Questions and 100% Verified Correct Answers
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A female patient is diagnosed with deep-vein thrombosis. Which nursing diagnosis
should receive the highest priority at this time?
a. Impaired gas exchange related to increased blood flow
b. Fluid volume excess related to peripheral vascular disease
c. Risk for injury related to edema
d. Altered peripheral tissue perfusion related to venous congestion - CORRECT
ANSWER: Answer: d
* This answer takes highest priority because venous inflammation and clot formation
impede blood flow in a patient with deep-vein thrombosis
A healthcare provider ordered enalapril (Vasotec) 2 mg IV push for a patient with HTN.
The pharmacy sent vials marked 1.25 mg enalapril/ml. How many mL does the nurse
administer? - CORRECT ANSWER: 1.6 mL
A home health nurse notices significant bruising on a 2-year-old patient's head, arms,
abdomen, and legs. The patient's mother describes the patient's frequent falls. What is
the best nursing action for the home health nurse to take?
a. Document her findings and treat the patient
b. Instruct the mother on safe handling of a 2-year-old child
c. Contact a child abuse hotline
d. Discuss this story with a colleague. - CORRECT ANSWER: Answer: c
,A nurse accidentally gives a patient medications that were ordered for the patient's
roommate. What is the nurse's first priority?
a. Complete an occurrence report
b. Notify the healthcare provider
c. Inform the chargers of the error
d. Assess the patient for adverse effects - CORRECT ANSWER: Answer: d
A nurse admits a 72 year old patient with a medical history of hypertension, heart
failure, renal failure, and depression to a general medical patient care unit. The nurse
reviews the patient's medication orders and notes that the patient has three healthcare
providers who have ordered a total of 13 medications. What is the most appropriate
action for the nurse to take next?
a. Give the medication after identifying the patient using to patient identifiers
b. Provide medication education to the patient to help with adherence to the medical
plan
c. Review the list of medication's with the healthcare providers to insure that the patient
needs all 13 medications
d. Set up a medication schedule for the patient that is least disruptive to the expected
treatment schedule in the hospital - CORRECT ANSWER: Answer: c
A nurse is assigned to care for a postoperative male client who has diabetes mellitus.
During the assessment interview, the client reports that he's impotent and says he's
concerned about the effect on his marriage. In planning this client's care, the most
appropriate intervention would be to:
a. Encourage the client to ask questions about personal sexuality
b. Provide time for privacy
c. Suggest referral to a sex counselor or other appropriate professional
d. Provide support for the spouse - CORRECT ANSWER: Answer: c
, A nurse is assigned to care for the following patients. Which patient is most at risk for
developing skin problems and thus requiring thorough bathing and skin care?
a. A 44-year-old female patient who has had removal of a breast lesion and is having
her menstrual period
b. A 56-year-old male patient who is homeless and admitted to the emergency
department with malnutrition and dehydration and who has an intravenous line
c. A 60-year-old female patient who experienced a stroke with right-sided paralysis and
has an orthopedic brace applied to the left leg
d. A 70-year-old patient who has diabetes and dementia and has been incontinent of
stool - CORRECT ANSWER: Answer: d
A nurse is caring for a patient who has poor pain control. The patient has a history of
opioid abuse. During the day the patient made frequent requests for a pain medication.
In order to make an effective clinical decision about this patient, the nurse needs to ask
questions about the data available on the patient to make a thorough and thoughtful
decision. The nurse asks herself, "How does my view about the patient's pain tolerance
compare with the patient's, and does that pose a problem?" This is an example of:
a. A question about assumptions.
b. A question about evidence.
c. A question about procedure.
d. A question about perspective - CORRECT ANSWER: Answer: d
A nurse is conducting a home visit with a new mom and her three children. While in the
home the nurse weighs each family member and reviews their 3-day food diary. She
checks the mom's blood pressure and encourages the mom to take the children for a
15- to 30-minute walk every day. The nurse is addressing which level of need, according
to Maslow?
a. Physiological
b. Safety and security