Questions and Answers 100% Pass
A nurse is teaching a client about carbon monoxide poisoning. Which of the following
statements should the nurse identify as an indication that the client needs further
instruction?
- "A high concentration of carbon monoxide can cause death."
- "I can detect the presence of carbon monoxide by a metallic odor."
- "I should purchase a carbon monoxide detector for my home."
- "Breathing in carbon monoxide can cause headaches and nausea." - ✔✔"I can detect
the presence of carbon monoxide by a metallic odor."
A nurse is assessing a client who had left femoral cardiac angiography. Identify where
the nurse will palpate to assess the most distal pulse on the affected side. (Selectable
areas, or "Hot Spots," are outlines in the artwork below. Select only the outlined area
that corresponds to your answer.) - ✔✔Left pedal pulse:
The most distal pulse refers to the pulse that is at the farthest point on the affected
extremity. The dorsalis pedis pulse on the anterior foot is the most distal pulse below
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,the femoral artery. Because the client had left-sided angiography, the correct answer
will be the left pedal pulse.
A rehabilitation nurse is caring for a client who has had a spinal cord injury that
resulted in paraplegia. After a week on the unit, the nurse notes that the client is
withdrawn and increasingly resistant to rehabilitative efforts by the staff. Which of the
following actions should the nurse take?
- Inform the client that privileges are related to participation in therapy.
- Limit visiting hours until the client begins to participate in therapy.
- Allow the client to control the timing and frequency of the therapy.
- Establish a plan of care with the client that sets attainable goals. - ✔✔Establish a plan
of care with the client that sets attainable goals.
A nurse is monitoring a client who was admitted with a severe burn injury and is
receiving IV fluid resuscitation therapy. The nurse should identify a decrease in which
of the which of the following findings as an indication of adequate fluid replacement?
- BP
- Heart rate
- Urine output
- Weight - ✔✔Heart rate
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,A nurse is caring for a client who has urinary incontinence. Which of the following
actions should the nurse implement to prevent the development of skin breakdown?
- Apply a moisture barrier ointment to the client's skin.
- Clean the client's skin and perineum with hot water after each episode of incontinence.
- Check the client's skin every 8 hr for signs of breakdown.
- Request a prescription for the insertion of an indwelling urinary catheter. - ✔✔Apply a
moisture barrier ointment to the client's skin.
A nurse is teaching a class of older adults about the expected physiologic changes of
aging. Which of the following changes should the nurse include in the discussion?
(Select all that apply.)
- More difficulty seeing due to a greater sensitivity to glare
- Decreased cough reflex
- Decreased bladder capacity
- Decreased systolic blood pressure
- Dehydration of intervertebral discs - ✔✔More difficulty due to a greater sensitivity to
glare,
Decreased cough reflex,
Decreased bladder capacity,
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, Dehydration of intervertebral discs is correct
A nurse is assessing a client who is 2 days postoperative and auscultates bilateral breath
sounds, but absent breath sounds in the bases. The nurse should suspect which of the
following postoperative complications?
- Atelectasis
- Pneumonia
- Pulmonary embolism
- Arterial thrombus - ✔✔Atelectasis
Atelectasis is an incomplete alveolar expansion or collapse. Breath sounds are dull or
absent over areas of alveolar collapse.
A nurse is working with a team of nursing personnel within a facility. Which of the
following are necessary task performance roles that members of the group or the leader
must perform? (Select all that apply.)
- Self-confessor
- Coordinator
- Evaluator
- Energizer
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