Solutions
•The nurse is making morning rounds and has discovered that
the total parenteral nutrition (TPN) was off and not running into
the central line. What assessment should the nurse watch the
client carefully for?
A. Excessive thirst and urination
B. Fever and chills
C. Shakiness and diaphoresis
D. Hypertension and crackles Correct Answer C
A 70-year-old male is scheduled for surgery. He says to the
nurse, "I am so frightened—what if I don't wake up?" What
would be the nurse's best response?
a. "You have a wonderful doctor."
b. "Let's talk about how you are feeling."
c. "Everyone wakes up from surgery!"
d. "Don't worry, you will be just fine." Correct Answer B
A 72-year-old woman who is scheduled for a hip replacement is
taking several medications on a regular basis. Which drug
category might create a surgical risk for this patient?
a. Anticoagulants
b. Antacids
c. Laxatives
d. Sedatives Correct Answer A
,A cleansing enema is ordered for a client who is scheduled to
have colon surgery. What is the rationale for this procedure?
A) Surgical clients routinely are given a cleansing enema.
B) Cleansing enemas are given before surgery at the client's
request.
C) There will be less flatus and discomfort postoperatively.
D) Peristalsis does not return for 24 to 48 hours after surgery.
Correct Answer D
A client has been prescribed a clear liquid diet. What food or
fluids will be served?
A) Milk, frozen dessert, egg substitutes
B) High-calorie, high-protein supplements
C) Hot cereals, ice cream, chocolate milk
D) Jell-O, carbonated beverages, apple juice Correct Answer D
A client has had a head injury affecting the brain stem. What is
located in the brain stem that may affect respiratory function?
A) Chemoreceptors
B) Stretch receptors
C) Respiratory center
D) Oxygen center Correct Answer C
A client is discussing weight loss with a nurse. The patient says,
"I will not eat for two weeks, then I will lose at least 10 pounds."
What should the nurse tell the client?
,A) "What a good idea. Go ahead. That will jump start your
weight loss!"
B) "Many people find that to be an ideal way to lose weight
quickly and easily."
C) "That will increase your metabolic rate and help you lose
weight."
D) "That will decrease your metabolic rate and make weight loss
more difficult." Correct Answer D
A client is experiencing hypoxia. Which of the following
nursing diagnoses would be appropriate?
A) Anxiety
B) Nausea
C) Pain
D) Hypothermia Correct Answer A
A client is interested in losing 15 pounds, and she informs the
nurse she is counting her calorie intake each day. The client has
a goal of losing one pound a week until she reaches her goal.
The client asks the nurse how many calories she should decrease
daily to lose a pound a week. What is the nurse's best response?
A) 500 calories/day
B) 200 calories/day
C) 300 calories/day
D) 400 calories/day Correct Answer A
A client returning to the floor after orthopedic surgery is
complaining of nausea. The nurse is aware that an appropriate
intervention is to do which of the following?
, A) Avoid strong smelling foods.
B) Provide clear liquids with a straw.
C) Avoid oral hygiene until the nausea subsides.
D) Hold all medications. Correct Answer A
A client scheduled for major surgery will receive general
anesthesia. Why is inhalation anesthesia often used to provide
the desired actions?
A) Rapid excretion and reversal of effects
B) Safe administration in the client's own room
C) Involves only the respiratory system and skin
D) Slow onset of action and maintains reflexes Correct Answer
A
A client visits a health care facility with complaints of loss of
appetite following a prolonged illness. How should the nurse
document the client's condition?
A) Emaciation
B) Cachexia
C) Anorexia
D) Nausea Correct Answer C
A client visits the health care facility for a scheduled physical
assessment. What should the nurse do when physically assessing
the quality of the client's oxygenation? Select all that apply.
A) Monitor the client's respiratory rate.
B) Note the amount of oxygen administered.