PN VATI FUNDAMENTALS
1.A nurse is collecting data from a client who has an elevated temperature
with no sweating. Which of the following findings is an indication of
hyperna- tremia?
Thirst
Muscle
twitching
Headache
Abdominal cramps
ANS Thirst.
Rationale
Thirst, combined with an elevated temperature and a lack of sweating,
can be an indication of hypernatremia.
2.A nurse is caring for a client who reports difficulty sleeping due to the
noise on the nursing unit. Which of the following actions should the nurse
,take to reduce environmental noise?
Close the door to the client's room.
Turn off the alarms and beeps on monitoring
equipment. Conduct change-of-shift report outside the
client's door.
Keep the television on low in the client's room.
ANS Close the door to the client's room.
Rationale
The nurse should close the door to the client's room whenever possible
to reduce environmental noise.
3.A nurse is reinforcing teaching about health promotion with a client.
Which of the following actions should the nurse take first to promote
effective learn- ing?
Identify areas of concern.
Prioritize learning objectives.
Demonstrate psychomotor skills.
Observe nonverbal communication.
,ANS Identify areas of concern.
Rationale
The first action the nurse should take when using the nursing process is
to collect data from the client. Identifying and understanding the client's
concerns prior to reinforcing teaching promotes effective learning.
, 4.A home health nurse is assisting with the plan of care for a client. Which
of the following should the nurse include during the orientation phase of
the helping relationship?
Review current client data.
Assist to meet client goals.
Review shared memories of interactions with client.
Clarify the role of this individual nurse.
ANS Clarify the role of this individual nurse.
Rationale
The nurse should plan to establish a warm, caring relationship while
clarifying the role of each participant, which occurs during the
orientation phase of the relationship.
5.A nurse is preparing to assist with the admission of a client who has
pneu- monia. Which of the following observations about the client's room
requires immediate attention?
The wall BP gauge is missing.
1.A nurse is collecting data from a client who has an elevated temperature
with no sweating. Which of the following findings is an indication of
hyperna- tremia?
Thirst
Muscle
twitching
Headache
Abdominal cramps
ANS Thirst.
Rationale
Thirst, combined with an elevated temperature and a lack of sweating,
can be an indication of hypernatremia.
2.A nurse is caring for a client who reports difficulty sleeping due to the
noise on the nursing unit. Which of the following actions should the nurse
,take to reduce environmental noise?
Close the door to the client's room.
Turn off the alarms and beeps on monitoring
equipment. Conduct change-of-shift report outside the
client's door.
Keep the television on low in the client's room.
ANS Close the door to the client's room.
Rationale
The nurse should close the door to the client's room whenever possible
to reduce environmental noise.
3.A nurse is reinforcing teaching about health promotion with a client.
Which of the following actions should the nurse take first to promote
effective learn- ing?
Identify areas of concern.
Prioritize learning objectives.
Demonstrate psychomotor skills.
Observe nonverbal communication.
,ANS Identify areas of concern.
Rationale
The first action the nurse should take when using the nursing process is
to collect data from the client. Identifying and understanding the client's
concerns prior to reinforcing teaching promotes effective learning.
, 4.A home health nurse is assisting with the plan of care for a client. Which
of the following should the nurse include during the orientation phase of
the helping relationship?
Review current client data.
Assist to meet client goals.
Review shared memories of interactions with client.
Clarify the role of this individual nurse.
ANS Clarify the role of this individual nurse.
Rationale
The nurse should plan to establish a warm, caring relationship while
clarifying the role of each participant, which occurs during the
orientation phase of the relationship.
5.A nurse is preparing to assist with the admission of a client who has
pneu- monia. Which of the following observations about the client's room
requires immediate attention?
The wall BP gauge is missing.
