Basic questions

A 65-year-old female who has diabetes mellitus and has sustained a large laceration on her left wrist asks the nurse, "How long will it take for my scars to disappear?" which statement would be the nurse's best response?

a. "The contraction phase of wound healing can take 2 to 3 years." b. "Wound healing is very individual but within 4 months the scar should fade." c. "With your history and the type of location of the injury, it's hard to say." d. "If you don't develop an infection, the wound should heal any time between 1 and 3 years from now Answer C. Wound healing in a client with diabetes will be delayed. Providing the client with a time frame could give the client false information.

A female client is readmitted to the facility with a warm, tender, reddened area on her right calf. Which contributing factor would the nurse recognize as most important?

a. A history of increased aspirin use b. Recent pelvic surgery c. An active daily walking program d. A history of diabetes The client shows signs of deep vein thrombosis (DVT). The pelvic area is rich in blood supply, and thrombophlebitis of the deep vein is associated with pelvic surgery. Aspirin, an antiplatelet agent, and an active walking program help decrease the client's risk of DVT. In general, diabetes is a contributing factor associated with peripheral vascular disease.

A female client who received general anesthesia returns from surgery. Postoperatively, which nursing diagnosis takes highest priority for this client?

a. Acute pain related to surgery b. Deficient fluid volume related to blood and fluid loss from surgery c. Impaired physical mobility related to surgery d. Risk for aspiration related to anesthesia .Answer B. A client on bed rest suffers from a lack of movement and a negative nitrogen balance. Therefore, inadequate protein intake impairs wound healing. Inadequate vitamin D intake and low calcium levels aren't factors in poor healing for this client. A pressure ulcer should never be massaged.

Nurse Berri inspects a client's pupil size and determines that it's 2 mm in the left eye and 3 mm in the right eye. Unequal pupils are known as:

a. Anisocoria b. Ataxia c. Cataract d. Diplopia 28.Answer A. Unequal pupils are called anisocoria. Ataxia is uncoordinated actions of involuntary muscle use. A cataract is an opacity of the eye's lens. Diplopia is double vision.

A male client is admitted to the hospital with blunt chest trauma after a motor vehicle accident. The first nursing priority for this client would be to:

a. Assess the client's airway b. Provide pain relief c. Encourage deep breathing and coughing d. Splint the chest wall with a pillow .Answer A. The first priority is to evaluate airway patency before assessing for signs of obstruction, sternal retraction, stridor, or wheezing. Airway management is always the nurse's first priority. Pain management and splinting are important for the client's comfort, but would come after airway assessment. Coughing and deep breathing may be contraindicated if the client has internal bleeding and other injuries.

Nurse Margareth is revising a client's care plan. During which step of the nursing process does such revision take place?

a. Assessment b. Planning c. Implementation d. Evaluation During the evaluation step of the nursing process the nurse determines whether the goals established in the care plan have been achieved, and evaluates the success of the plan. If a goal is unmet or partially met the nurse reexamines the data and revises the plan. Assessment involves data collection. Planning involves setting priorities, establishing goals, and selecting appropriate interventions.

The nurse in charge identifies a patient's responses to actual or potential health problems during which step of the nursing process?

a. Assessment b. Nursing diagnosis c. Planning d. Evaluation Answer B. The nurse identifies human responses to actual or potential health problems during the nursing diagnosis step of the nursing process. During the assessment step, the nurse systematically collects data about the patient or family. During the planning step, the nurse develops strategies to resolve or decrease the patient's problem. During the evaluation step, the nurse determines the effectiveness of the plan of care.

Nurse Danny has been teaching a client about a high-protein diet. The teaching is successful if the client identifies which meal as high in protein?

a. Baked beans, hamburger, and milk b. Spaghetti with cream sauce, broccoli, and tea c. Bouillon, spinach, and soda d. Chicken cutlet, spinach, and soda Answer A. Baked beans, hamburger, and milk are all excellent sources of protein. The spaghetti-broccoli-tea choice is high in carbohydrates. The bouillon-spinach-soda choice provides liquid and sodium as well as some iron, vitamins, and carbohydrates. Chicken provides protein but the chicken-spinach-soda combination provides less protein than the baked beans-hamburger-milk selection.

While examining a client's leg, the nurse notes an open ulceration with visible granulation tissue in the wound. Until a wound specialist can be contacted, which type of dressings is most appropriate for the nurse in charge to apply?

a. Dry sterile dressing b. Sterile petroleum gauze c. Moist, sterile saline gauze d. Povidone-iodine-soaked gauze .Answer C. Moist, sterile saline dressings support would heal and are cost-effective. Dry sterile dressings adhere to the wound and debride the tissue when removed. Petroleum supports healing but is expensive. Povidone-iodine can irritate epithelial cells, so it shouldn't be left on an open wound.

A nurse assigned to care for a postoperative male client who has diabetes mellitus. During the assessment interview, the client reports that he's impotent and says that he's concerned about its effect on his marriage. In planning this client's care, the most appropriate intervention would be to:

a. Encourage the client to ask questions about personal sexuality b. Provide time for privacy c. Provide support for the spouse or significant other d. Suggest referral to a sex counselor or other appropriate professional The nurse should refer this client to a sex counselor or other professional. Making appropriate referrals is a valid part of planning the client's care. The nurse doesn't normally provide sex counseling. Therefore, providing time for privacy and providing support for the spouse or significant other are important, but not as important as referring the client to a sex counselor.

Nurse Cay inspects a client's back and notices small hemorrhagic spots. The nurse documents that the client has:

a. Extravasation b. Osteomalacia c. Petechiae d. Uremia Answer C. Petechiae are small hemorrhagic spots. Extravasation is the leakage of fluid in the interstitial space. Osteomalacia is the softening of bone tissue. Uremia is an excess of urea and other nitrogen products in the blood.

