NUR 1140 EXAM WITH VERIFIED SOLUTIONS
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. - ANSWER-
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. -
ANSWER-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) -
ANSWER-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 - ANSWER-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. - ANSWER-
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. - ANSWER-
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. - ANSWER-
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
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. - ANSWER-
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. -
ANSWER-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) -
ANSWER-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 - ANSWER-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. - ANSWER-
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. - ANSWER-
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. - ANSWER-
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
