Comprehensive Exam-Style Q&A with
Detailed Rationalesudy online at
https://quizlet.com/_ets6wc
1. A client is receiving a full strength continuous enteral
tube feeding at 50 ml/hour and has developed
diarrhea. The client has a new prescription to change
the feeding to half strength. What intervention
should
the nurse implement?
add equal amounts of wa ter and feeding to a feed ing bag and
infused at 50
ml/hr
2. A female client reports that her hair is becoming
coarse and breaking off, that the outer
part of her eyebrows have disappeared, and that her
eyes are all puffy. Which follow up question is best for the nurse to
ask?
have you noticed any
changes in your finger nails?
3. After a third hospitalization 6 months ago, a client is
admitted to the hospital with
,ascites
and malnutrition. The client is drowsy but responding
to verbal stimuli and reports recently spitting up
blood. What assessment finding warrants immediate
intervention by the nurse?
cap refill of 8 seconds
4. After the nurse witnesses a preoperative client sign
the surgical consent form, the nurse signs the form
as
a witness. What are the legal implications of the
nurse's signature on the client's surgical consent
form?
(select all that apply)
• The client voluntarily
grants permission for the
procedure to be done
• The client is competent
to sign the consent with out impairment of judg ment
• The client understands
the risks and benefits as sociated with the proce dure
x
,Study online at https://quizlet.com/_ets6wc
5. 34. Following surgery, a male client with antisocial
personality disorder frequently requests
that a specific nurse be assigned to his care and is bel ligerent when
another nurse is assigned. What action
should the charge nurse implement?
• Advise the client that as signments are not based
on clients requests
6. A client with cervical cancer is hospitalized for inser tion of a sealed
internal cervical radiation implant.
While providing care, the nurse finds the radiation
implant in the bed. What action should the nurse take?
• Place the implant in
a lead container using
long-handled forceps
7. The client with which type of wound is most likely to
need immediate intervention by the nurse?
laceration
8. The nurse is planning care for a client admitted with a
diagnosis of pheochromocytoma. Which
intervention has the highest priority for inclusion in
this client's plan of care?
monitor blood pressure
, frequently
9. When caring for a client who has acute respiratory
distress syndrome (ARDS), the nurse elevates the
head of the bed 30 degrees. What is the reason for this
intervention?
to reduce abdominal
pressure on the di aphragm
10. When assessing a mildly obese 35-year-old female
client, the nurse is unable to locate the gallbladder
when palpating below the liver margin at the lateral
border of the rectus abdominal muscle. What is
the most likely explanation for failure to locate the
gallbladder by palpation?
the gallbladder is normal
11. A woman with an anxiety disorder calls her obstetri cian's office
and tells the nurse of increased anxiety
Inform her that some an tianxiety medications are
x
Study online at https://quizlet.com/_ets6wc
since the normal vaginal delivery of her son three
weeks ago. Since she is breastfeeding, she stopped