Fundamental Nursing Care, 2nd Edition by Roberta Pavy Ramont – Test Bank

Complete Test Bank With Answers

 

 

Sample Questions Posted Below

 

Exam

Name___________________________________

MULTIPLE CHOICE. Choose the one alternative that best completes the statement or answers the question.

1) A nurse is preparing to administer three medications to a client. The client was admitted two days

ago with deep vein thrombophlebitis, is on bed rest, and has oxygen per nasal cannula. The nurse

verifies the client’s identity and elevates the head of the bed. What is the most appropriate next

nursing action that promotes the client’s physiological safety?

A) Remove the nasal cannula.

B) Ask the client if he would like to take the medications one at a time or all together.

C) Have the client take several sips of water.

D) Assess the client’s gag reflex.

Answer: C

Explanation: A) Oxygen is drying to the mucous membranes. People receiving oxygen by nasal

cannula tend to be mouth breathers and this increases the dryness. To facilitate

swallowing medications (whether one by one or all at the same time), have the

client first moisten the mucous membranes of the mouth and pharynx. The nurse

can ascertain the client’s preference for the order in which to take the medications,

but it is more important to address the oral dryness to promote safety for the client.

There is no indication that the gag reflex is absent or diminished. This is more

important with a new postoperative client or someone with swallowing

difficulties. An advantage of a nasal cannula is that it does not need to be removed

for the client to eat or take oral medications.

Planning

Physiological Integrity – Reduction of Risk Potential

Analysis

B) Oxygen is drying to the mucous membranes. People receiving oxygen by nasal

cannula tend to be mouth breathers and this increases the dryness. To facilitate

swallowing medications (whether one by one or all at the same time), have the

client first moisten the mucous membranes of the mouth and pharynx. The nurse

can ascertain the client’s preference for the order in which to take the medications,

but it is more important to address the oral dryness to promote safety for the client.

There is no indication that the gag reflex is absent or diminished. This is more

important with a new postoperative client or someone with swallowing

difficulties. An advantage of a nasal cannula is that it does not need to be removed

for the client to eat or take oral medications.

Planning

Physiological Integrity – Reduction of Risk Potential

Analysis

C) Oxygen is drying to the mucous membranes. People receiving oxygen by nasal

cannula tend to be mouth breathers and this increases the dryness. To facilitate

swallowing medications (whether one by one or all at the same time), have the

client first moisten the mucous membranes of the mouth and pharynx. The nurse

can ascertain the client’s preference for the order in which to take the medications,

but it is more important to address the oral dryness to promote safety for the client.

There is no indication that the gag reflex is absent or diminished. This is more

important with a new postoperative client or someone with swallowing

difficulties. An advantage of a nasal cannula is that it does not need to be removed

for the client to eat or take oral medications.

Planning

Physiological Integrity – Reduction of Risk Potential

Analysis

1

1)D) Oxygen is drying to the mucous membranes. People receiving oxygen by nasal

cannula tend to be mouth breathers and this increases the dryness. To facilitate

swallowing medications (whether one by one or all at the same time), have the

client first moisten the mucous membranes of the mouth and pharynx. The nurse

can ascertain the client’s preference for the order in which to take the medications,

but it is more important to address the oral dryness to promote safety for the client.

There is no indication that the gag reflex is absent or diminished. This is more

important with a new postoperative client or someone with swallowing

difficulties. An advantage of a nasal cannula is that it does not need to be removed

for the client to eat or take oral medications.

Planning

Physiological Integrity – Reduction of Risk Potential

Analysis

2) A home care client with rheumatoid arthritis is seen by the home health nurse. The client is taking

naproxen (Naprosyn) 500 milligrams orally twice a day for pain control. As part of the nursing

assessment for this client, it is essential that the nurse:

A) Assess if the client has had any weight loss since the last nursing visit.

B) Determine if the client is taking the medication 30 minutes before meals.

C) Reinforce the necessity for range of motion exercises to all joints at least twice a day.

D) Ask the client about the color of her stools.

Answer: D

Explanation: A) The client is taking a large dose of a nonsteroidal antiinflammatory medication that

can cause gastrointestinal bleeding. The color of the stools can be an indicator of

bleeding. The medication should be taken with food, not on an empty stomach. A

client with rheumatoid arthritis who is overweight is encouraged to lose weight;

but this is not the focus of this question. Range of motion exercises need to be

tailored to the individual client and the status of the arthritis.

