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MULTIPLE CHOICE 1. An older client is hospitalized after an operation. When assessing the client for postoperative infection, the nurse places priority on which assessment? a. Change in behavior b. Daily white blood cell count c. Presence of fever and chills d. Tolerance of increasing activity ANS: A Older people have an age-related decrease in immune system functioning and may not show classic signs of infection such as increased white blood cell count, fever and chills, or obvious l...

MULTIPLE CHOICE 1. A nurse teaches clients at a community center about risks for dehydration. Which client is at greatest risk for dehydration? a. A 36-year-old who is prescribed long-term steroid therapy b. A 55-year-old receiving hypertonic intravenous fluids c. A 76-year-old who is cognitively impaired d. An 83-year-old with congestive heart failure ANS: C Older adults, because they have less total body water than younger adults, are at greater risk for development of dehydration. ...

MULTIPLE CHOICE 1. A nurse assesses a client with diabetes mellitus who is admitted with an acid-base imbalance. The clients arterial blood gas values are pH 7.36, PaO2 98 mm Hg, PaCO2 33 mm Hg, and HCO3 18 mEq/L. Which manifestation should the nurse identify as an example of the clients compensation mechanism? a. Increased rate and depth of respirations b. Increased urinary output c. Increased thirst and hunger d. Increased release of acids from the kidneys ANS: A This client has met...

MULTIPLE CHOICE 1.A nurse is caring for a client who has just had a central venous access line inserted. Which action should the nurse take next? a. Begin the prescribed infusion via the new access. b. Ensure an x-ray is completed to confirm placement. c. Check medication calculations with a second RN. d. Make sure the solution is appropriate for a central line. ANS: B A central venous access device, once placed, needs an x-ray confirmation of proper placement before it is used Th...

MULTIPLE CHOICE 1. A nurse working with older adults in the community plans programming to improve morale and emotional health in this population. What activity would best meet this goal? a. Exercise program to improve physical function b. Financial planning seminar series for older adults c. Social events such as dances and group dinners d. Workshop on prevention from becoming an abuse victim ANS: A All activities would be beneficial for the older population in the community. However, f...

MULTIPLE CHOICE 1. Acid-base balance occurs when the pH level of the blood is between: a. 7.3 and 7.5 b. 7.35 and 7.45 c. 7.4 and 7.5 d. 7.25 and 7.35 ANS: B Acid-base balance is the maintenance of arterial blood pH between 7.35 and 7.45 through hydrogen ion production and elimination. DIF: Understanding/Comprehension REF: 13 KEY: Assessment MSC: Physiological Adaptation | Fluid and Electrolyte Imbalances NOT: Describe common fluid, electrolyte, and acid-base imbalances. 2. The nurs...

MULTIPLE CHOICE 1. A nurse is educating a client about genetic screening. The client asks why red-green color blindness, an Xlinked recessive disorder noted in some of her family members, is expressed more frequently in males than females. How should the nurse respond? a. Females have a decreased penetrance rate for this gene mutation and are therefore less likely to express the trait. b. Females have two X chromosomes and one is always inactive. This inactivity decreases the effect of the ...

MULTIPLE CHOICE 1. A student asks the nurse what is the best way to assess a clients pain. Which response by the nurse is best? a. Numeric pain scale b. Behavioral assessment c. Objective observation d. Clients self-report ANS: D Many ways to measure pain are in use, including numeric pain scales, behavioral assessments, and other objective observations. However, the most accurate way to assess pain isto get a self-report from the client. DIF: Remembering/Knowledge REF: 46 KEY: Pain| p...

1. On a hot humid day, an emergency department nurse is caring for a client who is confused and has these vital signs: temperature 104.1 F (40.1 C), pulse 132 beats/min, respirations 26 breaths/min, blood pressure 106/66 mm Hg. Which action should the nurse take? a. Encourage the client to drink cool water or sports drinks. b. Start an intravenous line and infuse 0.9% saline solution. c. Administer acetaminophen (Tylenol) 650 mg orally. d. Encourage rest and re-assessin 15 minutes. ANS: B...

Chapter 08: Concepts of Emergency and Trauma Nursing MULTIPLE CHOICE 1. An emergency room nurse assesses a client who has been raped. With which health care team member should the nurse collaborate when planning this clients care? a. Emergency medicine physician b. Case manager c. Forensic nurse examiner d. Psychiatric crisis nurse ANS: C All other members of the health care team listed may be used in the management of this clients care. However, the forensic nurse examiner is educated...