NUR 1140
A nurse is caring for a client who is acidotic. The nurse asks the charge nurse why the client is
breathing rapidly. What response by
The charge nurse is best?
a. Anxiety is causing the client to breathe rapidly.
b. The client is trying to get rid of excess body acids.
c. The rapid respirations cause buildup of bicarbonate.
d. An increased respiratory rate is due to increased metabolism. - ANS ANS: B
The client is acidotic, and the respiratory system is attempting to compensate by "blowing off"
excess acid in the form of carbon
dioxide. The increased respiratory rate is not due to anxiety or increased metabolism. An
increased respiratory rate does not cause a
buildup of bicarbonate.
A client had a recent thromboembolism and must resume work which requires frequent car and
plane travel. What self-care
measure does the nurse teach to reduce the risk of impaired clotting in this client?
a. Get up and walk around at least every 2 hours while traveling.
b. Use a soft toothbrush and an electric razor for safety.
c. Be sure to sit with the legs elevated as much as possible.
d. Increase fiber in the diet so as not to strain to move the bowels. - ANS ANS: A
Clients who are at risk of increased clotting (as evidenced by prior thromboembolic event) can
take several measures to reduce their risk of further problems. One measure is to get up and
walk frequently when sitting for a long period of time. Using a soft toothbrush and an electric
razor and needing to prevent constipation would be important for a client at risk of bleeding.
Elevating the legs is not as beneficial as ambulating.
A nurse is caring for four clients. Which client does the nurse assess first for impaired cognition?
a. A 28-year-old client 2 days post-open cholecystectomy
b. An 88-year-old client 3 days post-hemorrhagic stroke
c. A 32-year-old client with a 20-pack-year history of smoking
d. A 42-year-old client with a serum sodium of 134 mEq/L (134 mmol/L) - ANS ANS: B
,There are many risk factors for impaired cognition including advanced age and diseases and
disorders that affect the brain. The
88-year-old client who is recovering from a stroke has two such risk factors and is at highest risk
for impaired cognition. The nurse
assesses this client first. The other clients have a much lower risk of developing impaired
cognition.
The assistive personnel (AP) reports to the registered nurse that a postoperative client has a
pulse of 132 beats/min and a blood
pressure of 168/90 mm Hg. What response by the nurse is most appropriate?
a. Ask the AP to repeat the client's vital signs in 15 minutes.
b. Assess the client for pain.
c. Ask the client if something is bothersome.
d. Instruct the AP to reposition the client - ANS ANS: B
The "fight-or-flight" syndrome can occur from sympathetic nervous stimulation due to acute pain.
Symptoms can include nausea, vomiting, diaphoresis, tachycardia, tachypnea, hypertension,
and dilated pupils. Since this client is postoperative, it is reasonable to believe that he or she
might be in pain. The nurse first assesses for pain or discomfort and treats it. If the client is not
in pain, the nurse would conduct further assessments to determine the cause of the abnormal
vital signs.
A client has urinary incontinence. Which assessment finding indicates that outcomes for a
priority nursing diagnosis have been
met?
a. Client reports satisfaction with undergarments for incontinence.
b. Client reports drinking 8 to 9 glasses of water each day.
c. Skin in perineal area is intact without redness on inspection.
d. Family states that client is more active and socializes more. - ANS ANS: C
Urinary incontinence can lead to skin breakdown and possibility of infection. Skin that is intact
without redness shows that a major goal for this client has been met. Becoming more social is a
positive finding as many adults with incontinence limit their social activities, but this psychosocial
outcome is not the priority over a physical outcome. Being satisfied with undergarments is also
not the priority. Drinking adequate water can sometimes help with incontinence and is important
for general health, but is not directly related to an important goal for this client.
The registered nurse asks the nursing assistant why a cardiac client's morning weight has not
yet been done. The nursing assistant
says, "I'll get to it, what's the big deal?" When deciding how to respond, the nurse considers
what information about weight?
