Nursing 170 Exam 3 100% Solved 100%
A client experiences acute shortness of breath. Which noninvasive technique should the
nurse use to assess this client's arterial oxygen saturation? - Answers-Pulse oximetry
A client who has been hospitalized for an infection states, "The nursing assistant told
me my vital signs are all within normal limits; that means I'm cured." What would be the
nurse's best response? - Answers-"Your vital signs are stable, but there are other things
to assess."
A client's axillary temperature is 100.8°F. The nurse realizes this is outside normal
range for this client and that axillary temperatures do not reflect core temperature. What
should the nurse do to obtain a good estimate of the core temperature? - Answers-
Obtain a rectal temperature reading.
A client's radial pulse is full and bounding. Which nursing diagnosis should the nurse
select to address this clinical finding? - Answers-Excess fluid volume
A confused patient asks to use the bathroom even though the patient was toilette only
30 minutes earlier. Which should the nurse do? - Answers-Immediate toileting meets
the patient's need to void and promotes contience
A culture and sensitivity test of a patient's urine is ordered. Which should the nurse do
to ensure accurate results of a urine culture and sensitivity test? - Answers-a midstream
urine sample contains a specimen that is relatively free of microorganisms from the
urethra. After perineal care, cleansing of the urethral opening, and the initiation of
urination, a specimen is collected during the mid portion of the stream.
a dangerous heat emergency - Answers-heatstroke
A mother of a school-age child seeks healthcare because her child has had diarrhea
after being ill with a viral infection. The patient states that after vomiting for 24 hours, his
appetite has returned. Which recommendation should the nurse make to this mother? -
Answers-Consume a diet consisting of bananas, white rice, applesauce, and toast.
A nurse collected information from several patients. Which information indicates the
patient who has the highest risk for developing diarrhea? - Answers-Psychological
stress initially increases intentional motility and mucus secretion, promoting diarrhea.
A nurse initiates contact precautions for a patient with a wound infection. Which should
the nurse do to help the patient cope with the psychological aspects of these
precautions? - Answers-Explanations support understanding, acceptance, and
compliance with isolation precautions. When people understand the reason for a
procedure, fear of the unknown and anxiety usually are reduced.
, A nurse irrigates the wound of a patient on contact precautions. Which should the nurse
do first to remove personal protective equipment when leaving the patient's room? -
Answers-The waist is considered contaminated and should be untied with a gloved
hand
A nurse is assessing a patient's wound. Which characteristic of the wound's exudate
indicates to the nurse that the wound may be infected? - Answers-Purulent exudate
contains material such as dead and living bacteria and dead tissue; it indicates the
possibility of an infection
A nurse is caring for a debilitated patient who is constipated and unable to tolerate a
large volume of enema solution. - Answers-A hypertonic enema solution uses only 120
to 180 mL of solution. hypertonic solutions expend osmotic pressure that draws fluid out
of interstitial spaces.
A nurse is caring for a patient diagnosed with stress incontinence. Which is the common
underlying cause of stress incontinence that the nurse needs to consider when caring
for this patient? - Answers-When intra abdominal pressure increases, the person with
stress incontinence usually experiences urinary dribbling or an approximate loss of 50
mL of urine or less.
A nurse is caring for a patient with an infection. For which most common response to
infection should the nurse assess the patient? - Answers-Fever is the most common
response of the hypothalamus
A nurse is changing a patient's bed linens. Where should the nurse place soiled linen
when it is removed from the bed? - Answers-Depositing soiled linen in a soiled linen
hamper is a safe and acceptable way to contain microorganisms.
A nurse is cleaning an emesis basin containing purulent material. Which should the
nurse do first? - Answers-Rinsing the basin with cold running water is a correct action
because it does not coagulate the protein of organic material, permitting it to be flushed
from the surface of the basin
A nurse is planning care for patients who are diagnosed with acquired
immunodeficiency syndrome. For which complication are all these patients at the
greatest risk? - Answers-All patients who have AIDS are immunosuppressed and have
a decreased ability to fight infection; this places them at the greatest risk for acquired
infections
A nurse is teaching a group of business people about disease transmission. He knows
that he needs to reeducate when one of the participants states which of the following? -
Answers-"If I don't feel sick, then I don't have to worry about transmitted diseases."
