imbalances that can result in confusion. Maybe we need to adjust the timing of your fluids."
CORRECT ANSWERS.
An oncology client has just returned from the post anesthesia care unit after an open
hemicolectomy. This client's plan of nursing care should prioritize which of the following? -
Answer Assess the client's wound for dehiscence every 4 hours.
A gerontologic nurse practitioner provides primary care for older adults who are living with
various forms of cardiovascular disease. This nurse is well aware that heart disease is the
leading cause of death in the aged. What is an age-related physiologic change that contributes
to this trend? - Answer Heart muscle and arteries lose their elasticity.
A nurse is planning care for a nephrology client with a new nursing graduate. The nurse states,
"A client in kidney disease partially loses the ability to regulate changes in pH." What is the
cause of this partial inability? - Answer The kidneys regenerate and reabsorb bicarbonate to
maintain a stable pH.
A client comes into the emergency department (ED) by ambulance after slipping on a small
carpet in his home. The client fell on his hip with a resultant fracture. He is alert and oriented;
his pupils are equal and reactive to light and accommodation. His heart rate is elevated, he is
anxious and thirsty, a Foley catheter is placed, and 40 mL of urine is present. What is the nurse's
most likely explanation for the low urine output? - Answer The man is having a sympathetic
reaction, which has stimulated the renin-angiotensin-aldosterone system that results in
diminished urine output.
The nurse is providing care for an 82-year-old man whose signs and symptoms of Parkinson
disease have worsened over the past several months. The man states that he can no longer do
as many things for himself as he used to be able to. What factor should the nurse recognize as
impacting the client's life most significantly? - Answer Loss of independence
The nurse is caring for a client with metastatic bone cancer. The client asks the nurse why he has
had to keep getting larger doses of his pain medication, although they do not seem to affect
him. What is the nurse's best response? - Answer "Over time you become more tolerant of
the drug."
An oncology client has begun to experience skin reactions to radiation therapy, prompting the
nurse to make the diagnosis Impaired Skin Integrity: erythematous reaction to radiation
therapy. What intervention best addresses this nursing diagnosis? - Answer Avoid rubbing or
scratching the affected area
An immunocompromised older adult has developed a urinary tract infection and the care team
recognizes the need to prevent an exacerbation of the client's infection that could result in
, urosepsis and septic shock. What action should the nurse perform to reduce the client's risk of
septic shock? - Answer Remove invasive devices as soon as they are no longer needed
An elderly female client who is bedridden is admitted to the unit because of a pressure ulcer
that can no longer be treated in a community setting. During assessment, the nurse finds that
the ulcer extends into the muscle and bone. At what stage should the nurse document this
ulcer? - Answer IV
An elderly client has come in to the clinic for her twice-yearly physical. The client tells the nurse
that she is generally enjoying good health, but that she has been having occasional episodes of
constipation over the past 6 months. What intervention should the nurse first suggest? - Answer
Increase daily intake of water.
An oncology nurse is contributing to the care of a client who has failed to respond appreciably
to conventional cancer treatments. As a result, the care team is considering the possible use of
biologic response modifiers (BRMs). The nurse should know that these achieve a therapeutic
effect by what means? - Answer Altering the immunologic relationship between the tumor
and the client
The nurse is caring for a female client who developed a pressure ulcer as a result of decreased
mobility. The nurse on the previous shift has provided client teaching about pressure ulcers and
healing promotion. The nurse determines that the client has understood the teaching by
observing the client: - Answer avoid placing her body weight on the healing site.
The mother of a client with cancer comes to the nurse concerned with her daughter's safety.
She states that the dose of morphine that her daughter requires to control her pain is getting
"higher and higher." As a result, the mother is afraid that her daughter will overdose. The nurse
should educate the mother about what aspect of her pain management? - Answer There is
no absolute maximum opioid dose and her daughter is becoming more tolerant to the drug.
The critical care nurse is preparing to initiate an infusion of a vasoactive medication to a client in
shock. What goal of this treatment should the nurse identify? - Answer Maintenance of
adequate mean arterial pressure
The community health nurse is performing a home visit to an older client recovering from hip
surgery. The nurse notes that the client seems uncharacteristically confused and has dry
mucous membranes. When asked about fluid intake, the client states, "I stop drinking water
early in the day because it is just too difficult to get up during the night to go to the bathroom."
What would be the nurse's best response? - Answer "Limiting your fluids can create
imbalances that can result in confusion. Maybe we need to adjust the timing of your fluids."