,a. Decisions on treatment often depend on the daily weight.
b. The nursing assistant needs to ensure that tasks are done on time.
c. Weight is the most accurate noninvasive indicator of fluid status.
d. A change in weight may indicate the need to change IV fluids. - ANS ANS: C
Weight is the best (noninvasive) indicator of fluid status. Primary health care providers may
base treatment decisions on weight, because the weight reflects fluid balance, but this answer
does not explain why. IV fluid rates or solutions may change for the same reason. The nursing
assistant would perform tasks on a timely basis, but this is not related to information about
weight.
The nurse in the emergency department (ED) is caring for four clients. Which client does the
nurse assess for gas exchange
abnormalities first?
a. Involved in motor vehicle crash, has broken femur.
b. Brought in unconscious by roommate after opioid overdose.
c. Asthmatic client being discharged after bronchodilator therapy.
d. History of COPD, presents to ED after being bitten by a dog. - ANS ANS: B
Opioid medications can cause respiratory depression, so this client is most at risk for gas
exchange problems. Diminished respirations will allow a buildup of carbon dioxide in the blood.
The clients with asthma and COPD have the potential for gas exchange problems but this is not
indicated in answer option as he or she is being discharged. The client with a broken femur
does
not have information suggesting gas exchange problems.
The nurse caring for a client with malnutrition assesses which laboratory value as the priority?
a. Albumin
b. Prealbumin
c. Prothrombin time
d. Serum sodium - ANS ANS: B
Both albumin and prealbumin are indicators for nutrition. However, prealbumin changes more
rapidly with decreased nutrition, so it is the better test. Prothrombin time and serum sodium are
not directly related to nutritional status.
A nurse is planning primary prevention measures for community-dwelling adults to prevent
visual impairment. What action by the
nurse will best meet this objective?
a. Provide glaucoma screening.
b. Assess visual acuity.
, c. Teach clients about instilling eyedrops.
d. Offer a healthy lifestyle class. - ANS ANS: D
Primary prevention activities are those designed to actually prevent the onset of a disease or
health problem. Secondary prevention focuses on screening and early diagnosis/detection.
Tertiary measures are those that offer treatment and rehabilitation. Encouraging a healthy
lifestyle through classes may help prevent diabetes, a common cause of visual impairment, and
is a primary prevention
measure. Assessing for glaucoma and visual acuity is a secondary prevention measure.
Teaching clients how to instill eyedrops is tertiary.
The nurse tells the staff development nurse he/she is very uncomfortable discussing sexuality
with clients, especially those who are older. What suggestion by the staff development nurse is
most appropriate?
a. "Find a trusted friend and role play."
b. "Don't worry it will get easier."
c. "A sexual assessment is usually not needed."
d. "It's hard for me to do, too." - ANS ANS: A
Discussing sexuality and sex is difficult for most people. Since it is important to be able to
assess this aspect of people's lives, the nurse needs to become comfortable. Role-playing with
a trusted friend will build confidence and comfort. Saying that it will get
easier and that it is hard for the staff development nurse too does not give the nurse any ideas
for improvement. Sexuality is important to assess.
A nurse is planning a community education event-related to impaired cellular regulation. What
teaching topics would the nurse
include in this event? (Select all that apply.)
a. Ways to minimize exposure to sunlight
b. Resources available for smoking cessation
c. Strategies to remain hydrated during hot weather
d. Use of indoor tanning beds instead of sunbathing
e. Creative cooking techniques to increase dietary fiber
f. How to determine sodium content in food? - ANS ANS: A, B, E
Disrupted cellular regulation can lead to both benign and malignant tumors (cancer). Ways to
minimize the risk of developing cancer include decreasing exposure to sunlight, smoking
cessation, and increasing dietary fiber. Tanning beds do not reduce the risk of cancer as
opposed to sunbathing. While staying hydrated is a good health measure, it is not related to
cellular regulation. Maintaining a normal intake of sodium is also not related to cellular
regulation.
