Submission Details
Submission Date: 11/9/2014
Submission Time: 11:53 AM
Points Awarded: 100
Points Missed: 0
Number of Attempts Allowed:
Unlimited Not Scored: 0
Percentage: 100%
Questions
1.ID: 283571104
A nurse is working in the emergency department. Which of the following clients should be assessed
first?
A client with new-onset dizziness
A client admitted with a recent ear injury
A client who has been experiencing nausea and vomiting for 12 hours
A client with new-onset atrial fibrillation with a rate of 118 beats/min Correct
Rationale: The client with new-onset atrial fibrillation is at risk for complications associated with the
tachydysrhythmia. This dysrhythmia may result in decreased cardiac output because of ineffective atrial
contractions. Thrombi form in the atria as a result of the pooling of blood. All of the other clients will
require the nurse’s attention, but the client who requires immediate attention and is the most
hemodynamically unstable is the one with atrial fibrillation.
Test-Taking Strategy: Use the process of elimination and use the ABCs — airway, breathing, and
circulation — to find the correct option. The client experiencing atrial fibrillation is the least stable of the
clients identified in the other options. Review the principles of prioritization if you had difficulty with this
,question.
Reference: Black, J., & Hawks, J. (2009). Medical-surgical nursing: Clinical management for positive
outcomes (8th ed., pp. 1457-1458, 2203). St. Louis: Saunders.
Level of Cognitive Ability: Applying
Client Needs: Physiological
Integrity
Integrated Process: Nursing Process/Implementation
Content Area: Delegating/Prioritizing
Awarded 1.0 points out of 1.0 possible
points. 2.ID: 283569282
A client who experienced a brain attack (stroke) exhibits right-sided unilateral neglect. The nurse caring
for this client plans to place the client’s personal care items:
Within the client’s reach on the left side
Within the client’s reach on the right side Correct
Just out of the client’s reach on the left side
Just out of the client’s reach on the right side
Rationale: Unilateral neglect is unawareness of one side of the body. The client behaves as if that part is
not there. The client does not look at the paralyzed limb when moving about. Unilateral neglect results
in increased risk for injury. It is possible for the client to relearn to look for and to move the affected
limb(s). Therefore in this condition the client’s personal care items are placed within the client’s reach
on the right side. Hemiparesis is a weakness of the face, arm, and leg on one side. The client with one-
sided hemiparesis benefits from having objects placed on the unaffected side and within reach. This
reduces client frustration and aids in ensuring client safety because the client does not have to strain
and reach for needed items. The nurse adapts the client’s environment to the deficit by focusing on the
client’s unaffected side and by placing the client’s personal care items on the affected side within reach.
Placing items out of the client’s reach presents a risk of injury.
,Test-Taking Strategy: Use the process of elimination. Eliminate the options first that are potentially
hazardous to the client. To select from the remaining options, focus on the subject, unilateral neglect.
With unilateral neglect, objects are placed on the affected side to train the client to attend to that part of
the environment. Review care of the client with unilateral neglect if you had difficulty with this question.
Reference: Black, J., & Hawks, J. (2009). Medical-surgical nursing: Clinical management for positive
outcomes (8th ed., pp. 1850, 1865). St. Louis: Saunders.
Level of Cognitive Ability: Applying
Client Needs: Physiological
Integrity
Integrated Process: Nursing Process/Planning
Content Area: Adult Health/Neurological
Awarded 1.0 points out of 1.0 possible
points. 3.ID: 283569800
A woman in labor suddenly complains of abdominal tenderness and pain and states that she felt as
though “something ripped.” For which manifestations does the nurse, suspecting uterine rupture,
assess the client? Select all that apply.
Bradypnea
Severe chest pain Correct
Absence of fetal heart tones Correct
Increased blood pressure
Increased frequency of uterine contractions
Rationale: Signs of uterine rupture vary with the degree of rupture. Signs and symptoms include
abdominal pain and tenderness, chest pain, hypovolemic shock, signs associated with impaired fetal
, oxygenation, an absence of fetal heart tones, cessation of uterine contractions, and palpation of the
fetus outside the uterus if the rupture is complete. Signs of hypovolemic shock include tachycardia;
tachypnea; pallor; cool, clammy skin; and anxiety.
Test-Taking Strategy: Use the process of elimination, thinking about the manifestations that would be
present in the event of uterine rupture. Knowing that bleeding would occur and recalling the signs of
shock will assist you in answering correctly. Also, recalling that contractions would cease if rupture
occurred will assist you in eliminating the option of increased frequency of uterine contractions.
Review the manifestations associated with uterine rupture if you had difficulty with this question.
Reference: Lowdermilk, D., Perry, S., & Cashion, K. (2010). Maternity nursing (8th ed., p. 719). St. Louis:
Mosby.
Level of Cognitive Ability: Analyzing
Client Needs: Physiological
Integrity
Integrated Process: Nursing Process/Assessment
Content Area: Maternity/Intrapartum
Awarded 1.0 points out of 1.0 possible
points. 4.ID: 283570730
A client is transported to the recovery area of the ambulatory care unit after cataract surgery. In which
position does the nurse place the client?
