Nursing 170 Exam 3 Questions With Complete Solutions
24 hour minimum amount of urination Correct Answer 30
mL/hr, 720 absolute minimum
A client experiences acute shortness of breath. Which
noninvasive technique should the nurse use to assess this client's
arterial oxygen saturation? Correct Answer 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? Correct Answer "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?
Correct Answer 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?
Correct Answer 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? Correct Answer 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? Correct Answer 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 Correct Answer 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? Correct Answer 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? Correct Answer 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? Correct
Answer 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.
24 hour minimum amount of urination Correct Answer 30
mL/hr, 720 absolute minimum
A client experiences acute shortness of breath. Which
noninvasive technique should the nurse use to assess this client's
arterial oxygen saturation? Correct Answer 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? Correct Answer "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?
Correct Answer 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?
Correct Answer 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? Correct Answer 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? Correct Answer 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 Correct Answer 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? Correct Answer 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? Correct Answer 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? Correct
Answer 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.
