EXIT K 5 Q&A
The nurse is preparing to insert an intravenous (IV) catheter in a client who is being
admitted for uncontrolled diabetes. Upon assessment of the client's forearm for a
potential insertion site, the nurse notes that the client has an excessive amount of hair.
What should the nurse plan to do in order to properly prepare the site for insertion? -
(correct answer)Clip the hair.
What are expected changes that the nurse might identify when assessing the skin of an
older adult? Select all that apply. - (correct answer)Increased wrinkles
Hyperpigmented patches
A common method for assessing the size of a burn wound is to use the Rule of Nines.
Based on this method, estimate the extent of burns if the front chest, front abdomen,
both sides of both upper extremities, and entire head were affected. Using the Rule of
Nines, the estimate is: __% (Record your answer as a whole number) - (correct
answer)45
A nurse evaluates the condition of a client with burns of the upper body. Which
assessment findings indicate potential respiratory obstruction? Select all that apply. -
(correct answer)Dry cough
Singed nasal hair
Hoarse quality to the voice
A client with major burns of the head and chest is admitted to the burn unit. Twenty-four
hours after the burn, the client is complaining of severe thirst. The average urinary
output is 60 mL/hr for the last 10 hours. No bowel sounds are heard. The nurse's best
action is to: - (correct answer)Moisten the lips with wet gauze
A nurse is assessing a client with second-degree burns. The shaded areas in the
illustration indicate the parts of the body where the client sustained burns. Calculate the
percentage of the body that was burned using the Rule of Nines. Record your answer
using one decimal place. ___% - (correct answer)22.5
,A client is burned on the anterior part of both legs, from the knees to the feet. The nurse
uses the Rule of Nines to assess the percentage of total body surface area (TBSA)
burned. What percentage should the nurse document in the client's hospital record? -
(correct answer)9%
A client is admitted to the hospital after sustaining serious burns that involve a large
surface of the skin. The nurse is caring for the client during the emergent phase after
the injury. Which nursing objective is the priority during this phase? - (correct
answer)Restore fluid volume
The nurse is caring for a client with burns and reviews the client's laboratory results:
blood urea nitrogen (BUN) 30 mg/dL, creatinine 2.4 mg/dL, serum potassium 6.3
mEq/L, pH 7.1, Po2 90 mm Hg, and Hgb 7.4 g/dL. The nurse concludes that these
findings indicate: - (correct answer)Azotemia
A client has a supratentorial craniotomy for a tumor in the right frontal lobe of the
cerebral cortex. The nurse recognizes that, postoperatively, the position that is most
appropriate for this client is: - (correct answer)Head of the bed elevated 30 to 45
degrees with the neck in neutral alignment
Which is the priority assessment for the client with Guillain-Barré syndrome with rapidly
ascending paralysis? - (correct answer)Monitoring respiratory status.
A debilitated older client with glaucoma who places great value on independence is
being prepared for discharge from the hospital. To promote independence, the nurse
should encourage the client to: - (correct answer)Self-administer the eye medications
using appropriate technique
A nurse is teaching a client with a diagnosis of open-angle glaucoma. The nurse
explains that the chief aim of treatment is to: - (correct answer)Control the intraocular
pressure.
, A client exhibits blurred and double vision and muscular weakness, and diagnostic tests
are prescribed. The client is informed that a diagnosis of multiple sclerosis (MS) has
been made. The client becomes visibly upset. How should the nurse respond? - (correct
answer)That must have really shocked you. Tell me what the health care provider told
you about it.
The nurse is preparing to initiate intravenous antibiotic therapy on a client who
developed an infection along the incision after having a total knee replacement. Before
starting the first dose of intravenous antibiotics, which task should the nurse ensure has
been completed? - (correct answer)Wound culture
The nurse is caring for a client with rheumatoid arthritis. When should the nurse expect
the client to experience increased pain and limited movement of the joints? - (correct
answer)In the morning on awakening
A client is diagnosed as having expressive aphasia. What type of impairment does the
nurse expect the client to exhibit? - (correct answer)Speaking or writing
A client with rheumatoid arthritis asks the nurse why it is necessary to inject
hydrocortisone into the knee joint. What reason should the nurse include in a response
to this question? - (correct answer)Reduce inflammation
A client with myasthenia gravis experiences dysphagia. What is the priority risk
associated with dysphagia that must be considered when planning nursing care? -
(correct answer)Aspiration
The nurse is caring for a client with Parkinson disease. Which of the following is a
priority nursing concern? - (correct answer)Risk for injury
A client with Parkinsonism is taking an anticholinergic medication for morning stiffness
and tremors in the right arm. During a visit to the clinic the client complains of some
numbness in the left hand. What is the nurse's priority intervention? - (correct
The nurse is preparing to insert an intravenous (IV) catheter in a client who is being
admitted for uncontrolled diabetes. Upon assessment of the client's forearm for a
potential insertion site, the nurse notes that the client has an excessive amount of hair.
