Exam (elaborations)

Nr547 week 1 Latest Update Questions with Correct Answers Accurate

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Nursing

Institution
Nursing

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nursing

Institution Nursing
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A client asks about the purpose of a pulse oximeter. The nurse explains that it is used to measure what?

1

Respiratory rate

2

Amount of oxygen in the blood

3

Percentage of hemoglobin-carrying oxygen

4

Amount of carbon dioxide in the blood - Answer 3

The pulse oximeter measures the oxygen saturation of blood by determining the percentage of
hemoglobin-carrying oxygen. A pulse oximeter does not measure respiratory rate, nor does it interpret
the amount of oxygen or carbon dioxide carried in the blood.

A client expresses concern about insomnia and asks, "What can I do to get better sleep?" What activities
should the nurse recommend? Select all that apply.

1

Drink a glass of wine.

2

Engage in mild exercise before bedtime.

3

Eat foods containing lysine.

4

Follow the same bedtime ritual each night.

5

Perform deep-breathing exercises - Answer 4,5

A bedtime ritual provides a familiar routine that promotes comfort and the self-fulfilling prophesy of
sleep. Relaxation exercises slow body processes and reduces tension, both of which facilitate rest and
promote sleep. People who drink alcohol may fall asleep more quickly but have depressed levels of rapid

,eye movement, less stage 4 sleep, and interruptions between sleep stages (sleep fragmentation).
Physical exercise before bedtime has a stimulating rather than a relaxing effect. Lysine, an amino acid,
maintains nitrogen equilibrium and promotes growth and development, but it does not influence sleep.

A client has excessive edema. Which is the most objective method a nurse can use to assess the extent
of edema?

1

Weighing the client

2

Monitoring the intake and output

3

Performing the Trendelenburg test

4

Assessing the extent of pitting edema - Answer 1

One liter of fluid weighs approximately 2.2 pounds (1 kg); weight reflects subtle changes in fluid balance.
Although monitoring the intake and output is important to assess fluid balance, it does not account for
intake and output that cannot be measured. The Trendelenburg test facilitates assessment of venous
peripheral vascular disease, not the extent of edema. Assessing the extent of pitting edema is effective in
determining localized, not generalized, edema; it is more subjective than is weighing the client.

A client has undergone surgery with general anesthesia. Within how many hours after surgery should the
nurse notify the primary healthcare provider if the client does not void?

1

4 hours

2

8 hours

3

10 hours

4

12 hours - Answer 2

Clients should urinate 6 to 8 hours after catheter removal. Decreased bladder muscle tone results from
the depressant effects of anesthesia and the handling of tissues and adjacent organs during surgery.
Catheterization may be necessary to prevent overdistention of the bladder. Four hours may be too early
to expect recovery from the depressant effects of anesthesia. Ten and 12 hours are too long to wait to

, call the primary health care provider. This length of time without voiding may result in overdistention of
the bladder

A client is admitted with dehydration. Which findings should the nurse expect the client to exhibit?
Select all that apply.

1

Supple skin turgor

2

Rapid, thready pulse

3

Decreased hematocrit

4

Elevated specific gravity

5

Adventitious breath sounds - Answer 2,4

The pulse is rapid and thready because of the decreased blood volume associated with dehydration. The
specific gravity of urine increases as the body reabsorbs water to correct the fluid deficit; as a result, the
urine is concentrated. Skin turgor is decreased with evidence of tenting. The hematocrit is increased
because of hemoconcentration. Adventitious breath sounds, such as crackles, occur with fluid volume
excess, not with deficit.

A client is experiencing stomatitis as a result of chemotherapy. Which action should the nurse take when
caring for this client?

1

Provide frequent saline mouthwashes

2

Use karaya powder to decrease irritation

3

Increase fluid intake to compensate for accompanying diarrhea

4

Offer meticulous skin care of the abdomen with a gentle antiseptic - Answer 1

Saline mouthwashes are soothing to the oral mucosa and help clean the mouth, minimizing infection.
Stomatitis refers to the oral cavity; karaya is used to protect the skin around a stoma created on the

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