Assessment

Physiological Integrity — Pharmacological Therapies

Application

B) The client is taking a large dose of a nonsteroidal antiinflammatory medication that

can cause gastrointestinal bleeding. The color of the stools can be an indicator of

bleeding. The medication should be taken with food, not on an empty stomach. A

client with rheumatoid arthritis who is overweight is encouraged to lose weight;

but this is not the focus of this question. Range of motion exercises need to be

tailored to the individual client and the status of the arthritis.

Assessment

Physiological Integrity — Pharmacological Therapies

Application

C) The client is taking a large dose of a nonsteroidal antiinflammatory medication that

can cause gastrointestinal bleeding. The color of the stools can be an indicator of

bleeding. The medication should be taken with food, not on an empty stomach. A

client with rheumatoid arthritis who is overweight is encouraged to lose weight;

but this is not the focus of this question. Range of motion exercises need to be

tailored to the individual client and the status of the arthritis.

Assessment

Physiological Integrity — Pharmacological Therapies

Application

2)

2D) The client is taking a large dose of a nonsteroidal antiinflammatory medication that

can cause gastrointestinal bleeding. The color of the stools can be an indicator of

bleeding. The medication should be taken with food, not on an empty stomach. A

client with rheumatoid arthritis who is overweight is encouraged to lose weight;

but this is not the focus of this question. Range of motion exercises need to be

tailored to the individual client and the status of the arthritis.

Assessment

Physiological Integrity — Pharmacological Therapies

Application

3) A nurse turns a client to the side, and notes that the client has several lightly reddened areas over

the back and hips. The skin is intact. What is an appropriate independent nursing action for the

nurse to perform at this time?

A) Massage the client’s back with lotion using circular motions around the reddened areas.

B) Place small pillows under the shoulders and coccyx.

C) Order an air mattress for the client.

D) Document the observation and inform the nurse in charge.

Answer: A

Explanation: A) An independent decision and action that can be made by the nurse at this time is to

stimulate circulation by providing a back massage. Reddened areas are not directly

massaged, because this may promote tissue damage in an already compromised

area. It cannot be determined from the information in the scenario whether the

client is at risk for skin breakdown. There is none at this time. Although the

observation will be documented and the charge nurse will be informed, these two

actions are expected responses to observations, not independent nursing actions.

Ordering an air mattress will require a collaborative (rather than independent)

decision to identify the most appropriate nursing interventions for the client.

Placing small pillows under the shoulder and coccyx is not correct and will lead to

further pressure on these areas.

Implementation

Physiological Integrity – Basic Care and Comfort

Application

B) An independent decision and action that can be made by the nurse at this time is to

stimulate circulation by providing a back massage. Reddened areas are not directly

massaged, because this may promote tissue damage in an already compromised

area. It cannot be determined from the information in the scenario whether the

client is at risk for skin breakdown. There is none at this time. Although the

observation will be documented and the charge nurse will be informed, these two

actions are expected responses to observations, not independent nursing actions.

Ordering an air mattress will require a collaborative (rather than independent)

decision to identify the most appropriate nursing interventions for the client.

Placing small pillows under the shoulder and coccyx is not correct and will lead to

further pressure on these areas.

Implementation

Physiological Integrity – Basic Care and Comfort

Application

3)

3C) An independent decision and action that can be made by the nurse at this time is to

stimulate circulation by providing a back massage. Reddened areas are not directly

massaged, because this may promote tissue damage in an already compromised

area. It cannot be determined from the information in the scenario whether the

client is at risk for skin breakdown. There is none at this time. Although the

observation will be documented and the charge nurse will be informed, these two

actions are expected responses to observations, not independent nursing actions.

Ordering an air mattress will require a collaborative (rather than independent)

decision to identify the most appropriate nursing interventions for the client.

Placing small pillows under the shoulder and coccyx is not correct and will lead to

further pressure on these areas.

Implementation

Physiological Integrity – Basic Care and Comfort

Application

D) An independent decision and action that can be made by the nurse at this time is to

stimulate circulation by providing a back massage. Reddened areas are not directly

massaged, because this may promote tissue damage in an already compromised

area. It cannot be determined from the information in the scenario whether the

client is at risk for skin breakdown. There is none at this time. Although the

observation will be documented and the charge nurse will be informed, these two

actions are expected responses to observations, not independent nursing actions.

Ordering an air mattress will require a collaborative (rather than independent)

decision to identify the most appropriate nursing interventions for the client.

Placing small pillows under the shoulder and coccyx is not correct and will lead to

further pressure on these areas.

