QUESTIONS AND ANSWERS
Prior to administering a newly prescribed medication to a client, the nurse reviews the adverse
effects of the medication listed in a drug reference guide and determines the priority risks to
the client. While performing this action, the nurse is engaged in which step of the nursing
process?
Assessment.
Analysis.
Implementation.
Evaluation. - ANS analysis
A client who is fully awake after a gastroscopy asks the nurse for something to drink. After
confirming that liquids are allowed, which assessment action should the nurse consider a
priority?
Listen to bilateral lung and bowel sounds.
Obtain the client's pulse and blood pressure.
Assist the client to the bathroom to void.
Check the client's gag and swallow reflexes. - ANS check the client's gag and swallow reflexes
What is the rationale for using the nursing process in planning care for clients?
As a scientific process to identify nursing diagnoses of a clients' healthcare problems.
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,To establish nursing theory that incorporates the biopsychosocial nature of humans.
As a tool to organize thinking and clinical decision making about clients' healthcare needs.
To promote the management of client care in collaboration with other healthcare
professionals. - ANS As a tool to organize thinking and clinical decision making about clients'
healthcare needs.
A client who is diagnosed with methillicin-resistant Staphylococcus aureus receives a
prescription for vancomycin (Vancocin). Which assessment should the nurse perform to identify
a potential adverse effect?
Whisper test.
Romberg test.
Tactile discrimination.
Skin turgor. - ANS whisper test
A 40-year-old male client diagnosed with schizophrenia and alcohol dependence has not had
any visitors or phone calls since admission. He reports he has no family that cares about him
and was living on the streets prior to this admission. According to Erikson's theory of
psychosocial development, which stage is the client in at this time?
Isolation.
Stagnation.
Despair.
Role confusion. - ANS stagnation
The nurse is planning a community-based project to reduce obesity in a school-aged
population. Which outcome statement best supports the goal for this population?
Increase in exercise will decrease obesity in children with a sedentary life style.
Students with a body mass index above the 95 percentile will decrease.
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, Within 2 years, students with a body mass index greater than 95% will be reduced by 50%.
In the target population, 30% of students will be below the 95 percentile in weight. -
ANS Within 2 years, students with a body mass index greater than 95% will be reduced by
50%.
A client is brought to the Emergency Center after a snow-skiing accident. Which intervention is
most important for the nurse to implement?
Review the electrocardiogram tracing.
Obtain blood for coagulation studies.
Apply a warming blanket.
Provide heated PO fluids. - ANS review the electrocardiogram tracing
An older client with a fractured left hip is on strict bedrest. Which nursing measure is essential
to the client's nursing care?
Massage any reddened areas for at least five minutes.
Encourage active range of motion exercises on extremities.
Position the client laterally, prone, and dorsally in sequence.
Gently lift the client when moving into a desired position. - ANS gently lift the client when
moving into a desired position
A male client who is on the liver transplant list is called to the unit for a possible transplant.
When learning that the donor organ is no longer available, the client slams doors and shouts
vulgarities about his situation. What action should the nurse implement?
Encourage him to share his feelings more appropriately.
Express concern over his disappointment.
Arrange to have a clergy person visit.
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