TEST BANK FOR FUNDAMENTALS OF NURSING BASIC PHYSICAL CARE, 7th Edition by Taylor Lillis (Full test bank, 100% Verified Answers) // LATEST

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FUNDAMENTALS OF NURSING BASIC PHYSICAL CARE
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(Full test bank, 100% Verified Answers)
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,1.
As y a y nurse y helps y a y client y ambulate, y the y client y says, y "I yhad y trouble y sleeping y last y night." y Which
y action yshould ythe ynurse ytake?
2. Recommending ywarm ymilk yor ya ywarm yshower yat ybedtime
3. Gathering ymore yinformation yabout ythe yclient's ysleep yproblem
4. Determining ywhether ythe yclient yis yworried yabout ysomething
5. Finding yout ywhether ythe yclient yis ytaking ymedication ythat ymay yimpede
sleep yCorrect yanswer: y2
y

,RATIONALE: yThe ynurse yfirst yshould ydetermine ywhat ythe yclient ymeans yby y"trouble ysleeping." yThe ynurse
lacks ysufficient yinformation yto yrecommend ywarm ymilk yor ya ywarm yshower yor yto ymake yinferences yabout
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the ycause yof ythe ysleep yproblem, ysuch yas yworries yor ymedication yuse. yCLIENT yNEEDS yCATEGORY:
y


Physiological yintegrity yCLIENT yNEEDS ySUBCATEGORY: yBasic ycare yand ycomfort yCOGNITIVE yLEVEL:
y


Application yREFERENCE: yWeber, yJ., yand yKelley, yJ. yHealth yAssessment yin yNursing, y3rd yed. yPhiladelphia:
y


Lippincott yWilliams y& yWilkins, y2007, yp. y32.
y


1002
A yclient ywho yrecently yimmigrated yto ythe yUnited yStates yfrom yKorea yis yhospitalized ywith ysecond- yand
y third-degree yburns. yHe yspeaks ylittle yEnglish yand yhas ybeen ylying yquietly yin ybed. yTen yhours yafter ythe
y client's yadmission, ythe ynurse yconducts ya yserial yassessment yand yasks yhim ywhether yhe's yin ypain. yHe
smiles yand yshakes yhis yhead yvigorously yback yand yforth. yWhich ynursing yaction yis yappropriate yat ythis
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y time?
1. Documenting ythat ythe yclient yis yresting yquietly yand ydenies ypain
2. Calling ya yfamily ymember yto yobtain yinformation yabout ythe yclient
3. Giving ythe yclient ythe yordered yas-needed ypain ymedication
4. Checking yvital ysigns yand yassessing yfor ynonverbal yindications yof
pain yCorrect yanswer: y4
y


RATIONALE: yThe ynurse yshould yconsider ythe ypossibility ythat ythe yclient ydidn't yunderstand ythe yquestion yor
has ybeen yconditioned yculturally ynot yto ycomplain yopenly yof ypain. yChecking yvital ysigns yand yassessing yfor
y


nonverbal yindications yof ypain yhelp ythe ynurse ydetermine ywhether ythe yclient yis yin ypain. yAccepting ythe
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client's yresponse ywithout yquestion yor yfurther yassessment ymay yresult yin yinadequate yintervention. yCalling
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the yfamily yor ygiving ypain ymedication yisn't ywarranted yat ythis ytime ybecause ythe yclient ydenies ypain yand
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the ynurse yneeds yto yobtain ymore yinformation. yCLIENT yNEEDS yCATEGORY: yPhysiological yintegrity yCLIENT
y


NEEDS ySUBCATEGORY: yBasic y care yand ycomfort yCOGNITIVE yLEVEL: yApplication yREFERENCE: yTaylor, yC.,
y


et yal.
y

, Fundamentals yof yNursing: yThe yArt yand yScience yof yNursing yCare, y6th yed. yPhiladelphia: yLippincott yWilliams y&
Wilkins, y2008, yp. y1375.
y


1003
When ypreparing ya yclient yfor ya ydiagnostic ystudy yof ythe ycolon, ythe ynurse yteaches ythe yclient yhow yto yself-
y administer ya yprepackaged yenema. yWhich ystatement yby ythe yclient yindicates yeffective yteaching?
1. "I ywill yadminister ythe yenema ywhile ysitting yon ythe ytoilet."
2. "I ywill yadminister ythe yenema ywhile ylying yon ymy yleft yside ywith ymy yright yknee yflexed."
3. "I ywill yadminister ythe yenema ywhile ylying yon ymy yright yside ywith ymy yleft yknee yflexed."
4. "I ywill yadminister ythe yenema ywhile ylying yon ymy yback ywith yboth yknees
flexed." yCorrect yanswer: y2
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RATIONALE: yLying yon ythe yleft yside yallows ythe yenema ysolution yto yflow ydownward yby ygravity yinto ythe
rectum yand ysigmoid ycolon. yThe yother yoptions ydon't yaccomplish ythis ygoal yand, ytherefore, yare yless
y


effective yin yevacuating ythe ylower ybowel. yCLIENT yNEEDS yCATEGORY: ySafe, yeffective ycare yenvironment
y


CLIENT yNEEDS ySUBCATEGORY: ySafety yand yinfection ycontrol yCOGNITIVE yLEVEL: yComprehension
y


REFERENCE: yTaylor, yC., yet yal. yFundamentals yof yNursing: yThe yArt yand yScience yof yNursing yCare, y6th yed.
y


Philadelphia: yLippincott yWilliams y& yWilkins, y2008, yp. y1588.
y


1004
A yphysician yorders yhourly yurine youtput ymeasurement yfor ya ypostoperative yclient ywith yan yindwelling
y catheter. yThe ynurse yrecords ythe yfollowing yamounts yof youtput yfor y2 yconsecutive yhours: y8 ya.m.: y50
y ml; y9 ya.m.: y60 yml. yBased yon ythese yamounts, ywhich yaction yshould ythe ynurse ytake?
1. Continue yto ymonitor yand yrecord yhourly yurine youtput.
2. Notify ythe yphysician.
3. Irrigate ythe yindwelling yurinary ycatheter.
4. Increase ythe yI.V. yfluid yinfusion
rate. yCorrect yanswer: y1
y


RATIONALE: yNormal yurine youtput yfor yan yadult ywith yan yindwelling ycatheter yis yat yleast y30 yml/hour.
Therefore, ythis yclient's youtput yis ynormal. yBeyond ycontinued yevaluation, yno ynursing yaction yis
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warranted. yCLIENT yNEEDS yCATEGORY: yPhysiological yintegrity yCLIENT yNEEDS ySUBCATEGORY: yBasic ycare
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and ycomfort yCOGNITIVE yLEVEL: yAnalysis yREFERENCE: yCraven, yR.F., yand yHirnle, yC.J. yFundamentals yof
y


Nursing: yHuman yHealth yand yFunction, y5th yed. yPhiladelphia: yLippincott yWilliams y& yWilkins, y2007,
y


p.1079.
y


1005
Nursing ylicensure yand ypractice yare yregulated yby:
1. nurse ypractice yacts.
2. standards yof ycare.
3. civil ylaw.
4. the yAmerican yNurses yAssociation.