and Answers 2023 with complete solution
A nurse is a caring for a client who has borderline personality disorder. Which of
the following is a manifestation of the disorder?
Unstable interpersonal relationships
So, the question is asking which manifestation is a characteristic of borderline
personality disorder. This is a positively worded, traditional multiple choice item, which
means there are four options. Of these options, one is correct, called the key, and three
are incorrect, called the distracters. Because the question indicates there is only one
correct option, it is not a priority setting item.
Next you should review each option and determine if it is probably correct, possibly
correct, or probably incorrect, and assign the appropriate code to each option.
Unstable interpersonal relationships is correct. Borderline personality disorder is
characterized by unstable interpersonal relationships, emotional instability, impulsivity,
unstable mood, and self image distortions.Test: Testing and Remediation Advanced
Test
A nurse in a long-term care facility is assisting with an educational program
regarding common sites of health care associated infections for a group of newly
hired assistive personnel. Which of the following sites should be included in the
teaching? (Select all that apply.)
Blood stream, Urinary tract , Surgical wound, Respiratory tract
Urinary tract is correct. Health care associated infections are caused from health care
delivery in a health care facility. These result from prescribed antibiotic administration,
presence of multi-medication resistant organisms, breeches in infection control
practices, and invasive procedures. The urinary tract is a common site for health care
associated infections.
Surgical wound is correct. Surgical wounds are a common site for health care
associated infections.
Musculoskeletal system is incorrect. While injuries can occur in the health care setting
that affect the musculoskeletal system, this is not a common site for health care
associated infections.
Respiratory tract is correct. The respiratory tract is a common site for health care
associated infections.
Blood stream is correct. The blood stream is common site for health care associated
infections.
, A nurse is assessing a client who is postoperative following a gastric bypass.
Which of the following findings indicates the client could be experiencing an
anastomotic leak?
Oliguria
Oliguria is correct. When a gastric bypass is performed, the stomach, duodenum, and
part of the jejunum are bypassed by surgically connecting the small intestine to a newly
created stomach pouch. The leakage of gastric or intestinal fluids at this connection is
an anastomotic leak and can result in peritonitis or death. Oliguria, or decreased urine
production, is a finding consistent with peritonitis and can indicate the client is
experiencing an anastomotic leak.
A nurse is working with administration to enhance the quality of care provided to
clients during the prenatal period. In which of the following roles is the nurse
functioning?
Advocate
Advocate is correct. A nurse advocate acts as a liaison between clients and providers in
order to improve or maintain the quality of care that clients receive. The nurse is
functioning in the role of the nurse advocate for the clients during the prenatal period.
A nurse is reviewing the laboratory results of four clients. Which of the following
should be immediately reported to the provider?
A client who is prescribed digoxin (Lanoxin) and furosemide (Lasix) with a potassium of
3.1 mEq/L
A client who is prescribed digoxin and furosemide with a potassium of 3.1 mEq/L is
correct. This value is clearly abnormal and indicates that the client has hypokalemia, or
decreased potassium. This is a common complication with the use of loop diuretics,
such as furosemide. The nurse should also note that the client receives digoxin.
Hypokalemia places the client at increased risk for digoxin toxicity, so this is the client
who is at immediate risk for injury and whose laboratory findings should be reported to
the provider.
A nurse is caring for a client who is from a culture different than his own. Which
of the following actions by the nurse is most important in the provision of
culturally competent care?
Identify one's own beliefs and values.
To answer this item, start by critically reading the stem and reviewing the scenario, as
well as identifying the person of focus, key words, and what the question is asking. Also,
you should have determined if the question was positively worded, negatively worded,
or if it involves priority setting.
Scenario: A nurse is caring for a client who is from a culture different than his own.
Question: Which of the following actions by the nurse is most important in the provision
of culturally competent care?