Implementation

Physiological Integrity – Basic Care and Comfort

Application

4) The desired outcome for a client is to have an oral temperature less than 100 degrees Fahrenheit

(37.8 degrees Celsius) at 4:00 p.m. The client’s oral temperature at 4:00 p.m. is found to be 101

degrees Fahrenheit (38.3 degrees Celsius). What should be the initial action by the nurse at this

time?

A) Document the client’s temperature and note in narrative charting that the nursing goal was

not met successfully.

B) Wait at least five minutes and then re–check the client’s temperature.

C) Revise the goal on the client’s nursing care plan.

D) Determine possible reasons the goal has not been reached.

Answer: D

Explanation: A) When nursing goals are evaluated and it is found that they have not been reached,

the next action is to identify reasons why the goal may have not been met. The

reasons can include improper technique in obtaining the temperature, ingestion of

hot beverages immediately prior to the measurement, a correct measurement of the

client’s body temperature, or broken equipment. Goals are not revised unless it is

found that they are not realistic for a client. The nurse may decide to re–check the

client’s temperature after identifying possible influencing factors. Documentation

should not be done as an initial action.

Evaluation

Physiological Integrity – Reduction of Risk Potential

Analysis

4)

4B) When nursing goals are evaluated and it is found that they have not been reached,

the next action is to identify reasons why the goal may have not been met. The

reasons can include improper technique in obtaining the temperature, ingestion of

hot beverages immediately prior to the measurement, a correct measurement of the

client’s body temperature, or broken equipment. Goals are not revised unless it is

found that they are not realistic for a client. The nurse may decide to re–check the

client’s temperature after identifying possible influencing factors. Documentation

should not be done as an initial action.

Evaluation

Physiological Integrity – Reduction of Risk Potential

Analysis

C) When nursing goals are evaluated and it is found that they have not been reached,

the next action is to identify reasons why the goal may have not been met. The

reasons can include improper technique in obtaining the temperature, ingestion of

hot beverages immediately prior to the measurement, a correct measurement of the

client’s body temperature, or broken equipment. Goals are not revised unless it is

found that they are not realistic for a client. The nurse may decide to re–check the

client’s temperature after identifying possible influencing factors. Documentation

should not be done as an initial action.

Evaluation

Physiological Integrity – Reduction of Risk Potential

Analysis

D) When nursing goals are evaluated and it is found that they have not been reached,

the next action is to identify reasons why the goal may have not been met. The

reasons can include improper technique in obtaining the temperature, ingestion of

hot beverages immediately prior to the measurement, a correct measurement of the

client’s body temperature, or broken equipment. Goals are not revised unless it is

found that they are not realistic for a client. The nurse may decide to re–check the

client’s temperature after identifying possible influencing factors. Documentation

should not be done as an initial action.

Evaluation

Physiological Integrity – Reduction of Risk Potential

Analysis

5) A certified nursing assistant reports to the nurse that a client’s temperature is 39.1 degrees

Centigrade (102.4 degrees Fahrenheit). The client has an order for acetaminophen (Tylenol) 650

milligrams orally or rectally every 4 hours prn for temperature above 38.5 degrees C. (101.4 degrees

F.). The nurse should first:

A) Check the medication record to determine when the client last had the medication.

B) Ask the client if he is nauseated or has diarrhea and then determine the route to use.

C) Retake the temperature to determine if the nursing assistant’s measurement was accurate.

D) Give the medication orally if there are no contraindications to using this route.

Answer: A

Explanation: A) Prior to giving any prn medication, the nurse must determine when the last dosage

was administered. There is no reason that the temperature needs to be reevaluated,

because the certified nursing assistant should be qualified to obtain an accurate

temperature reading. After determining the time of the prior dose, the nurse can

assess the client to determine which route to use for the medication.

Assessment

Physiological Integrity – Pharmacological Therapies

Analysis

5)

5B) Prior to giving any prn medication, the nurse must determine when the last dosage

was administered. There is no reason that the temperature needs to be reevaluated,

because the certified nursing assistant should be qualified to obtain an accurate

temperature reading. After determining the time of the prior dose, the nurse can

assess the client to determine which route to use for the medication.

Assessment

Physiological Integrity – Pharmacological Therapies

Analysis

C) Prior to giving any prn medication, the nurse must determine when the last dosage

was administered. There is no reason that the temperature needs to be reevaluated,

because the certified nursing assistant should be qualified to obtain an accurate

temperature reading. After determining the time of the prior dose, the nurse can

assess the client to determine which route to use for the medication.