If a blood pressure cuff is too small for a client, blood pressure readings taken with such a cuff may do which of the following?

a. Fail to show changes in blood pressure b. Produce a false-high measurement c. Cause sciatic nerve damage d. Produce a false-low measurement Answer B. Using an undersized blood pressure cuff produces a falsely elevated blood pressure because the cuff can't record brachial artery measurements unless it's excessively inflated. The sciatic nerve wouldn't be damaged by hyperinflation of the blood pressure cuff because the sciatic nerve is located in the lower extremity.

A female patient is receiving furosemide (Lasix), 40 mg P.O. b.i.d. in the plan of care, the nurse should emphasize teaching the patient about the importance of consuming:

a. Fresh, green vegetables b. Bananas and oranges c. Lean red meat d. Creamed corn Answer B. Because furosemide is a potassium-wasting diuretic, the nurse should plan to teach the patient to increase intake of potassium-rich foods, such as bananas and oranges. Fresh, green vegetables; lean red meat; and creamed corn are not good sources of potassium.

The nurse in charge is caring for an Italian client. He's complaining of pain, but he falls asleep right after his complaint and before the nurse can assess his pain. The nurse concludes that:

a. He may have a low threshold for pain b. He was faking pain c. Someone else gave him medication d. The pain went away .Answer A.People of Italian heritage tend to verbalize discomfort and pain. The pain was real to the client, and he may need medication when he wakes up.

A female patient is diagnosed with deep-vein thrombosis. Which nursing diagnosis should receive highest priority at this time?

a. Impaired gas exchanges related to increased blood flow b. Fluid volume excess related to peripheral vascular disease c. Risk for injury related to edema d. Altered peripheral tissue perfusion related to venous congestion Answer D. Altered peripheral tissue perfusion related to venous congestion" takes highest priority because venous inflammation and clot formation impede blood flow in a patient with deep-vein thrombosis. Option A is incorrect because impaired gas exchange is related to decreased, not increased, blood flow. Option B is inappropriate because no evidence suggest that this patient has a fluid volume excess. Option C may be warranted but is secondary to altered tissue perfusion.

A male client is on prolonged bed rest has developed a pressure ulcer. The wound shows no signs of healing even though the client has received skin care and has been turned every 2 hours. Which factor is most likely responsible for the failure to heal?

a. Inadequate vitamin D intake b. Inadequate protein intake c. Inadequate massaging of the affected area d. Low calcium level Answer B. A client on bed rest suffers from a lack of movement and a negative nitrogen balance. Therefore, inadequate protein intake impairs wound healing. Inadequate vitamin D intake and low calcium levels aren't factors in poor healing for this client. A pressure ulcer should never be massaged.

A male client blood test results are as follows: white blood cell (WBC) count, 100ul; hemoglobin (Hb) level, 14 g/dl; hematocrit (HCT), 40%. Which goal would be most important for this client?

a. Promote fluid balance b. Prevent infection c. Promote rest d. Prevent injury The client is at risk for infection because WBC count is dangerously low. Hb level and HCT are within normal limits; therefore, fluid balance, rest, and prevention of injury are inappropriate.

Using Abraham Maslow's hierarchy of human needs, a nurse assigns highest priority to which client need?

a. Security b. Elimination c. Safety d. Belonging According to Maslow, elimination is a first-level or physiological need, and therefore takes priority over all other needs. Security and safety are second-level needs; belonging is a third-level need. Second- and third-level needs can be met only after a client's first-level needs have been satisfied.

Following a tonsillectomy, a female client returns to the medical-surgical unit. The client is lethargic and reports having a sore throat. Which position would be most therapeutic for this client?

a. Semi-Fowler's b. Supine c. High-Fowler's d. Side-lying Answer D. Because of lethargy, the post tonsillectomy client is at risk for aspirating blood from the surgical wound. Therefore, placing the client in the side-lying position until he awake is best. The semi-Fowler's, supine, and high-Fowler's position don't allow for adequate oral drainage in a lethargic post tonsillectomy client, and increase the risk of blood aspiration.

21. Which document addresses the client's right to information, informed consent, and treatment refusal?

a. Standard of Nursing Practice b. Patient's Bill of Rights c. Nurse Practice Act d. Code for Nurses Answer B. The Patient's Bill of Rights addresses the client's right to information, informed consent, timely responses to requests for services, and treatment refusal. A legal document, it serves as a guideline for the nurse's decision making. Standards of Nursing Practice, the Nurse Practice Act, and the Code for Nurses contain nursing practice

When positioned properly, the tip of a central venous catheter should lie in the

a. Superior vena cava b. Basilica vein c. Jugular vein d. Subclavian vein 8.Answer A. When the central venous catheter is positioned correctly, its tip lies in the superior vena cava, inferior vena cava, or the right atrium—that is, in central venous circulation. Blood flows unimpeded around the tip, allowing the rapid infusion of large amounts of fluid directly into circulation. The basilica, jugular, and subclavian veins are common insertion sites for central venous catheters.

A newly hired charge nurse assesses the staff nurses as competent individually but ineffective and nonproductive as a team. In addressing her concern, the charge nurse should understand that the usual reason for such a situation is:

a. Unhappiness about the charge in leadership b. Unexpected feeling and emotions among the staff c. Fatigue from overwork and understaffing d. Failure to incorporate staff in decision making Answer A. The first priority is to evaluate airway patency before assessing for signs of obstruction, sternal retraction, stridor, or wheezing. Airway management is always the nurse's first priority. Pain management and splinting are important for the client's comfort, but would come after airway assessment. Coughing and deep breathing may be contraindicated if the client has internal bleeding and other injuries.