QUESTIONS & CORRECT ANSWERS.
Terms in this set (100)
To evaluate a client's reason Correct Answer: Organs
for seeking care, the nurse The purpose of deep palpation, in which the nurse indents
performs deep palpation. the client's skin approximately 1-1/2", is to assess underlying
The purpose of deep organs and structures such as the kidneys and spleen. Skin
palpation is to assess which turgor, hydration, and temperature can be assessed using
of the following? light touch or light palpation.
A client is brought to the The Correct answer is: assessment of vital signs Vital sign
emergency department assessment would be the priority nursing intervention. This
and the physician would provide an indication of the amount of blood loss
determines he has that has occurred and also provide a baseline by which to
gastrointestinal (GI) monitor the progress of treatment. The other answers (b, c,
bleeding. In planning for and d) are important but not priority actions.
his care, which of the
following would be first
priority?
When providing
Correct Answer: Discuss the importance of avoiding social
instructions to the
events in order to stay out of trouble.
adolescent regarding
Socialization is very important to teenagers and is a normal part
physical development of
of their development. The other answers
her body, the RN should do
(b, c, and d) are all accurate instructions and discussions for
all of the following
the adolescent regarding development.
EXCEPT
,The nurse is developing Correct answer: A referral. A referral is recommending home
discharge plans for a 65year- care services or giving information to an home care service
old client. The discharge regarding the client and the client's needs. Typically the
plans indicate the client will sources of referral to a home care agency are family
be discharged home with members, nurses, physicians, social workers, discharge
home health nursing care. planners or therapists.
The nurse provides the home
health agency with details
regarding the needs of the
patient. The nurse made
which of the following to the
home health agency?
Which of the following is the Correct answer: 1.6 to 2.4 mEq/L
normal serum electrolyte
level for magnesium?
The Correct answer is: in the morning, when the child awakens
Visualization of pinworms by means of a tape test is necessary
for the diagnosis. Transparent tape is lightly touched to the
The school nurse is anus and then applied to a slide for microscopic examination.
approached by a mother The best specimen is obtained as the child awakens, before
who explains that her toileting or bathing.
kindergarten child is
constantly scratching the
perianal area and that the
area is irritated. The RN
understands that she should
instruct the mother to obtain
a rectal specimen by a tape
test and that the mother
should obtain the specimen
when?
, A 20-year-old patient is Correct Answer: Suction the lungs
admitted to the hospital with The first priority is to make sure the client's airways are clear
respiratory failure. He's and that he can breathe. The other choices can be addressed
intubated, given oxygen, and after ensuring the client can breathe.
is coughing with copious
secretions in his lungs. What
should be done first?
A high school student is Correct Answer: The student accepts a referral to a
referred to the school nurse substance abuse counselor. All of the outcomes stated are
for suspected substance desirable; however, the best outcome is that the student
abuse. Following the nurse's would agree to seek the assistance of a professional
assessment and intervention, substance abuse counselor.
what would be the MOST
desirable outcome?
The RN is preparing an Normal saline (0.9%) solution. Phenytoin (Dilantin) should be
intravenous infusion of administered by injection into a large vein by intermittent
phenytoin (Dilantin) as intravenous infusion. Normal saline (0.9%) solution is the
prescribed by the physician preferred solution. Dextrose should be avoided because of
for the client with seizures. medication precipitation.
Which of the following
solutions will the nurse use
to dilute this medication?
Gravida
Which of the following terms
Gravida is another word for pregnancy.
corresponds with the phrase:
a woman that is pregnant? Spermatogonia refers to male sperm cells. Placenta previa is
when the placenta is too close to the cervix.