Assessment

Physiological Integrity – Pharmacological Therapies

Analysis

D) Prior to giving any prn medication, the nurse must determine when the last dosage

was administered. There is no reason that the temperature needs to be reevaluated,

because the certified nursing assistant should be qualified to obtain an accurate

temperature reading. After determining the time of the prior dose, the nurse can

assess the client to determine which route to use for the medication.

Assessment

Physiological Integrity – Pharmacological Therapies

Analysis

6) A nursing diagnosis of Risk for Ineffective Airway Clearance related to shallow breathing pattern,

pain, and fatigue has been established for a postoperative client. Nursing interventions have been

established. The nurse will determine that the diagnosis is no longer needed when the client:

A) Consistently has a pulse oximetry above 95% when active and when at rest.

B) Is able to deep–breathe and cough without discomfort.

C) Has clear lung fields bilaterally.

D) Correctly uses the incentive spirometer independently.

Answer: A

Explanation: A) A pulse oximetry reading over 95% is considered normal. Of the options provided,

oxygen saturation is the most objective evaluation of the effectiveness of the client’s

respiratory effort and efficiency. Consistently obtaining this value indicates that the

airway is remaining clear. Correctly using the incentive spirometer and being able

to deep–breathe and cough without discomfort are nursing interventions to attain

the desired outcomes of effective airway clearance and prevent respiratory

complications. Bilateral clear lung fields are an important assessment in

determining if nursing interventions have been successful.

Evaluation

Physiological Integrity — Reduction of Risk Potential

Analysis

6)

6B) A pulse oximetry reading over 95% is considered normal. Of the options provided,

oxygen saturation is the most objective evaluation of the effectiveness of the client’s

respiratory effort and efficiency. Consistently obtaining this value indicates that the

airway is remaining clear. Correctly using the incentive spirometer and being able

to deep–breathe and cough without discomfort are nursing interventions to attain

the desired outcomes of effective airway clearance and prevent respiratory

complications. Bilateral clear lung fields are an important assessment in

determining if nursing interventions have been successful.

Evaluation

Physiological Integrity — Reduction of Risk Potential

Analysis

C) A pulse oximetry reading over 95% is considered normal. Of the options provided,

oxygen saturation is the most objective evaluation of the effectiveness of the client’s

respiratory effort and efficiency. Consistently obtaining this value indicates that the

airway is remaining clear. Correctly using the incentive spirometer and being able

to deep–breathe and cough without discomfort are nursing interventions to attain

the desired outcomes of effective airway clearance and prevent respiratory

complications. Bilateral clear lung fields are an important assessment in

determining if nursing interventions have been successful.

Evaluation

Physiological Integrity — Reduction of Risk Potential

Analysis

D) A pulse oximetry reading over 95% is considered normal. Of the options provided,

oxygen saturation is the most objective evaluation of the effectiveness of the client’s

respiratory effort and efficiency. Consistently obtaining this value indicates that the

airway is remaining clear. Correctly using the incentive spirometer and being able

to deep–breathe and cough without discomfort are nursing interventions to attain

the desired outcomes of effective airway clearance and prevent respiratory

complications. Bilateral clear lung fields are an important assessment in

determining if nursing interventions have been successful.

Evaluation

Physiological Integrity — Reduction of Risk Potential

Analysis

7) A nurse is obtaining admission information from a client and his family. All of the following

information is obtained during the interview. The nurse should document what data as primary

objective information? (Select all that apply.)

A) The nurse observes that the client is pale and gets short of breath when talking.

B) The client’s pulse rate is 94 and his blood pressure is 108/72.

C) The client’s wife reports that the nurse at the doctor’s office told her that the client’s white

blood cell count was 1800.

D) The client says he sleeps 6 – 7 hours each night and has been taking short naps during the

day more frequently.

E) The client’s wife states that the client “has felt worse over the last week.”

F) The client reports a pain level of 4 on a scale of 1 through 10.

Answer: A, B

Explanation: A) Primary objective data is observable, can be measured or tested against an

accepted standard, and is obtained directly from the client. It includes information

that can be seen, felt, heard, or smelled.

Assessment

Health Promotion and Maintenance

Application

7)

7B) Primary objective data is observable, can be measured or tested against an

accepted standard, and is obtained directly from the client. It includes information

that can be seen, felt, heard, or smelled.

Assessment

Health Promotion and Maintenance

Application

C) Primary objective data is observable, can be measured or tested against an

accepted standard, and is obtained directly from the client. It includes information

that can be seen, felt, heard, or smelled.

