WITH 100% ACCURATE ANSWERS
1. A nurse is caring for a client who has received chemotherapy. The client
experiences severe nausea and vomiting. The nurse should monitor the
client for which of the following clinical manifestations?
A. Metabolic acidosis
Rationale: Metabolic acidosis occurs when there is a loss in
gastrointestinal fluid.
B. Metabolic alkalosis
Rationale: Metabolic alkalosis occurs when there is excessive vomiting
and there is a loss in hydrochloric acid.
C. Respiratory acidosis
Rationale: Respiratory acidosis occurs when there is an alteration in
respiratory function.
D. Respiratory alkalosis
Rationale: Respiratory alkalosis occurs when there is an alteration in
respiratory function.
2. A client with sleep apnea receives a new prescription for a continuous
positive airway pressure (CPAP) device. A week later the client returns to
the clinic and says that severe daytime fatigue is still a problem. Which
action should the nurse take first?
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,A. Teach the patient about radiofrequency ablation.
B. Plan to schedule a night-time sleep study.
C. Ask the client if the CPAP device is being used every night.
Rationale: CORRECT ANSWER. CPAP is very effective in
reducing sleep apnea, but compliance is frequently a
problem. Surgery and other studies may be indicated, but
the nurse's first action should be to assess whether the
CPAP is being used as prescribed. (ATI Adult Med-Surg
Nursing, 9th ed., p. 207; Brunner & Suddarth, p.
511)
D. Discuss the possible surgical approaches used for sleep apnea.
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,3. A client has a warm, moist compress to the lower extremity. Which of the
following actions should the nurse recognize as a risk to client safety?
A. Placing plastic wrap around the client’s compress and extremity
Rationale: Plastic wrap can be used to insulate the compress and
retain heat. This does not pose a risk to client safety.
B. Securing the client’s moist compress with a dry towel
Rationale: A dry towel can be used to retain heat. This is not a risk to client
safety.
C. Changing the client’s warm, moist compress frequently
Rationale: Heat from the warm compress dissipates quickly. The
compress should be changed often to maintain a constant
temperature.
D. Removing the client’s robe and blankets covering compress
Rationale: Moist heat promotes vasodilation and evaporation of
heat from the skin’s surface. The client can become cool
and shiver. This could potentially decrease the client’s body
temperature and place the client at risk. The nurse should
control drafts within the room and keep the client covered
with a blanket or robe.
4. A nurse is caring for a client who is confused and refuses to let the nurse
insert an NG tube. The provider tells the nurse to restrain the client in order to
insert the tube. The nurse recognizes that following the provider’s order is
A. assault.
Rationale: The nurse commits assault if she threatens to touch the
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, client without consent.
B. invasion of privacy.
Rationale: Invasion of privacy occurs when the nurse violates the
client’s confidentiality.
C. defamation of character.
Rationale: Defamation of character occurs if the nurse writes
derogatory statements about the client’s refusal of the
treatment.
D. false imprisonment.
Rationale: False imprisonment occurs when the nurse restrains the
client in order to perform a treatment that the client has
refused.
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