AND ANSWERS WITH SOLUTIONS 2024
Which skin care measures are used to manage a client who is experiencing fecal and urinary
incontinence? - ANSWER Using an incontinence cleaner, followed by application of a moisture-barrier
ointment
How should the nurse position the client who has to undergo administration of medication into the
ethmoid sinus? Select all that apply. - ANSWER - Tilt the head back over the edge of the bed.
- Place a pillow under the shoulder and tilt the head back
The nurse is attending to a client recently diagnosed with diabetes. Following an initial assessment, the
nurse writes down several nursing-sensitive client outcomes. Which nursing-sensitive client outcomes
are correctly written? Select all that apply. - ANSWER - The client will administer a self-injection by
discharge.
- The body temperature will remain at or below 98.6 ° F.
- The heart rate will remain between 70 to 90 beats per minute.
The nurse is caring for a preoperative client in a coronary care unit. After reviewing the nursing
diagnoses, the nurse prioritizes the nursing diagnoses. Which nursing diagnoses are considered to be
high priorities for the client? Select all that apply. - ANSWER - Impaired gas exchange
- Decreased cardiac output
A 45-year-old client has been advanced to a low-residue diet postoperatively. What food should be
avoided in the client's diet? - ANSWER Steamed vegtables
Which of the following are examples of collaborative problems? Select all that apply. - ANSWER -
Hemorrhage
- Wound infecction
A nurse is educating a diabetic client about how to administer insulin. Which of the nurse's statements
pertaining to use of insulin are appropriate? Select all that apply. - ANSWER - Insulin should not be mixed
with any other medication.
- Insulin detemir should not be mixed with any insulin.
, The nurse is caring for a 16-year-old client with acne. What instructions should be included when
teaching skin care to the client? Select all that apply. - ANSWER - Avoid squeezing the acne
- Use prescribed topical applications.
- Eliminate foods that aggravate the condition from diet.
A client diagnosed with pancreatitis complains of pain in the abdomen. The client has vomited three
times, and has a temperature of 101 degrees Fahrenheit. Following an initial interview and assessment,
the nurse prepares a nursing care plan. The nurse formulates a diagnosis of acute pain. What could be
the related factor for this diagnostic label? - ANSWER Inflammation of the pancreas
Which description best fits that of serous drainage from a wound? - ANSWER Clear, watery plasma
The nurse works in a long-term care facility and understands that integrity is an essential attitude in
critical thinking. Which of the following behaviors indicate the nurse's understanding of the "Integrity"
aspect of critical thinking? Select all that apply. - ANSWER - The nurse follows the highest standards of
practice.
- The nurse questions his or her own knowledge and beliefs.
- The nurse is honest about and willing to accept his or her mistakes or inadequacies.
Review the following nursing diagnoses and identify the diagnoses that are stated correctly. Select all
that apply. - ANSWER - Anxiety related to fear of dying
- Risk for infection
A 3-year-old child has rickets. Which vitamin should be supplemented to the child's diet? - ANSWER
Vitamin D
A nurse weighs a dressing and compares it to the weight of a dry dressing to assess the quantity of
wound drainage. How much volume of drainage would equal 1 g of dressing? Record your answer using
a whole number. ___ mL - ANSWER 1 g of drainage weighed in a dressing equals 1 mL of drainage in
volume, and this rule is generally used to determine the quantity of drainage from a wound site.