A client experiences acute shortness of breath. Which noninvasive technique should the
nurse use to assess this client's arterial oxygen saturation? - Answers-Pulse oximetry
A client who has been hospitalized for an infection states, "The nursing assistant told
me my vital signs are all within normal limits; that means I'm cured." What would be the
nurse's best response? - Answers-"Your vital signs are stable, but there are other things
to assess."
A client's axillary temperature is 100.8°F. The nurse realizes this is outside normal
range for this client and that axillary temperatures do not reflect core temperature. What
should the nurse do to obtain a good estimate of the core temperature? - Answers-
Obtain a rectal temperature reading.
A client's radial pulse is full and bounding. Which nursing diagnosis should the nurse
select to address this clinical finding? - Answers-Excess fluid volume
A confused patient asks to use the bathroom even though the patient was toilette only
30 minutes earlier. Which should the nurse do? - Answers-Immediate toileting meets
the patient's need to void and promotes contience
A culture and sensitivity test of a patient's urine is ordered. Which should the nurse do
to ensure accurate results of a urine culture and sensitivity test? - Answers-a midstream
urine sample contains a specimen that is relatively free of microorganisms from the
urethra. After perineal care, cleansing of the urethral opening, and the initiation of
urination, a specimen is collected during the mid portion of the stream.
a dangerous heat emergency - Answers-heatstroke
A mother of a school-age child seeks healthcare because her child has had diarrhea
after being ill with a viral infection. The patient states that after vomiting for 24 hours, his
appetite has returned. Which recommendation should the nurse make to this mother? -
Answers-Consume a diet consisting of bananas, white rice, applesauce, and toast.
A nurse collected information from several patients. Which information indicates the
patient who has the highest risk for developing diarrhea? - Answers-Psychological
stress initially increases intentional motility and mucus secretion, promoting diarrhea.
A nurse initiates contact precautions for a patient with a wound infection. Which should
the nurse do to help the patient cope with the psychological aspects of these
precautions? - Answers-Explanations support understanding, acceptance, and
compliance with isolation precautions. When people understand the reason for a
procedure, fear of the unknown and anxiety usually are reduced.
, A nurse irrigates the wound of a patient on contact precautions. Which should the nurse
do first to remove personal protective equipment when leaving the patient's room? -
Answers-The waist is considered contaminated and should be untied with a gloved
hand
A nurse is assessing a patient's wound. Which characteristic of the wound's exudate
indicates to the nurse that the wound may be infected? - Answers-Purulent exudate
contains material such as dead and living bacteria and dead tissue; it indicates the
possibility of an infection
A nurse is caring for a debilitated patient who is constipated and unable to tolerate a
large volume of enema solution. - Answers-A hypertonic enema solution uses only 120
to 180 mL of solution. hypertonic solutions expend osmotic pressure that draws fluid out
of interstitial spaces.
A nurse is caring for a patient diagnosed with stress incontinence. Which is the common
underlying cause of stress incontinence that the nurse needs to consider when caring
for this patient? - Answers-When intra abdominal pressure increases, the person with
stress incontinence usually experiences urinary dribbling or an approximate loss of 50
mL of urine or less.
A nurse is caring for a patient with an infection. For which most common response to
infection should the nurse assess the patient? - Answers-Fever is the most common
response of the hypothalamus
A nurse is changing a patient's bed linens. Where should the nurse place soiled linen
when it is removed from the bed? - Answers-Depositing soiled linen in a soiled linen
hamper is a safe and acceptable way to contain microorganisms.
A nurse is cleaning an emesis basin containing purulent material. Which should the
nurse do first? - Answers-Rinsing the basin with cold running water is a correct action
because it does not coagulate the protein of organic material, permitting it to be flushed
from the surface of the basin
A nurse is planning care for patients who are diagnosed with acquired
immunodeficiency syndrome. For which complication are all these patients at the
greatest risk? - Answers-All patients who have AIDS are immunosuppressed and have
a decreased ability to fight infection; this places them at the greatest risk for acquired
infections
A nurse is teaching a group of business people about disease transmission. He knows
that he needs to reeducate when one of the participants states which of the following? -
Answers-"If I don't feel sick, then I don't have to worry about transmitted diseases."
