ASSESSMENT COMPLETE EXAM
QUESTIONS WITH CORRECT ANSWERS
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Case Study:
A nurse is caring for a client with voniting for the last 3 days. The client is NPO
with NG to low intermittent suction.
1. Which acid base imbalance
2. What manifestation
3. At-risk for which fluid and electrolyte imbalances?
4. Treatment/nursing intervention - ANSWER ✓ 1. Metabolic alkalosis
2. Restlessness, muscle twitching, numbness and tingling
3. Low sodium, low potassium, hypovolemia
4. Control vomiting/nausea with meds and give fluids IV. Monitor I&Os
Which client is at risk for Respiratory Alkalosis?
1. Opioid overdose (6 breaths per min)
2. Aspirin overdose
3. Hyperventilating (28 breaths per min)
4. Emphysema (chronic lung condition) - ANSWER ✓ 3
Which client is at risk for Respiratory Acidosis? (Select all that apply)
1. Hyperventilating
2. Emphysema
3. Acetylsalicylic acid overdose
,4. Opioid overdose
5.Vomiting and set up with NG section
6. Diarrhea after a GI infection - ANSWER ✓ 2, 4
Anticipatory Grief - ANSWER ✓ This grief implies the "letting go" of an object
or person before the loss, as in a terminal illness.
Individuals have the opportunity to start the grieving process before the actual loss.
Complicated Grief - ANSWER ✓ Usually, the work of grief is prolonged. The
manifestations of grief are more severe, and they can result in depression or
exacerbate a preexisting disorder.
The client can develop suicidal ideation, intense feelings of guilt, and lowered
self-esteem.
Diabetic Foot Care - ANSWER ✓ Inspect feet daily
Wash with mild soap and warm water - DO NOT soak! avoid lotions to decrease
excess moisture and prevent infection
Use mild foot powder with cornstarch on sweaty feet
Avoid open-toe, open-heel shoes
Leather shoes instead of plastic
DO NOT go barefoot!
Avoid prolonged sitting, standing, and crossing of legs
Clean cuts with warm water, mild soap, gently dry & apply dressing
Herbal Supplements
Aloe:
Chamomile:
Echinacea:
Garlic:
Ginger:
Ginkgo biloba:
Ginseng:
Valerian:
Promotes sleep, reduces anxiety
Wound healing
Antiemetic
Improves memory
, Anti-inflammatory, calming
Increases physical endurance
Enhances immunity
Inhibits platelet aggregation - ANSWER ✓ Aloe: Wound healing
Chamomile: Anti-inflammatory, calming
Echinacea: Enhances immunity
Garlic: Inhibits platelet aggregation
Ginger: Antiemetic
Ginkgo biloba: Improves memory
Ginseng: Increases physical endurance
Valerian: Promotes sleep, reduces anxiety
Restraints - ANSWER ✓ Medical- for client's pulling out lines/tubes or getting out
of bed
Behavioral- for client's in imminent risk to themselves or others
Restraint nurse's roles and responsibilities: - ANSWER ✓ Obtain physician order
in writing after the patient has been seen face-to-face by the provider (usually
within 1 hour)
Renew restraint orders every 24 hours
Release every 2 hours for assessment of skin, ROM activities, and for hygiene and
elimination
Secure restraints to an immovable part of the bed frame. If restraints with a buckle
strap are not available, use a quick-release knot to tie the strap.
When assessing the client with a wrist restraint , which observation by the charge
nurse indicates that the nurse who placed the restraint on failed to follow safety
guidelines?
A.A safety knot was used to secure the restraint.
B.The call light was placed within reach of the client.
C.The restraint was applied tightly around the client's wrist.
D.The clients record indicates that the restraint was released every 2 hours. -
ANSWER ✓ B
A nurse manager is reviewing with nurses on the unit in the care of a client who
has had a seizure. Which of the following statements by a nurse requires further
instruction?