BSNlHESIl225lFundamentalsloflNursingl
ExamlV1l(LatestlUpdate)lQuestionslandl
VerifiedlAnswers|100%lCorrect|lGradelA-
lNightingale
Q:lAllow-sodium,llow-proteinldietlislprescribedlforlal45-year-
oldlclientlwithlrenallinsufficiencylandlhypertension,lwholgainedl3lpoundslinlthellastlmonth.lTh
elnurseldetermineslthatlthelclientlhaslbeenlnoncompliantlwithltheldiet,lbasedlonlwhichlreportlfr
omlthel24-hourldietarylrecall?l(Selectlalllthatlapply.)lSelectlalllthatlapply
Somelcorrectlanswerslwerelnotlselected
Snackloflpotatolchips,landldietlsoda.
l
Lunchlofltunalfishlsandwich,lcarrotlsticks,lfreshlfruit,landlcoffee.lBreakfastlofleggs,lbacon,ltoas
t,landlcoffee.
Dinnerloflvegetablellasagna,ltossedlsalad,lsherbet,landlicedltea.
Bedtimelsnackloflcrackerslandlmilk.
Answer:
lSomelcorrectlanswerslwerelnotlselected
Snackloflpotatolchips,landldietlsoda.
Lunchlofltunalfishlsandwich,lcarrotlsticks,lfreshlfruit,landlcoffee.lBedtimelsnackloflcrackerslan
dlmilk.
Rationale
Potatolchipsl(A)larelhighlinlsodium.lTunal(B)lislhighlinlprotein.lBaconl(C)landlcrackersl(E)lare
lhighlinlsodium.lOnlyl(D)lislalmeallthatlislinlcompliancelwithlallowlsodium,llowlproteinldiet.
Q:lThelnurselislcaringlforlalclientlwholislweaklfromlinactivitylbecauselofla
2-
weeklhospitalization.lInlplanninglcarelforlthelclient,lthelnurselshouldlincludelwhichlrangeloflm
otionl(ROM)lexercises?
PassivelROMlexercisesltolallljointslonlalllextremitieslfourltimeslalday.lActivelROMlexerciseslt
olbothlarmslandllegsltwolorlthreeltimeslalday.lActivelROMlexerciseslwithlweightsltwicelaldayl
withl20lrepetitionsleach.
PassivelROMlexercisesltolthelpointloflresistancelandlslightlylbeyond.
Answer:
lActive
ROMlexercisesltolbothlarmslandllegsltwolorlthreeltimeslalday.lRationale
Active,lratherlthanlpassive,lROMlislbestltolrestorelstrengthlandl(B)lislanleffectivelschedule.lPas
sivelROMl4ltimeslaldayl(A)lislnotlaslbeneficiallforlthelclientlasl(B).lWithlweightsl(C),lthelclien
,tlmaylfatiguelquicklylandldeveloplmusclelsoreness.lROMlislnotlperformedlbeyondlthelpointlofl
resistancelorlpainl(D)lbecauseloflthelrisklofldamageltolunderlyinglstructures.
Q:lWhatlclientlstatementlindicatesltolthelnurselthatlthelclientlrequireslassis-
ltancelwithlbathing?
"Ilwasn'tlableltolpacklalbaglbeforelIlleftlforlthelhospital."l"Ildon'tlunderstandlwhylI'mlsolweakl
andltired."
"Ilonlylbatheleverylotherlday."
"Illeftlmyleyeglasseslatlhome."
Answer:
l"Ildon'tlunderstandlwhylI'mlsolweaklandltired."
Rationale
Bathingloftenlmakeslalclientlfeellweak,landliflalclientlislalreadylfeelinglweakl(B),lassistancelisl
requiredlduringlthelbathinglprocessltolensurelthelclient'slsafety.l(A
l
andlC)ldolnotlposelsafetylissues.lAlthoughl(D)lmaylposelalsafetylissue,lfurtherlassessmentlislne
ededltoldetermineliflthislinlfactlposeslalsafetylissuelforlthelclient.