A nurse is caring for a client who is acidotic. The nurse asks the charge nurse why the client is
breathing rapidly. What response by
The charge nurse is best?
a. Anxiety is causing the client to breathe rapidly.
b. The client is trying to get rid of excess body acids.
c. The rapid respirations cause buildup of bicarbonate.
d. An increased respiratory rate is due to increased metabolism. - ANS ANS: B
The client is acidotic, and the respiratory system is attempting to compensate by "blowing off"
excess acid in the form of carbon
dioxide. The increased respiratory rate is not due to anxiety or increased metabolism. An
increased respiratory rate does not cause a
buildup of bicarbonate.
A client had a recent thromboembolism and must resume work which requires frequent car and
plane travel. What self-care
measure does the nurse teach to reduce the risk of impaired clotting in this client?
a. Get up and walk around at least every 2 hours while traveling.
b. Use a soft toothbrush and an electric razor for safety.
c. Be sure to sit with the legs elevated as much as possible.
d. Increase fiber in the diet so as not to strain to move the bowels. - ANS ANS: A
Clients who are at risk of increased clotting (as evidenced by prior thromboembolic event) can
take several measures to reduce their risk of further problems. One measure is to get up and
walk frequently when sitting for a long period of time. Using a soft toothbrush and an electric
razor and needing to prevent constipation would be important for a client at risk of bleeding.
Elevating the legs is not as beneficial as ambulating.
A nurse is caring for four clients. Which client does the nurse assess first for impaired cognition?
a. A 28-year-old client 2 days post-open cholecystectomy
b. An 88-year-old client 3 days post-hemorrhagic stroke
c. A 32-year-old client with a 20-pack-year history of smoking
d. A 42-year-old client with a serum sodium of 134 mEq/L (134 mmol/L) - ANS ANS: B
,There are many risk factors for impaired cognition including advanced age and diseases and
disorders that affect the brain. The
88-year-old client who is recovering from a stroke has two such risk factors and is at highest risk
for impaired cognition. The nurse
assesses this client first. The other clients have a much lower risk of developing impaired
cognition.
The assistive personnel (AP) reports to the registered nurse that a postoperative client has a
pulse of 132 beats/min and a blood
pressure of 168/90 mm Hg. What response by the nurse is most appropriate?
a. Ask the AP to repeat the client's vital signs in 15 minutes.
b. Assess the client for pain.
c. Ask the client if something is bothersome.
d. Instruct the AP to reposition the client - ANS ANS: B
The "fight-or-flight" syndrome can occur from sympathetic nervous stimulation due to acute pain.
Symptoms can include nausea, vomiting, diaphoresis, tachycardia, tachypnea, hypertension,
and dilated pupils. Since this client is postoperative, it is reasonable to believe that he or she
might be in pain. The nurse first assesses for pain or discomfort and treats it. If the client is not
in pain, the nurse would conduct further assessments to determine the cause of the abnormal
vital signs.
A client has urinary incontinence. Which assessment finding indicates that outcomes for a
priority nursing diagnosis have been
met?
a. Client reports satisfaction with undergarments for incontinence.
b. Client reports drinking 8 to 9 glasses of water each day.
c. Skin in perineal area is intact without redness on inspection.
d. Family states that client is more active and socializes more. - ANS ANS: C
Urinary incontinence can lead to skin breakdown and possibility of infection. Skin that is intact
without redness shows that a major goal for this client has been met. Becoming more social is a
positive finding as many adults with incontinence limit their social activities, but this psychosocial
outcome is not the priority over a physical outcome. Being satisfied with undergarments is also
not the priority. Drinking adequate water can sometimes help with incontinence and is important
for general health, but is not directly related to an important goal for this client.
The registered nurse asks the nursing assistant why a cardiac client's morning weight has not
yet been done. The nursing assistant
says, "I'll get to it, what's the big deal?" When deciding how to respond, the nurse considers
what information about weight?