Assessment

Health Promotion and Maintenance

Application

D) Primary objective data is observable, can be measured or tested against an

accepted standard, and is obtained directly from the client. It includes information

that can be seen, felt, heard, or smelled.

Assessment

Health Promotion and Maintenance

Application

E) Primary objective data is observable, can be measured or tested against an

accepted standard, and is obtained directly from the client. It includes information

that can be seen, felt, heard, or smelled.

Assessment

Health Promotion and Maintenance

Application

F) Primary objective data is observable, can be measured or tested against an

accepted standard, and is obtained directly from the client. It includes information

that can be seen, felt, heard, or smelled.

Assessment

Health Promotion and Maintenance

Application

8) A nursing staff that consists of RNs and LPN/LVNs are discussing their difficulties with up–to–date

nursing care plans when most of their clients are discharged after only a few days’ stay. Most of

them feel that it is just more paperwork to do and interferes with the amount of time they have

available for the client. A helpful statement for these nurses to encourage them to continue using

the nursing process in the care of their clients is that:

A) Completed care plans are required to be done on all clients admitted to their unit.

B) The focus of client care is quality rather than quantity.

C) The incidence of nosocomial infections will decrease on their unit.

D) They will make fewer errors in medication administration.

Answer: B

Explanation: A) The purpose of using the nursing process in client care is to provide a systematic,

logical, holistic, and individualized framework to the practice of nursing and client

care. The reduction of medication errors and nosocomial infections are part of

quality care and are more directly the result of how nurses carry out various

nursing procedures, rather than whether the nursing process is used.

Implementation

Safe, Effective Care Environment – Coordinated Care

Application

8

8)B) The purpose of using the nursing process in client care is to provide a systematic,

logical, holistic, and individualized framework to the practice of nursing and client

care. The reduction of medication errors and nosocomial infections are part of

quality care and are more directly the result of how nurses carry out various

nursing procedures, rather than whether the nursing process is used.

Implementation

Safe, Effective Care Environment – Coordinated Care

Application

C) The purpose of using the nursing process in client care is to provide a systematic,

logical, holistic, and individualized framework to the practice of nursing and client

care. The reduction of medication errors and nosocomial infections are part of

quality care and are more directly the result of how nurses carry out various

nursing procedures, rather than whether the nursing process is used.

Implementation

Safe, Effective Care Environment – Coordinated Care

Application

D) The purpose of using the nursing process in client care is to provide a systematic,

logical, holistic, and individualized framework to the practice of nursing and client

care. The reduction of medication errors and nosocomial infections are part of

quality care and are more directly the result of how nurses carry out various

nursing procedures, rather than whether the nursing process is used.

Implementation

Safe, Effective Care Environment – Coordinated Care

Application

9) A client is admitted to a skilled nursing facility after being discharged from an acute care hospital.

The client is to be ambulated with assistance at least four times a day. To plan for the client’s

ambulation, the nurse should initially gather information about the client’s: (Select all that apply.)

A) Self–identified needs for assistance when ambulating.

B) Ambulation orders from the discharge information.

C) Weight.

D) Assistance requirements from the nurse’s notes from the acute care facility.

E) Vital signs including pulse, respirations, and blood pressure.

F) Height.

Answer: A, C, E, F

Explanation: A) To determine the amount and kind of assistance needed to safely ambulate the

client, the nurse should gather information about the client’s size, personal

experience with ambulation while in the acute care facility, and vital signs. The

nursing notes from the acute care facility are not transferred with the client. The

ambulation order is to ambulate four times a day with assistance; it does not spell

out the amount and kind of assistance needed.

Assessment

Safe, Effective Care Environment — Safety and Infection Control

Analysis

B) To determine the amount and kind of assistance needed to safely ambulate the

client, the nurse should gather information about the client’s size, personal

experience with ambulation while in the acute care facility, and vital signs. The

nursing notes from the acute care facility are not transferred with the client. The

ambulation order is to ambulate four times a day with assistance; it does not spell

out the amount and kind of assistance needed.

Assessment

Safe, Effective Care Environment — Safety and Infection Control

Analysis

9

9)C) To determine the amount and kind of assistance needed to safely ambulate the

client, the nurse should gather information about the client’s size, personal

experience with ambulation while in the acute care facility, and vital signs. The

nursing notes from the acute care facility are not transferred with the client. The

ambulation order is to ambulate four times a day with assistance; it does not spell

out the amount and kind of assistance needed.

