Solutions
68-year-old female client is exhibiting slight confusion and
restlessness. She is anemic and HgB 7. Room air SpO2 is 89%.
Pulse is 110. Which of the following is the MOST likely
explanation of this current condition?
A. HgB of 7 reduce carrying capacity of oxygen molecules to
tissues
B. Increased metabolic rate causes confusion and restlessness
C. Cyanosis causes findings outside normal
D. Decreased metabolic rate causes increased pulse oximetry
Correct Answer A. HgB of 7 reduce carrying capacity of
oxygen molecules to tissues
A client comes to the clinic for ID skin testing. What question(s)
do you want to ask the client? (Mark ALL that apply)
A. Have you ever had a positive skin test in the past?
B. Will you be able to return to the clinic in 72 hours for the test
results to be read?
• Matters for the ppd test
C. What medications are you taking including OTC meds?
• Some medications may make them not get the right reaction
D. Do you have any scars or tattoos on your abdomen?
• ID is normally done in the forearms and sometimes the back
• Do care about tattoos, hair, and scar tissue on their forearms
because it could alter the results
E. Are you right or left handed?
• If they are right handed you would give the injection in the left
arm
,• Want to give injection in the non-dominant arm because it is
left active and you don't want the ppd to absorb rapidly Correct
Answer A. Have you ever had a positive skin test in the past?
B. Will you be able to return to the clinic in 72 hours for the test
results to be read?
E. Are you right or left handed?
A client is comatose and unable to state her name. How do you
verify she is the correct client for medication administration?
A. By checking the name and medical record number on the
MAR against the client's ID bracelet
B. By asking the visitor at the bedside to state the client's name
C. By asking the physician
D. By looking at the room number and bed the client is in
Correct Answer A. By checking the name and medical record
number on the
A client with a history of CVA has L-sided weakness and
difficulty with thick oral secretions and swallowing. Why would
you choose a Yankauer or tonsillar tip suction catheter to
perform oropharyngeal suctioning on this client instead of a
standard suction catheter?
A. It can also be used to suction the nares, if necessary
B. It is less likely to cause choking
C. It is less likely to damage oral mucus membranes
D. It can handle large volumes of secretions Correct Answer
D. It can handle large volumes of secretions
A confused client on a ventilator was restrained to prevent him
from pulling out his endotracheal tube. Which of the following
, could be a possible alternative measure that the nurse could use
to avoid the use of the restraints?
A. Orient client to the environment and explain the need to the
endotracheal tube
B. Provide a trained sitter to continuously supervise client
C. Camouflage the endotracheal tube with tockinette dressing
D. Promote relaxation techniques Correct Answer B. Provide
a trained sitter to continuously supervise client
A health care provider may suspect that a patient is experiencing
urinary retention when the patient has (Table 45-1)
A. Large amounts of voided cloudy urine polyuria; S/S of UTI
B. Pain in the suprapubic region S/S of infection
C. Spasms and difficulty during urination
D. Small amounts of urine voided 2 to 3 times per hour Correct
Answer D. Small amounts of urine voided 2 to 3 times per hour
Rationale: this means they really aren't emptying it all
A newly admitted client was found wandering the hallways for
the past two nights. The most appropriate nursing interventions
to prevent a fall for this client would include:
A. Raise all four side rails when darkness falls
B. Use an electronic bed-monitoring device
C. Place the client in a room close to the nursing station
D. Use a loose-fitting vest-type jacket restraint Correct Answer
B. Use an electronic bed-monitoring device
A newly admitted patient states that he has recently has a change
in meds and reports that stools are now dry and hard to pass.
This type f bowel pattern is consistent with
A. Abnormal defecation