with Correct Answers
RATIONALES: The nurse shouldn't give a positive appraisal of the child's prognosis
because doing so gives the parents false hope. The nurse must be honest about the
child's prognosis and provide them accurate information about treatment options, which
include palliative care, comfort care, and pain management. The physician — not the
nurse — should discuss such treatment options as chemotherapy or bone marrow
transplantation, if indicated.
A client is scheduled for surgery under general anesthesia. The night before surgery,
the client tells the nurse, "I can't wait to have breakfast tomorrow." Based on this
statement, the nurse should formulate which nursing diagnosis?
1. Deficient knowledge related to food restrictions associated with anesthesia
2. Fear related to surgery
3. Risk for impaired skin integrity related to upcoming surgery
4. Ineffective coping related to the stress of surgery - Answer-Correct Answer: 1
RATIONALES: The client's statement reveals a Deficient knowledge related to food
restrictions associated with general anesthesia.The other options may be applicable but
aren't related to the client's statement.
The nurse is caring for a client with skin grafts covering third-degree burns on the arms
and legs. During dressing changes, the nurse should be sure to:
,1. apply maximum bandages to allow for absorption of drainage.
2. wrap elastic bandages distally to proximally on dependent areas.
3. wrap elastic bandages on the arms and legs, proximally to distally, to promote
venous return.
4. put on sterile gloves only when removing bandages. - Answer-Correct Answer: 2
RATIONALES: Wrapping elastic bandages on dependent areas limits edema formation
and bleeding and promotes graft acceptance. The nurse should wrap the client's arms
and legs from the distal to proximal ends and use strict sterile technique throughout the
dressing change. Applying maximum bandages should be avoided because bulky
dressings limit mobility; instead, the nurse should use enough bandages to absorb
wound drainage. Sterile gloves are required throughout all phases of the dressing
change to prevent contamination.
A client with hyperemesis gravidarum is on a clear liquid diet. The nurse should serve
this client:
1. milk and ice pops.
2. decaffeinated coffee and scrambled eggs.
3. tea and gelatin dessert.
,4. apple juice and oatmeal. - Answer-Correct Answer: 3
RATIONALES: A clear liquid diet consists of foods that are clear liquids at room
temperature or body temperature, such as ice pops, regular or decaffeinated coffee and
tea, gelatin desserts, carbonated beverages, and clear juices. Milk, pasteurized eggs,
egg substitutes, and oatmeal are part of a full liquid diet.
Because of difficulties with hemodialysis, peritoneal dialysis is initiated to treat a client's
uremia. Which finding signals a significantproblem during this procedure?
1. Blood glucose level of 200 mg/dl
2. White blood cell (WBC) count of 20,000/mm3
3. Potassium level of 3.8 mEq/L
4. Hematocrit (HCT) of 35% - Answer-Correct Answer: 2
RATIONALES: An increased WBC count indicates infection, probably resulting from
peritonitis, which may have been caused by insertion of the peritoneal catheter into the
peritoneal cavity. Peritonitis can cause the peritoneal membrane to lose its ability to
filter solutes; therefore, peritoneal dialysis would no longer be a treatment option for this
client. Hyperglycemia occurs during peritoneal dialysis because of the high glucose
content of the dialysate; it's readily treatable with sliding-scale insulin. A potassium level
of 3.8 mEq/L is an acceptable value. An HCT of 35% is lower than normal. However, in
this client, the value isn't abnormally low because of the daily blood samplings. A lower
HCT is common in clients with chronic renal failure because of the lack of
erythropoietin.
The nurse is collecting data on an 8-month-old infant during a wellness checkup. Which
of the following is a normal developmental task for an infant this age?
1. Sitting without support
, 2. Saying two words
3. Feeding himself with a spoon
4. Playing patty-cake - Answer-Correct Answer: 1
RATIONALES: According to the Denver Developmental Screening Test, most infants
should be able to sit unsupported by age 7 months. A 15-month-old child should be able
to say two words. By 17 months, the toddler should be able to feed himself with a
spoon. A 10-month-old infant should be able to play patty-cake.
The nurse is caring for a client with tuberculosis. Which precautions should the nurse
take when providing care for this client?
Select all that apply:
1. Wear gloves when handling tissues containing sputum.
2. Wear a face mask at all times.
3. Keep the client in strict isolation.
4. When the client leaves the room for tests, have all people in contact with him wear a
mask.
5. Keep the client's door open to allow fresh air into room and prevent social isolation.