Q:lThelnursesldetermineslalclient'slIVlsolutionlislinfusinglatl250lml/hr.lThelprescribedlratelisl
125lml/hr.lWhatlactionlshouldlthelnurseltakelfirst?lDeterminelwhenlthelIVlsolutionlwaslstarted.
SlowlthelIVlinfusionltolkeeplveinlopenlrate.lAssesslthelIVlinsertionlsitelforlswelling.
Reportlthelfindingltolthelhealthcarelprovider.
Answer:
lSlowlthelIVlinfusionltolkeeplveinlopenlrate.
Rationale
ThelnurselshouldlfirstlslowlthelIVlflowlrateltolkeeplveinlopenl(KVO)lratel(B)ltolpreventlfurther
lriskloflfluidlvolumeloverload,lthenlgatherladditionallassessmentldata,lsuchlaslwhenlthelIVlsolu
tionlwaslstartedl(A)landlthelappearanceloflthelIVlinsertionlsitel(C)lbeforelcontactinglthelhealthc
arelproviderl(D)lforlfurtherlinstructions.
Q:lHowlshouldlthelnurselhandlellinenslthatlarelsoiledlwithlincontinentlfeces?lPutlthelsoiledlli
nenslinlanlisolationlbag,lthenlplacelitlinltheldirtyllinenlhamper.lPlacelanlisolationlhamperlinlthel
client'slroomlandldiscardlthellinenslinlit.lPlacelthelsoiledllinenslinlalpillowlcaselandldepositlthe
mlinltheldirtyllinenlhamper.
Asklthelhousekeepinglstaffltolpickluplthelsoiledllinenlfromltheldirtylutilitylroom.
Answer:
lPlacelthelsoiledllinenslinlalpillowlcaselandldepositlthemlinltheldirtyllinenlhamper.
Rationale
,Thelnurselshouldlbelcarefulltolkeeplthelsoiledllinenslfromlcontaminatinglthelfreshllinens,landls
houldlhandlelthelsoiledllinensllikelanylotherldirtyllinenl(C).l(A,lB,landlD)larelnotlindicated.
Q:lAlmiddle-
agedlwomanlwholenjoyslbeinglalteacherlandlmentorlfeelslthatlshelshouldlpassldownlherllegacyl
oflknowledgelandlskillsltolthelyoungerlgeneration.lAccordingltolErikson,lshelislinvolvedlinlwha
tldevelopmentallstage?
Generativity.lEgolintegrity.lIdentification.
Valuinglwisdom.
Answer:
lGenerativity.
l
Rationale
Healthylmiddle-
agedladultslfocuslonlestablishinglthelnextlgenerationlbylnurturinglandlguiding,lwhichlisldescrib
elbylEriksonlasltheldevelopmentallstageloflgenerativityl(A),landlislcharacteristicloflmiddleladul
thood.l(B,lClandlD)larelnotlstagesloflthislagelgrouplaccordingltolErickson'slpsychosocialldevel
opmentalltheory.
Q:lAlclientlhaslalnursingldiagnosislof,l"Spiritualldistresslrelatedltolallossloflhope,lsecondarylt
olimpendingldeath."lWhatlinterventionlislbestlforlthelnurseltolimplementlwhenlcaringlforlthislcl
ient?
Helplthelclientltolacceptlthelfinallstagelofllife.
Assistlandlsupportlthelclientlinlestablishinglshort-
termlgoals.lEncouragelthelclientltolmakelfuturelplans,levenlifltheylarelunrealistic.lInstructlthelcl
ient'slfamilyltolfocuslonlpositivelaspectsloflthelclient'sllife.
Answer:
lAs-lsistlandlsupportlthelclientlinlestablishinglshort-termlgoals.
Rationale
Hopefulnesslislnecessaryltolsustainlalmeaningfullexistence,levenlcloseltoldeath.lThelnurselshoul
dlhelplthelclientlsetlshort-termlgoals,landlrecognizelthelachieve-
lmentloflimmediatelgoalsl(B),lsuchlaslseeinglalfamilylmember,lorllisteningltolmusic.l(A)lisltool
vagueltolbelalhelpfullintervention.l(C)ldoeslnotlhelplthelclientldeallwithlthislnursingldiagnosis.l
(D)lmightlbelimplemented,lbutldoeslnotlhavelthelprioritylofl(B).
