Fundamentals of Nursing 11th Edition Potter Perry (testbank)

1. A nurse is assessing a patient with prolonged constipation. Which finding is most concerning and requires immediate action? A. Abdominal distension B. Hypoactive bowel sounds C. Hematochezia (bright red rectal bleeding) D. Hard, dry stool Correct Answer: C Rationale: Bright red rectal bleeding could indicate hemorrhoids, anal fissures, or colorectal pathology and requires prompt evaluation. ________________________________________ 2. A nurse is preparing a patient for a colonoscopy. W...

1. A nurse is educating a patient about normal urinary output. Which statement by the patient indicates understanding? A. “I should urinate about 100 mL per day.” B. “Normal urine output is at least 30 mL per hour.” C. “As long as I void once a day, it’s okay.” D. “Urine output depends only on how much I eat.” Correct Answer: B Rationale: Normal urinary output is approximately 30 mL/hour or 720 mL/day. Less than this may indicate impaired kidney function. _______________...

1. A patient with severe vomiting is at risk for which acid-base imbalance? A. Respiratory acidosis B. Respiratory alkalosis C. Metabolic alkalosis D. Metabolic acidosis Correct Answer: C Rationale: Vomiting leads to the loss of hydrochloric acid from the stomach, causing a metabolic alkalosis. ________________________________________ 2. Which electrolyte imbalance is most likely to cause cardiac dysrhythmias? A. Hypernatremia B. Hypokalemia C. Hypocalcemia D. Hypermagnesemia Correc...

1. What is the primary purpose of a patient’s medical record? A) To serve as a financial record for billing B) To provide legal evidence for malpractice claims C) To facilitate communication among members of the healthcare team D) To serve as a public document Answer: C Rationale: The medical record is a vital tool for interdisciplinary communication and continuity of care. ________________________________________ 2. Which documentation format uses a problem-solving approach to chartin...

A nurse evaluates the effectiveness of pain management interventions for a postoperative patient. Which finding indicates a positive patient outcome? A. The patient states, “The pain is still the same.” B. The patient refuses to ambulate due to pain. C. The patient rates pain as 3/10 and ambulates 50 feet with assistance. D. The patient requests more medication every hour. Correct Answer: C Rationale: Pain rating of 3/10 with improved mobility indicates that the intervention was effect...

1. A nurse is developing a care plan for a patient with chronic heart failure. Which of the following is the best example of a correctly written goal? A. The patient will increase physical activity. B. The patient will walk 50 feet using a walker within three days. C. The patient should try to feel better within the week. D. The nurse will assist the patient with mobility exercises. Answer: B. The patient will walk 50 feet using a walker within three days. Rationale: This goal is specific,...

1. A nurse is assessing a patient and determines that the patient has insufficient resources to meet basic nutritional needs. Which type of nursing diagnosis does this represent? A. Risk diagnosis B. Actual diagnosis C. Wellness diagnosis D. Syndrome diagnosis Answer: B. Actual diagnosis Rationale: An actual nursing diagnosis identifies an existing problem validated by signs and symptoms. ________________________________________ 2. Which component is essential in formulating an accurate ...

1. A nurse is assessing a client who is confused and has been noncompliant with medication. Which step of critical thinking is the nurse performing when identifying this client’s problem? A. Interpretation B. Analysis C. Evaluation D. Inference Answer: A. Interpretation Rationale: Interpretation involves understanding and explaining the meaning of the data gathered, such as recognizing client confusion and noncompliance as problems requiring intervention. _______________________________...

1. A nurse is assessing the structure of a patient’s family. Which question best helps determine the family structure? A. “How many meals do you eat together?” B. “What do you like to do on weekends?” C. “Who lives in your household and how are they related to you?” D. “Who makes the meals in your home?” Answer: C Rationale: Asking who lives in the household and their relationship helps the nurse identify family structure, essential for individualized care planning. ____...

1. A nurse is caring for an 82-year-old patient admitted for pneumonia. Which normal age-related change may affect the patient's ability to clear secretions effectively? A. Increased lung elasticity B. Decreased cough reflex C. Increased ciliary function D. Decreased alveolar surface tension Correct Answer: B Rationale: Aging leads to a decreased cough reflex, which impairs the older adult’s ability to clear respiratory secretions effectively. ________________________________________...