Chapter 03 Ignatavicius: Overview of
Health Concepts for Medical-Surgical
Nursing Bank Verified Edition.
1. 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.
2. 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.
3. 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 203pack-year history of smoking
, 4. 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.
5. 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.
6. 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.
Health Concepts for Medical-Surgical
Nursing Bank Verified Edition.
1. 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.
2. 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.
3. 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 203pack-year history of smoking
, 4. 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.
5. 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.
6. 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.
