Exam Prep (Updated)
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 - CORRECT
ANSWER-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 - CORRECT ANSWER-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 - CORRECT ANSWER-
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. -
CORRECT ANSWER-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.