What should the nurse plan to do in order to properly prepare the site for insertion? -
(correct answer)Clip the hair.
What are expected changes that the nurse might identify when assessing the skin of an
older adult? Select all that apply. - (correct answer)Increased wrinkles
Hyperpigmented patches
A common method for assessing the size of a burn wound is to use the Rule of Nines.
Based on this method, estimate the extent of burns if the front chest, front abdomen,
both sides of both upper extremities, and entire head were affected. Using the Rule of
Nines, the estimate is: __% (Record your answer as a whole number) - (correct
answer)45
A nurse evaluates the condition of a client with burns of the upper body. Which
assessment findings indicate potential respiratory obstruction? Select all that apply. -
(correct answer)Dry cough
Singed nasal hair
Hoarse quality to the voice
A client with major burns of the head and chest is admitted to the burn unit. Twenty-four
hours after the burn, the client is complaining of severe thirst. The average urinary
output is 60 mL/hr for the last 10 hours. No bowel sounds are heard. The nurse's best
action is to: - (correct answer)Moisten the lips with wet gauze
A nurse is assessing a client with second-degree burns. The shaded areas in the
illustration indicate the parts of the body where the client sustained burns. Calculate the
percentage of the body that was burned using the Rule of Nines. Record your answer
using one decimal place. ___% - (correct answer)22.5
,A client is burned on the anterior part of both legs, from the knees to the feet. The nurse
uses the Rule of Nines to assess the percentage of total body surface area (TBSA)
burned. What percentage should the nurse document in the client's hospital record? -
(correct answer)9%
A client is admitted to the hospital after sustaining serious burns that involve a large
surface of the skin. The nurse is caring for the client during the emergent phase after
the injury. Which nursing objective is the priority during this phase? - (correct
answer)Restore fluid volume
The nurse is caring for a client with burns and reviews the client's laboratory results:
blood urea nitrogen (BUN) 30 mg/dL, creatinine 2.4 mg/dL, serum potassium 6.3
mEq/L, pH 7.1, Po2 90 mm Hg, and Hgb 7.4 g/dL. The nurse concludes that these
findings indicate: - (correct answer)Azotemia
A client has a supratentorial craniotomy for a tumor in the right frontal lobe of the
cerebral cortex. The nurse recognizes that, postoperatively, the position that is most
appropriate for this client is: - (correct answer)Head of the bed elevated 30 to 45
degrees with the neck in neutral alignment
Which is the priority assessment for the client with Guillain-Barré syndrome with rapidly
ascending paralysis? - (correct answer)Monitoring respiratory status.
A debilitated older client with glaucoma who places great value on independence is
being prepared for discharge from the hospital. To promote independence, the nurse
should encourage the client to: - (correct answer)Self-administer the eye medications
using appropriate technique
A nurse is teaching a client with a diagnosis of open-angle glaucoma. The nurse
explains that the chief aim of treatment is to: - (correct answer)Control the intraocular
pressure.
, A client exhibits blurred and double vision and muscular weakness, and diagnostic tests
are prescribed. The client is informed that a diagnosis of multiple sclerosis (MS) has
been made. The client becomes visibly upset. How should the nurse respond? - (correct
answer)That must have really shocked you. Tell me what the health care provider told
you about it.
The nurse is preparing to initiate intravenous antibiotic therapy on a client who
developed an infection along the incision after having a total knee replacement. Before
starting the first dose of intravenous antibiotics, which task should the nurse ensure has
been completed? - (correct answer)Wound culture
The nurse is caring for a client with rheumatoid arthritis. When should the nurse expect
the client to experience increased pain and limited movement of the joints? - (correct
answer)In the morning on awakening
A client is diagnosed as having expressive aphasia. What type of impairment does the
nurse expect the client to exhibit? - (correct answer)Speaking or writing
A client with rheumatoid arthritis asks the nurse why it is necessary to inject
hydrocortisone into the knee joint. What reason should the nurse include in a response
to this question? - (correct answer)Reduce inflammation
A client with myasthenia gravis experiences dysphagia. What is the priority risk
associated with dysphagia that must be considered when planning nursing care? -
(correct answer)Aspiration
The nurse is caring for a client with Parkinson disease. Which of the following is a
priority nursing concern? - (correct answer)Risk for injury
A client with Parkinsonism is taking an anticholinergic medication for morning stiffness
and tremors in the right arm. During a visit to the clinic the client complains of some
numbness in the left hand. What is the nurse's priority intervention? - (correct