Assessment

Safe, Effective Care Environment — Safety and Infection Control

Analysis

D) To determine the amount and kind of assistance needed to safely ambulate the

client, the nurse should gather information about the client’s size, personal

experience with ambulation while in the acute care facility, and vital signs. The

nursing notes from the acute care facility are not transferred with the client. The

ambulation order is to ambulate four times a day with assistance; it does not spell

out the amount and kind of assistance needed.

Assessment

Safe, Effective Care Environment — Safety and Infection Control

Analysis

E) To determine the amount and kind of assistance needed to safely ambulate the

client, the nurse should gather information about the client’s size, personal

experience with ambulation while in the acute care facility, and vital signs. The

nursing notes from the acute care facility are not transferred with the client. The

ambulation order is to ambulate four times a day with assistance; it does not spell

out the amount and kind of assistance needed.

Assessment

Safe, Effective Care Environment — Safety and Infection Control

Analysis

F) To determine the amount and kind of assistance needed to safely ambulate the

client, the nurse should gather information about the client’s size, personal

experience with ambulation while in the acute care facility, and vital signs. The

nursing notes from the acute care facility are not transferred with the client. The

ambulation order is to ambulate four times a day with assistance; it does not spell

out the amount and kind of assistance needed.

Assessment

Safe, Effective Care Environment — Safety and Infection Control

Analysis

10) Several staff nurses from an orthopedic unit are attending a workshop entitled “Nursing Diagnoses

and Successful Client Care Planning.” An essential understanding for the nurses to take away from

this conference is/are the:

A) Correct methods to perform procedures that are required nursing activities on their unit.

B) Requirement for client and family members to participate in the nursing process.

C) Relationship of common nursing diagnoses and standardized care plans for orthopedic

clients.

D) Importance of being a critical thinker at all times.

Answer: B

10

10)Explanation: A) Client care, from assessment to evaluation, must have the input and cooperation of

the client and family to be successful. Client care is individualized, not

standardized. Nursing diagnoses reflect this client focus. Critical thinking is

required in many aspects of nursing practice; not “at all times.” The title of the

conferences does not suggest it is about learning nursing procedures.

Planning

Safe, Effective Care Environment – Coordinated Care

Analysis

B) Client care, from assessment to evaluation, must have the input and cooperation of

the client and family to be successful. Client care is individualized, not

standardized. Nursing diagnoses reflect this client focus. Critical thinking is

required in many aspects of nursing practice; not “at all times.” The title of the

conferences does not suggest it is about learning nursing procedures.

Planning

Safe, Effective Care Environment – Coordinated Care

Analysis

C) Client care, from assessment to evaluation, must have the input and cooperation of

the client and family to be successful. Client care is individualized, not

standardized. Nursing diagnoses reflect this client focus. Critical thinking is

required in many aspects of nursing practice; not “at all times.” The title of the

conferences does not suggest it is about learning nursing procedures.

Planning

Safe, Effective Care Environment – Coordinated Care

Analysis

D) Client care, from assessment to evaluation, must have the input and cooperation of

the client and family to be successful. Client care is individualized, not

standardized. Nursing diagnoses reflect this client focus. Critical thinking is

required in many aspects of nursing practice; not “at all times.” The title of the

conferences does not suggest it is about learning nursing procedures.

Planning

Safe, Effective Care Environment – Coordinated Care

Analysis

11) A mother brings her 3–week–old infant to the health center because of a large accumulation of

thick, yellow scales over the anterior fontanel. Before the infant is seen by the pediatrician, the

nurse gathers information from the mother. Which of the following questions by the nurse will

obtain the most helpful information?

A) “How do you wash your baby’s scalp?”

B) “Does this kind of skin disorder occur in other members of your family?”

C) “Has the baby been exposed to anything recently?”

D) “Have you changed the detergent you use for washing the baby’s clothing?”

Answer: A

Explanation: A) The case scenario suggests that the infant has seborrheic dermatitis, which is

commonly known as cradle cap. This is a non–genetic, noncommunicable skin

condition that commonly occurs because the caregiver is uncomfortable washing

the baby’s scalp over the fontanel. Dermatitis related to detergents used to wash

the baby’s clothes would not manifest only over the anterior fontanel.

Assessment

Health Promotion and Maintenance

Analysis

11

11)B) The case scenario suggests that the infant has seborrheic dermatitis, which is

commonly known as cradle cap. This is a non–genetic, noncommunicable skin

condition that commonly occurs because the caregiver is uncomfortable washing

the baby’s scalp over the fontanel. Dermatitis related to detergents used to wash

the baby’s clothes would not manifest only over the anterior fontanel.