,a. Decisions on treatment often depend on the daily weight.
b. The nursing assistant needs to ensure that tasks are done on time.
c. Weight is the most accurate noninvasive indicator of fluid status.
d. A change in weight may indicate the need to change IV fluids. - ANS ANS: C
Weight is the best (noninvasive) indicator of fluid status. Primary health care providers may
base treatment decisions on weight, because the weight reflects fluid balance, but this answer
does not explain why. IV fluid rates or solutions may change for the same reason. The nursing
assistant would perform tasks on a timely basis, but this is not related to information about
weight.
The nurse in the emergency department (ED) is caring for four clients. Which client does the
nurse assess for gas exchange
abnormalities first?
a. Involved in motor vehicle crash, has broken femur.
b. Brought in unconscious by roommate after opioid overdose.
c. Asthmatic client being discharged after bronchodilator therapy.
d. History of COPD, presents to ED after being bitten by a dog. - ANS ANS: B
Opioid medications can cause respiratory depression, so this client is most at risk for gas
exchange problems. Diminished respirations will allow a buildup of carbon dioxide in the blood.
The clients with asthma and COPD have the potential for gas exchange problems but this is not
indicated in answer option as he or she is being discharged. The client with a broken femur
does
not have information suggesting gas exchange problems.
The nurse caring for a client with malnutrition assesses which laboratory value as the priority?
a. Albumin
b. Prealbumin
c. Prothrombin time
d. Serum sodium - ANS ANS: B
Both albumin and prealbumin are indicators for nutrition. However, prealbumin changes more
rapidly with decreased nutrition, so it is the better test. Prothrombin time and serum sodium are
not directly related to nutritional status.
A nurse is planning primary prevention measures for community-dwelling adults to prevent
visual impairment. What action by the
nurse will best meet this objective?
a. Provide glaucoma screening.
b. Assess visual acuity.
, c. Teach clients about instilling eyedrops.
d. Offer a healthy lifestyle class. - ANS ANS: D
Primary prevention activities are those designed to actually prevent the onset of a disease or
health problem. Secondary prevention focuses on screening and early diagnosis/detection.
Tertiary measures are those that offer treatment and rehabilitation. Encouraging a healthy
lifestyle through classes may help prevent diabetes, a common cause of visual impairment, and
is a primary prevention
measure. Assessing for glaucoma and visual acuity is a secondary prevention measure.
Teaching clients how to instill eyedrops is tertiary.
The nurse tells the staff development nurse he/she is very uncomfortable discussing sexuality
with clients, especially those who are older. What suggestion by the staff development nurse is
most appropriate?
a. "Find a trusted friend and role play."
b. "Don't worry it will get easier."
c. "A sexual assessment is usually not needed."
d. "It's hard for me to do, too." - ANS ANS: A
Discussing sexuality and sex is difficult for most people. Since it is important to be able to
assess this aspect of people's lives, the nurse needs to become comfortable. Role-playing with
a trusted friend will build confidence and comfort. Saying that it will get
easier and that it is hard for the staff development nurse too does not give the nurse any ideas
for improvement. Sexuality is important to assess.
A nurse is planning a community education event-related to impaired cellular regulation. What
teaching topics would the nurse
include in this event? (Select all that apply.)
a. Ways to minimize exposure to sunlight
b. Resources available for smoking cessation
c. Strategies to remain hydrated during hot weather
d. Use of indoor tanning beds instead of sunbathing
e. Creative cooking techniques to increase dietary fiber
f. How to determine sodium content in food? - ANS ANS: A, B, E
Disrupted cellular regulation can lead to both benign and malignant tumors (cancer). Ways to
minimize the risk of developing cancer include decreasing exposure to sunlight, smoking
cessation, and increasing dietary fiber. Tanning beds do not reduce the risk of cancer as
opposed to sunbathing. While staying hydrated is a good health measure, it is not related to
cellular regulation. Maintaining a normal intake of sodium is also not related to cellular
regulation.