Supine
Semi-Fowler Correct
On the side that has undergone surgery
Prone on the side that has undergone surgery
Rationale: After cataract extraction surgery, the client should be placed in the semi-Fowler position or
on the unaffected side to prevent edema at the surgical site. Supine, on the affected side, and prone are
all
Submission Date: 11/9/2014
Submission Time: 11:53 AM
Points Awarded: 100
Points Missed: 0
Number of Attempts Allowed:
Unlimited Not Scored: 0
Percentage: 100%
Questions
1.ID: 283571104
A nurse is working in the emergency department. Which of the following clients should be assessed
first?
A client with new-onset dizziness
A client admitted with a recent ear injury
A client who has been experiencing nausea and vomiting for 12 hours
A client with new-onset atrial fibrillation with a rate of 118 beats/min Correct
Rationale: The client with new-onset atrial fibrillation is at risk for complications associated with the
tachydysrhythmia. This dysrhythmia may result in decreased cardiac output because of ineffective atrial
contractions. Thrombi form in the atria as a result of the pooling of blood. All of the other clients will
require the nurse’s attention, but the client who requires immediate attention and is the most
hemodynamically unstable is the one with atrial fibrillation.
Test-Taking Strategy: Use the process of elimination and use the ABCs — airway, breathing, and
circulation — to find the correct option. The client experiencing atrial fibrillation is the least stable of the
clients identified in the other options. Review the principles of prioritization if you had difficulty with this
,question.
Reference: Black, J., & Hawks, J. (2009). Medical-surgical nursing: Clinical management for positive
outcomes (8th ed., pp. 1457-1458, 2203). St. Louis: Saunders.
Level of Cognitive Ability: Applying
Client Needs: Physiological
Integrity
Integrated Process: Nursing Process/Implementation
Content Area: Delegating/Prioritizing
Awarded 1.0 points out of 1.0 possible
points. 2.ID: 283569282
A client who experienced a brain attack (stroke) exhibits right-sided unilateral neglect. The nurse caring
for this client plans to place the client’s personal care items:
Within the client’s reach on the left side
Within the client’s reach on the right side Correct
Just out of the client’s reach on the left side
Just out of the client’s reach on the right side
Rationale: Unilateral neglect is unawareness of one side of the body. The client behaves as if that part is
not there. The client does not look at the paralyzed limb when moving about. Unilateral neglect results
in increased risk for injury. It is possible for the client to relearn to look for and to move the affected
limb(s). Therefore in this condition the client’s personal care items are placed within the client’s reach
on the right side. Hemiparesis is a weakness of the face, arm, and leg on one side. The client with one-
sided hemiparesis benefits from having objects placed on the unaffected side and within reach. This
reduces client frustration and aids in ensuring client safety because the client does not have to strain
and reach for needed items. The nurse adapts the client’s environment to the deficit by focusing on the
client’s unaffected side and by placing the client’s personal care items on the affected side within reach.
Placing items out of the client’s reach presents a risk of injury.
,Test-Taking Strategy: Use the process of elimination. Eliminate the options first that are potentially
hazardous to the client. To select from the remaining options, focus on the subject, unilateral neglect.
With unilateral neglect, objects are placed on the affected side to train the client to attend to that part of
the environment. Review care of the client with unilateral neglect if you had difficulty with this question.
Reference: Black, J., & Hawks, J. (2009). Medical-surgical nursing: Clinical management for positive
outcomes (8th ed., pp. 1850, 1865). St. Louis: Saunders.
Level of Cognitive Ability: Applying
Client Needs: Physiological
Integrity
Integrated Process: Nursing Process/Planning
Content Area: Adult Health/Neurological
Awarded 1.0 points out of 1.0 possible
points. 3.ID: 283569800
A woman in labor suddenly complains of abdominal tenderness and pain and states that she felt as
though “something ripped.” For which manifestations does the nurse, suspecting uterine rupture,
assess the client? Select all that apply.
Bradypnea
Severe chest pain Correct
Absence of fetal heart tones Correct
Increased blood pressure
Increased frequency of uterine contractions
Rationale: Signs of uterine rupture vary with the degree of rupture. Signs and symptoms include
abdominal pain and tenderness, chest pain, hypovolemic shock, signs associated with impaired fetal
, oxygenation, an absence of fetal heart tones, cessation of uterine contractions, and palpation of the
fetus outside the uterus if the rupture is complete. Signs of hypovolemic shock include tachycardia;
tachypnea; pallor; cool, clammy skin; and anxiety.
Test-Taking Strategy: Use the process of elimination, thinking about the manifestations that would be
present in the event of uterine rupture. Knowing that bleeding would occur and recalling the signs of
shock will assist you in answering correctly. Also, recalling that contractions would cease if rupture
occurred will assist you in eliminating the option of increased frequency of uterine contractions.
Review the manifestations associated with uterine rupture if you had difficulty with this question.
Reference: Lowdermilk, D., Perry, S., & Cashion, K. (2010). Maternity nursing (8th ed., p. 719). St. Louis:
Mosby.
Level of Cognitive Ability: Analyzing
Client Needs: Physiological
Integrity
Integrated Process: Nursing Process/Assessment
Content Area: Maternity/Intrapartum
Awarded 1.0 points out of 1.0 possible
points. 4.ID: 283570730
A client is transported to the recovery area of the ambulatory care unit after cataract surgery. In which
position does the nurse place the client?
Supine
Semi-Fowler Correct
On the side that has undergone surgery
Prone on the side that has undergone surgery
Rationale: After cataract extraction surgery, the client should be placed in the semi-Fowler position or
on the unaffected side to prevent edema at the surgical site. Supine, on the affected side, and prone are
all
