And Correct Answers With Complete Verified Solution.
A nurse is teaching a client about carbon monoxide poisoning. Which of the
following statements should the nurse identify as an indication that the client
needs further instruction?
- "A high concentration of carbon monoxide can cause death."
- "I can detect the presence of carbon monoxide by a metallic odor."
- "I should purchase a carbon monoxide detector for my home."
- "Breathing in carbon monoxide can cause headaches and nausea."
"I can detect the presence of carbon monoxide by a metallic odor."
A nurse is assessing a client who had left femoral cardiac angiography. Identify
where the nurse will palpate to assess the most distal pulse on the affected side.
(Selectable areas, or "Hot Spots," are outlines in the artwork below. Select only
the outlined area that corresponds to your answer.)
Left pedal pulse:
The most distal pulse refers to the pulse that is at the farthest point on the affected
extremity. The dorsalis pedis pulse on the anterior foot is the most distal pulse below
the femoral artery. Because the client had left-sided angiography, the correct answer
will be the left pedal pulse.
A rehabilitation nurse is caring for a client who has had a spinal cord injury that
resulted in paraplegia. After a week on the unit, the nurse notes that the client is
withdrawn and increasingly resistant to rehabilitative efforts by the staff. Which
of the following actions should the nurse take?
- Inform the client that privileges are related to participation in therapy.
- Limit visiting hours until the client begins to participate in therapy.
- Allow the client to control the timing and frequency of the therapy.
- Establish a plan of care with the client that sets attainable goals.
Establish a plan of care with the client that sets attainable goals.
A nurse is monitoring a client who was admitted with a severe burn injury and is
receiving IV fluid resuscitation therapy. The nurse should identify a decrease in
which of the which of the following findings as an indication of adequate fluid
replacement?
- BP
- Heart rate
- Urine output
- Weight
Heart rate
A nurse is caring for a client who has urinary incontinence. Which of the
following actions should the nurse implement to prevent the development of skin
breakdown?
- Apply a moisture barrier ointment to the client's skin.
- Clean the client's skin and perineum with hot water after each episode of
incontinence.
, - Check the client's skin every 8 hr for signs of breakdown.
- Request a prescription for the insertion of an indwelling urinary catheter.
Apply a moisture barrier ointment to the client's skin.
A nurse is teaching a class of older adults about the expected physiologic
changes of aging. Which of the following changes should the nurse include in the
discussion? (Select all that apply.)
- More difficulty seeing due to a greater sensitivity to glare
- Decreased cough reflex
- Decreased bladder capacity
- Decreased systolic blood pressure
- Dehydration of intervertebral discs
More difficulty due to a greater sensitivity to glare,
Decreased cough reflex,
Decreased bladder capacity,
Dehydration of intervertebral discs is correct
A nurse is assessing a client who is 2 days postoperative and auscultates
bilateral breath sounds, but absent breath sounds in the bases. The nurse should
suspect which of the following postoperative complications?
- Atelectasis
- Pneumonia
- Pulmonary embolism
- Arterial thrombus
Atelectasis
Atelectasis is an incomplete alveolar expansion or collapse. Breath sounds are dull or
absent over areas of alveolar collapse.
A nurse is working with a team of nursing personnel within a facility. Which of the
following are necessary task performance roles that members of the group or the
leader must perform? (Select all that apply.)
- Self-confessor
- Coordinator
- Evaluator
- Energizer
- Dominator
Coordinator,
Evaluator,
Energizer
A nurse is reviewing the EKG strip of a client who has prolonged vomiting. Which
of the following abnormalities on the client's EKG should the nurse interpret as a
sign of hypokalemia?
- Abnormally prominent U wave
- Elevated ST segment
- Wide QRS
- Inverted P wave
Abnormally prominent U wave