BASIC NURSING PRACTICE
QUESTIONS AND ANSWERS.
The nurse caring for a resident of a long-term care facility discovers the client has a
body temperature of 102 F, nasal congestion, and body aches. The provider diagnosed
the resident with influenza the day prior. Which nursing diagnosis does the nurse
determine applies to this client?
A. Hyperthermia related to the body's inflammatory response to invading pathogens
B. Ineffective airway clearance related to thick and tenacious bronchial secretions.
C. Risk for altered thought processes (dementia) related to advanced age
D. Risk for infection related to hyperthermia, nasal congestions, and body aches -
Answers-A. Hyperthermia related to the body's inflammatory response to invading
pathogens
The nurse notes that a client with pneumonia is experiencing a decrease in oxygen
saturation and determines the client's nursing diagnosis is "Impaired gas exchange".
Which statement or related factors does the nurse determine is the etiology of this
nursing diagnosis?
A. Alveolar-capillary membrane exchange
B. Cough, chest pain, and fever
C. Pneumonia
D. Respiratory illness - Answers-A. Alveolar-capillary membrane exchange
The nurse notes that a client has the nursing diagnosis of "Fluid volume deficit related to
an inability to swallow". Which outcome criterion is appropriate for the nurse to set for
this client?
A. The client's fluid intake will be adequately restored.
B. The client will drink at least two liters of fluids daily
C. The client will swallow normally
D. The client will verbalize understanding the need to drink more fluids - Answers-B.
The client will drink at least two liters of fluids daily
, A two year old child has an endoscopic procedure to remove a small toy she swallowed.
During discharge teaching, which instruction is priority for the nurse to inform the child's
parents to prevent further risk of aspiration?
A. "Allow the child to play with one toy at a time and only under direct supervision.
B. "Follow the appropriate are recommendations marked on toys before giving them to
the child."
C."Notify the physician if the child complains of a sore throat within the next 24 hours."
D. Place all the child's toys at a level higher than can be reached without adult
assistance. - Answers-B. "Follow the appropriate are recommendations marked on toys
before giving them to the child."
A nurse is caring for five clients on a busy medical-surgery nursing unit. Which
technique implemented during medication administration will best reduce the risk of
making a medication error?
A. Assigning the nurse to a group of clients in close proximity of one another.
B. Having the nurse wear a sign that alerts other to avoid distracting the nurse.
C. Instituting a policy that severely punishes nurses who make medication errors.
D. Prescribing medications with a low adverse effects profile. - Answers-B. Having the
nurse wear a sign that alerts other to avoid distracting the nurse.
Which technique is regulated by The Joint Commission to improve the effectiveness of
communication between health care providers?
A. Annual review a list of look-alike drugs used in the organization.
B. Medication reconciliation whenever a client moves from one area to another.
C. Nurse safety review process in collaboration with the board of nursing.
D. Use of client's room number as indentifier. - Answers-B. Medication reconciliation
whenever a client moves from one area to another.
The nurse upon entering a client's room discovers a washcloth has caught fire after
being placed over a light source. After removing the client from the room, which action
should the nurse implement next?
A. Assess the client
B. Contain the fire
QUESTIONS AND ANSWERS.
The nurse caring for a resident of a long-term care facility discovers the client has a
body temperature of 102 F, nasal congestion, and body aches. The provider diagnosed
the resident with influenza the day prior. Which nursing diagnosis does the nurse
determine applies to this client?
A. Hyperthermia related to the body's inflammatory response to invading pathogens
B. Ineffective airway clearance related to thick and tenacious bronchial secretions.
C. Risk for altered thought processes (dementia) related to advanced age
D. Risk for infection related to hyperthermia, nasal congestions, and body aches -
Answers-A. Hyperthermia related to the body's inflammatory response to invading
pathogens
The nurse notes that a client with pneumonia is experiencing a decrease in oxygen
saturation and determines the client's nursing diagnosis is "Impaired gas exchange".
Which statement or related factors does the nurse determine is the etiology of this
nursing diagnosis?
A. Alveolar-capillary membrane exchange
B. Cough, chest pain, and fever
C. Pneumonia
D. Respiratory illness - Answers-A. Alveolar-capillary membrane exchange
The nurse notes that a client has the nursing diagnosis of "Fluid volume deficit related to
an inability to swallow". Which outcome criterion is appropriate for the nurse to set for
this client?
A. The client's fluid intake will be adequately restored.
B. The client will drink at least two liters of fluids daily
C. The client will swallow normally
D. The client will verbalize understanding the need to drink more fluids - Answers-B.
The client will drink at least two liters of fluids daily
, A two year old child has an endoscopic procedure to remove a small toy she swallowed.
During discharge teaching, which instruction is priority for the nurse to inform the child's
parents to prevent further risk of aspiration?
A. "Allow the child to play with one toy at a time and only under direct supervision.
B. "Follow the appropriate are recommendations marked on toys before giving them to
the child."
C."Notify the physician if the child complains of a sore throat within the next 24 hours."
D. Place all the child's toys at a level higher than can be reached without adult
assistance. - Answers-B. "Follow the appropriate are recommendations marked on toys
before giving them to the child."
A nurse is caring for five clients on a busy medical-surgery nursing unit. Which
technique implemented during medication administration will best reduce the risk of
making a medication error?
A. Assigning the nurse to a group of clients in close proximity of one another.
B. Having the nurse wear a sign that alerts other to avoid distracting the nurse.
C. Instituting a policy that severely punishes nurses who make medication errors.
D. Prescribing medications with a low adverse effects profile. - Answers-B. Having the
nurse wear a sign that alerts other to avoid distracting the nurse.
Which technique is regulated by The Joint Commission to improve the effectiveness of
communication between health care providers?
A. Annual review a list of look-alike drugs used in the organization.
B. Medication reconciliation whenever a client moves from one area to another.
C. Nurse safety review process in collaboration with the board of nursing.
D. Use of client's room number as indentifier. - Answers-B. Medication reconciliation
whenever a client moves from one area to another.
The nurse upon entering a client's room discovers a washcloth has caught fire after
being placed over a light source. After removing the client from the room, which action
should the nurse implement next?
A. Assess the client
B. Contain the fire