Assessment

Health Promotion and Maintenance

Analysis

C) The case scenario suggests that the infant has seborrheic dermatitis, which is

commonly known as cradle cap. This is a non–genetic, noncommunicable skin

condition that commonly occurs because the caregiver is uncomfortable washing

the baby’s scalp over the fontanel. Dermatitis related to detergents used to wash

the baby’s clothes would not manifest only over the anterior fontanel.

Assessment

Health Promotion and Maintenance

Analysis

D) The case scenario suggests that the infant has seborrheic dermatitis, which is

commonly known as cradle cap. This is a non–genetic, noncommunicable skin

condition that commonly occurs because the caregiver is uncomfortable washing

the baby’s scalp over the fontanel. Dermatitis related to detergents used to wash

the baby’s clothes would not manifest only over the anterior fontanel.

Assessment

Health Promotion and Maintenance

Analysis

12) Final discharge teaching is to be done for a client who has had a total knee replacement. When the

nurse begins to review the discharge instructions with the client, the client says that he does not

know if he will be able to follow the instructions because it makes him nervous to do any

movement with his operated knee. Which of the following options is the most appropriate nursing

action at this time?

A) Identify ways in which the client’s concerns can be alleviated.

B) Add the nursing diagnosis of Anxiety related to lack of self–confidence to the client’s nursing

care plan.

C) Document that the client is anxious about his ability to do self care when he is discharged.

D) Tell the client that he can call the surgeon’s office anytime he has questions or concerns.

Answer: A

Explanation: A) The nurse should plan to address the client’s nervousness first, in order to

determine whether there are interventions that can be done to facilitate the client’s

compliance with the discharge instructions. Based on findings, the nurse should

determine whether the client is able to correctly carry out the discharge

instructions. The client may need to be referred to a home care agency.

Planning

Psychosocial Integrity

Analysis

B) The nurse should plan to address the client’s nervousness first, in order to

determine whether there are interventions that can be done to facilitate the client’s

compliance with the discharge instructions. Based on findings, the nurse should

determine whether the client is able to correctly carry out the discharge

instructions. The client may need to be referred to a home care agency.

Planning

Psychosocial Integrity

Analysis

12

12)C) The nurse should plan to address the client’s nervousness first, in order to

determine whether there are interventions that can be done to facilitate the client’s

compliance with the discharge instructions. Based on findings, the nurse should

determine whether the client is able to correctly carry out the discharge

instructions. The client may need to be referred to a home care agency.

Planning

Psychosocial Integrity

Analysis

D) The nurse should plan to address the client’s nervousness first, in order to

determine whether there are interventions that can be done to facilitate the client’s

compliance with the discharge instructions. Based on findings, the nurse should

determine whether the client is able to correctly carry out the discharge

instructions. The client may need to be referred to a home care agency.

Planning

Psychosocial Integrity

Analysis

13) A resident of a long–term care facility has all of the following nursing diagnoses. Which nursing

diagnosis will have the lowest priority in planning nursing interventions?

A) Risk for Falls related to antihypertensive medication

B) Risk for Impaired Skin Integrity (perineal area) related to severe arthritis of both hands

C) Relocation Stress Syndrome related to isolation from family and friends.

D) Feeding Self–Care Deficit related to severe arthritis of both hands

Answer: C

Explanation: A) Nursing diagnoses related to psychosocial needs of a client will be lower in

priority than those for physiological and safety needs. Although the two nursing

diagnoses stating a risk for the client are potential rather than actual diagnoses,

they are still concerned with physiological and safety needs and will have a higher

priority in planning interventions. Note that having a lower priority does not mean

that less attention is paid to the diagnosis or that nursing interventions are less

important.

Planning

Safe, Effective Care Environment – Coordinated Care

Analysis

B) Nursing diagnoses related to psychosocial needs of a client will be lower in

priority than those for physiological and safety needs. Although the two nursing

diagnoses stating a risk for the client are potential rather than actual diagnoses,

they are still concerned with physiological and safety needs and will have a higher

priority in planning interventions. Note that having a lower priority does not mean

that less attention is paid to the diagnosis or that nursing interventions are less

important.

Planning

Safe, Effective Care Environment – Coordinated Care

Analysis

13

13)C) Nursing diagnoses related to psychosocial needs of a client will be lower in

priority than those for physiological and safety needs. Although the two nursing

diagnoses stating a risk for the client are potential rather than actual diagnoses,

they are still concerned with physiological and safety needs and will have a higher

priority in planning interventions. Note that having a lower priority does not mean

that less attention is paid to the diagnosis or that nursing interventions are less

important.