20.lThelnurselassesseslanlimmobile,lelderlylmalelclientlandldetermineslthatlhislbloodlpressureli
sl138/60,lhisltemperaturelisl95.8lF,landlhisloutputlisl100lmlloflconcentratedlurinelduringlthellas
tlhour.lHelhaslwet-
soundingllunglsounds,landlincreasedlrespiratorylsecretions.lBasedlonltheselassessmentlfindings,
lwhatlnursinglactionlislmostlimportantlforlthelnurseltolimplement?lAdministerlalPRNlantihyper
tensivelprescription.
Providelthelclientlwithlanladditionallblanket.lEncourageladditionallfluidlintake.
Turnlthelclientlq2h.
, Answer:
lTurnlthelclientlq2h.
Rationale
(D)lwilllhelpltolmovelandldrainlrespiratorylsecretionslandlpreventlpneumonialfromloccurring,ls
olthislinterventionlhaslthelhighestlpriority.lOlderladultsloftenlhavelanlincreasedlBP,landlalPRNl
antihypertensivelmedicationlislusuallylprescribedlforlalBPloverl140lsystoliclandl90ldiastolicl(A
).lOlderladultsloftenlrunlallowerltemperature,
l
particularlylinlthelmorning,landl(B)ldoeslnotlhavelthelprioritylofl(D).lEvenlthoughlthelclientlha
sladequateloutput,l(C)lmightlbelencouragedlbecauselthelurinelislconcentrated,lbutlthislinterventi
onldoeslnotlhavelthelprioritylofl(D).
Q:lThelnurselislpreparinglalmalelclientlwholhaslanlindwellinglcatheterlandlanlIVlinfusionltola
mbulatelfromlthelbedltolalchairlforlthelfirstltimelfollowinglabdominallsurgery.lWhatlaction(s)ls
houldlthelnurselimplementlpriorltolassist-linglthelclientltolthelchair?l(Selectlalllthatlapply.)
Selectlalllthatlapply
a.Pre-medicatelthelclientlwithlanlanalgesic.
b.Informlthelclientloflthelplanlforlmovingltolthelchair.lc.Obtainlandlplacelalportablelcommodel
bylthelbed.ld.AsklthelclientltolpushlthelIVlpoleltolthelchair.le.Clamplthelindwellinglcatheter.
f.lAssesslthelclient'slbloodlpressure.
Answer:
lA,lB,lD,landlF
Rationale
Thelnurselshouldlplanltolimplementl(A,lB,lD,landlF).lPre-
medicatinglthelclientlwithlanlanalgesicl(A)lreduceslthelclient'slpainlduringlmobilizationlandlma
ximizeslcompliance.lTolensurelthelclient'slcooperationlandlpromotelindependence,lthelnurselsho
uldlinformlthelclientlaboutlthelplanlforlmovingltolthelchairl(B)landlencouragelthelclientltolparti
cipatelbylpushinglthelIVlpolelwhenlwalkingltolthelchairl(D).lThelnurselshouldlassesslthelclient'
slbloodlpressurel(F)lpriorltolmobilization,lwhichlcanlcauselorthostaticlhypotension.l(ClandlE)lar
elnotlindicated.
Q:lAlmalelclientlwithlacquiredlimmunodeficiencylsyndromel(AIDS)ldevelopslcryptococcallm
eningitislandltellslthelnurselheldoeslnotlwantltolbelresusci-
ltatedliflhislbreathinglstops.lWhatlactionlshouldlthelnurselimplement?lDocumentlthelclient'slreq
uestlinlthelmedicallrecord.
Asklthelclientliflthisldecisionlhaslbeenldiscussedlwithlhislhealthcarelprovider.lInformlthelclientl
thatlalwritten,lnotarizedladvanceldirective,lislrequiredltolwithholdlresuscitationlefforts.
Adviselthelclientltoldesignatelalpersonltolmakelhealthcareldecisionslwhenlthelclientlislunablelto
ldolso.
Answer:
lAsklthelclientliflthisldecisionlhaslbeenldiscussedlwithlhislhealthcarelprovider.
