Nursing 230 Exam 3 Questions With Complete Solutions
Instruct the client to inhale slowly and as deeply as possible through the mouthpiece, without using the nose. Correct Answer-A nurse is educating a postoperative client on how to use an incentive spirometer. Which of the following is an accurate step that should be included in the teaching plan?
Anxiety Correct Answer-A client is experiencing hypoxia. Which of the following nursing diagnoses would be appropriate?
There is an accidental separation of the wound Correct Answer-A nurse caring for a client who has a surgical wound following a cesarean section notes dehiscence of the wound and contacts the surgeon. Which of the following is a finding related to this condition?
Primary intention Correct Answer-A nurse assessing the wound healing of a patient, documents that the wound formed a clean, straight line with little loss of tissue. This wound healed by:
"Your wound will heal slowly as granulation tissue forms and fills the wound." Correct Answer-The acute care nurse is caring for a client whose large surgical wound is healing by secondary intention. The client
asks, "Why is my wound still open? Will it ever heal?" Which of the following responses by the nurse is most appropriate? Stage II pressure ulcer Correct Answer-While performing a bed bath, the
nurse notes an area of tissue injury on the client's sacral area. The wound
presents as a shallow open ulcer with a red-pink wound bed and partial thickness loss of dermis. Which of the following is the correct name of this wound?
"Wounds heal better when a moist wound bed is maintained." Correct Answer-You are applying a saline-moistened dressing to a client's wound. The client asks, "Wouldn't it be better to let my wound dry out so a scab can form?" Which of the following responses is most appropriate?
stage 3 Correct Answer-A nurse inspecting a client's pressure ulcer documents the following: full-thickness tissue loss; visible subcutaneous
fat; bone, tendon, and muscle are not exposed. This pressure ulcer is categorized to be at which of the following stages?
Corticosteroids Correct Answer-Upon review of a postoperative patient's
medication list, the nurse recognizes that which medication will delay the healing of the operative wound?
Obstructive sleep apnea Correct Answer-The nurse has entered the room
of a newly admitted client and observed a continuous positive airway pressure (CPAP) on the client's bedside table. The nurse would recognize that this client likely has a history of what condition? Impaired gas exchange Correct Answer-A nurse is caring for a client diagnosed with sleep apnea. Which of the following nursing diagnoses should the nurse include in her nursing care plan?
Narcolepsy Correct Answer-When a client tells the clinic nurse that he has irresistible sleep attacks throughout the day lasting from 10 to 15 minutes, the nurse suspects that the client may be experiencing what?
Post signs for quiet and turn down hall lights during formal quiet times. Correct Answer-The nurse manager in an acute care facility has received
client evaluations in which the clients have complained about excessive noise that interfered with their rest. The nurse manager and nursing staff plan to do the following. Which activity will most assist clients in obtaining rest?
Newborns sleep 16 to 17 hours per day Correct Answer-The nurse is caring for new parents. During her education session, the nurse instructs the parents on a newborn's sleep patterns. Which of the following is a accurate about a newborn's sleep patterns?
sensory overload Correct Answer-A special needs child has been placed in a classroom with other special needs children. The classroom is noisy with a high level of activity, and the child appears to have difficulty concentrating on his work. What is the child likely experiencing?
coma Correct Answer-The nurse is caring for Jana Wok, a 23-year-old patient who suffered a traumatic brain injury in a motor vehicle accident.
Jana requires mechanical ventilation, cannot be aroused, and displays no
Instruct the client to inhale slowly and as deeply as possible through the mouthpiece, without using the nose. Correct Answer-A nurse is educating a postoperative client on how to use an incentive spirometer. Which of the following is an accurate step that should be included in the teaching plan?
Anxiety Correct Answer-A client is experiencing hypoxia. Which of the following nursing diagnoses would be appropriate?
There is an accidental separation of the wound Correct Answer-A nurse caring for a client who has a surgical wound following a cesarean section notes dehiscence of the wound and contacts the surgeon. Which of the following is a finding related to this condition?
Primary intention Correct Answer-A nurse assessing the wound healing of a patient, documents that the wound formed a clean, straight line with little loss of tissue. This wound healed by:
"Your wound will heal slowly as granulation tissue forms and fills the wound." Correct Answer-The acute care nurse is caring for a client whose large surgical wound is healing by secondary intention. The client
asks, "Why is my wound still open? Will it ever heal?" Which of the following responses by the nurse is most appropriate? Stage II pressure ulcer Correct Answer-While performing a bed bath, the
nurse notes an area of tissue injury on the client's sacral area. The wound
presents as a shallow open ulcer with a red-pink wound bed and partial thickness loss of dermis. Which of the following is the correct name of this wound?
"Wounds heal better when a moist wound bed is maintained." Correct Answer-You are applying a saline-moistened dressing to a client's wound. The client asks, "Wouldn't it be better to let my wound dry out so a scab can form?" Which of the following responses is most appropriate?
stage 3 Correct Answer-A nurse inspecting a client's pressure ulcer documents the following: full-thickness tissue loss; visible subcutaneous
fat; bone, tendon, and muscle are not exposed. This pressure ulcer is categorized to be at which of the following stages?
Corticosteroids Correct Answer-Upon review of a postoperative patient's
medication list, the nurse recognizes that which medication will delay the healing of the operative wound?
Obstructive sleep apnea Correct Answer-The nurse has entered the room
of a newly admitted client and observed a continuous positive airway pressure (CPAP) on the client's bedside table. The nurse would recognize that this client likely has a history of what condition? Impaired gas exchange Correct Answer-A nurse is caring for a client diagnosed with sleep apnea. Which of the following nursing diagnoses should the nurse include in her nursing care plan?
Narcolepsy Correct Answer-When a client tells the clinic nurse that he has irresistible sleep attacks throughout the day lasting from 10 to 15 minutes, the nurse suspects that the client may be experiencing what?
Post signs for quiet and turn down hall lights during formal quiet times. Correct Answer-The nurse manager in an acute care facility has received
client evaluations in which the clients have complained about excessive noise that interfered with their rest. The nurse manager and nursing staff plan to do the following. Which activity will most assist clients in obtaining rest?
Newborns sleep 16 to 17 hours per day Correct Answer-The nurse is caring for new parents. During her education session, the nurse instructs the parents on a newborn's sleep patterns. Which of the following is a accurate about a newborn's sleep patterns?
sensory overload Correct Answer-A special needs child has been placed in a classroom with other special needs children. The classroom is noisy with a high level of activity, and the child appears to have difficulty concentrating on his work. What is the child likely experiencing?
coma Correct Answer-The nurse is caring for Jana Wok, a 23-year-old patient who suffered a traumatic brain injury in a motor vehicle accident.
Jana requires mechanical ventilation, cannot be aroused, and displays no