Planning

Safe, Effective Care Environment – Coordinated Care

Analysis

D) Nursing diagnoses related to psychosocial needs of a client will be lower in

priority than those for physiological and safety needs. Although the two nursing

diagnoses stating a risk for the client are potential rather than actual diagnoses,

they are still concerned with physiological and safety needs and will have a higher

priority in planning interventions. Note that having a lower priority does not mean

that less attention is paid to the diagnosis or that nursing interventions are less

important.

Planning

Safe, Effective Care Environment – Coordinated Care

Analysis

1414) A client is receiving bumetanide (Bumex) 1 milligram orally once a day at 9:00 a.m. The nurse is

checking the most recent laboratory reports for the client. Which finding by the nurse is of most

concern in relation to this medication?

A) Potassium 4.1 mEq per liter C) Prothrombin time 12 seconds B) Hematocrit 35%

D) Hemoglobin 14.2 grams per deciliter

Answer: B

Explanation: A) Bumetanide (Bumex) is a diuretic. Although it is a potassium–depleting diuretic,

the potassium value in this client is within normal limits. The only laboratory

result that is outside of normal range is the hematocrit value. Dehydration is of

concern in any client receiving a diuretic.

Evaluation

Physiological Integrity – Reduction of Risk Potential

Analysis

B) Bumetanide (Bumex) is a diuretic. Although it is a potassium–depleting diuretic,

the potassium value in this client is within normal limits. The only laboratory

result that is outside of normal range is the hematocrit value. Dehydration is of

concern in any client receiving a diuretic.

Evaluation

Physiological Integrity – Reduction of Risk Potential

Analysis

C) Bumetanide (Bumex) is a diuretic. Although it is a potassium–depleting diuretic,

the potassium value in this client is within normal limits. The only laboratory

result that is outside of normal range is the hematocrit value. Dehydration is of

concern in any client receiving a diuretic.

Evaluation

Physiological Integrity – Reduction of Risk Potential

Analysis

D) Bumetanide (Bumex) is a diuretic. Although it is a potassium–depleting diuretic,

the potassium value in this client is within normal limits. The only laboratory

result that is outside of normal range is the hematocrit value. Dehydration is of

concern in any client receiving a diuretic.

Evaluation

Physiological Integrity – Reduction of Risk Potential

Analysis

15) A 97–year–old client has had a right–sided cerebrovascular accident and now has very little use of

her left arm and leg. The client is to be transferred to a rehabilitation center later today. Prior to the

discharge, the nurse should give priority to which of the following nursing actions identified on the

client’s nursing care plan?

A) Demonstrate how the client will learn to dress herself.

B) Make sure that none of the client’s belongings are left in the room.

C) Explain to the client where she is going and why.

D) Teach the client to do passive range–of–motion exercises of her left arm and leg.

Answer: C

Explanation: A) In this scenario, priority shouldbe given to meeting the client’s psychosocial needs

and ensuring that the client understands what is happening. Teaching the client to

do passive range of motion exercises and how to dress herself will be done at the

rehabilitation center. Gathering and checking a client’s belongings before transfer

is one part of the discharge/transfer process. It is not a priority activity.

Implementation

Psychosocial Integrity

Analysis

15

14)

15)B) In this scenario, priority shouldbe given to meeting the client’s psychosocial needs

and ensuring that the client understands what is happening. Teaching the client to

do passive range of motion exercises and how to dress herself will be done at the

rehabilitation center. Gathering and checking a client’s belongings before transfer

is one part of the discharge/transfer process. It is not a priority activity.

Implementation

Psychosocial Integrity

Analysis

C) In this scenario, priority shouldbe given to meeting the client’s psychosocial needs

and ensuring that the client understands what is happening. Teaching the client to

do passive range of motion exercises and how to dress herself will be done at the

rehabilitation center. Gathering and checking a client’s belongings before transfer

is one part of the discharge/transfer process. It is not a priority activity.

Implementation

Psychosocial Integrity

Analysis

D) In this scenario, priority shouldbe given to meeting the client’s psychosocial needs

and ensuring that the client understands what is happening. Teaching the client to

do passive range of motion exercises and how to dress herself will be done at the

rehabilitation center. Gathering and checking a client’s belongings before transfer

is one part of the discharge/transfer process. It is not a priority activity.

Implementation

Psychosocial Integrity

Analysis

16Answer Key

Testname: C5

1) C

2) D

3) A

4) D

5) A

6) A

7) A, B

8) B

9) A, C, E, F

10) B

11) A

12) A

13) C

14) B

15) C

17