A client describes a poorly localized pain as a squeezing and
pressure sensation. If the pain is caused by inflammation, what
type of pain is it? Correct Answers Visceral.
A client is experiencing cancer-related fatigue. What should the
nurse advise to help alleviate the symptoms? Correct Answers
Try to eat a well-balanced diet.
Participate in routine physical exercise.
Develop routine sleeping habits.
A client is experiencing dyspnea, respirations 24 breaths/
minute, O2 saturation of 89% on room air, nasal flaring, and
audible expiratory and inspiratory wheezing noted three feet
away. Which set of arterial blood gas (ABG) results is consistent
with the nurse's assessment of this client? Correct Answers pH
7.28; PaCO2 55; HCO3 24
A client with extracellular fluid volume deficit has received
500ml bolus of normal saline intravenously. Which finding from
the nurse's assessment indicates that the fluid deficit is
improving? Correct Answers Capillary refill less than 2
seconds.
A client's pulse oximeter is alarming and displaying 80% O2
saturation. The client is lying in bed with O2 running at 2
liters/min via nasal cannula. The client's respiratory rate is 16,
mucous membranes are pink, and breathing is not labored. What
, should the nurse do next? Correct Answers Check that the
placement of the pulse oximeter is correct
A nursing team is reviewing its quality improvement plan.
Which source of data will answer the question, "Are there fewer
nosocomial infections this year"? Correct Answers Client's
outcomes from delivery of care processes.
A spouse of a client appears to be in spiritual distress over the
anticipated death of the client and is crying "Why is this
happening to me?" What is the nurse's most therapeutic
response? Correct Answers Remain with the spouse and listen
empathetically.
A survivor of a horrific motor vehicle accident whose loved one
was killed has not been able to go back to work and spends most
of the day drinking alcohol and watching television for the past
ten months. Which type of complicated grieving is being
exhibited? Correct Answers Exaggerated grief.
A terminally ill client is demonstrating anger by often blaming
the spouse for the disease. The spouse asks the nurse how best to
deal with this anger. Which are therapeutic responses from the
nurse? Correct Answers Advise the spouse not to argue with
the client, but listen to the concerns.
Reassure the spouse that displaced anger is common in the
grieving process.
Encourage the spouse to focus on the present time and not to
dwell on previous negative behavior.
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