Exam 3 NURS 175

The student nurse asks, "What is interstitial fluid?" What is the appropriate nursing response? A. "Fluid in the tissue space between and around cells." B. "Fluid inside cells." C. "Fluid outside cells." D. "Watery plasma, or serum, portion of blood."

A. "Fluid in the tissue space between and around cells."

A Red Cross volunteer has recently returned from assisting families who survived a devastating forest fire. The volunteer is having trouble sleeping and has returned to smoking cigarettes. Which statement by the volunteer leads the nurse to suspect the nursing concern of role strain related to stress from being a caregiver during their disaster volunteer activities? A. "I cannot seem to calm down. I keep seeing those faces and hearing their words every time I close my eyes." B. "I guess the smoke in the air brought out my mental addiction to cigarettes." C. "I need to get back to work here at home. That will get me back into a routine." D. "I get so tired from working long hours at the site."

A. "I cannot seem to calm down. I keep seeing those faces and hearing their words every time I close my eyes."

A nurse must administer an isotonic intravenous solution to a client who has lost fluid. Which fluids are isotonic? Select all that apply. A. 0.9% NaCl (normal saline) B. 0.45% NaCl (½-strength saline) C. 0.33% NaCl (1/3-strength normal saline) D. 5% dextrose in lactated Ringer's solution C. Lactated Ringer's solution

A. 0.9% NaCl (normal saline) C. Lactated Ringer's solution

A postoperative vaginal hysterectomy client complains of pain that is more intense than this morning. This factor should be explained to the client as A. "Your present pain is worse because you had your packing removed." B. "Acute pain tends to increase during the day and is called a routine pain response" C. "I will call your doctor because you may have loosened sutures when walking." D. "You will need more pain medication as the days progress."

B. "Acute pain tends to increase during the day and is called a routine pain response"

A client is experiencing acute pain following the amputation of a limb. What nursing interventions would be most appropriate when treating this client? A. Treat the pain only as it occurs to prevent drug addiction. B. Encourage the use of nonpharmacologic complementary therapies as adjuncts to the medical regimen. C. Increase and decrease the serum level of the analgesic as needed. D. Do not provide analgesia if there is any doubt about the likelihood of pain occurring.

B. Encourage the use of nonpharmacologic complementary therapies as adjuncts to the medical regimen.

While assessing an infant, the nurse notes that the infant displays an occasional grimace and is withdrawn; legs are kicking, body is arched, and the infant is moaning during sleep. When awakened, the infant is inconsolable. Which scale/score should the nurse use while assessing pain in this infant? A. FACES scale B. FLACC scale C. Braden scale D. Apgar score

B. FLACC scale

A client comes to the health center for a routine visit. During the visit, the client tells the nurse, "I'm motivated to do things now to make sure I'm the healthiest I can be." When planning this client's care, the nurse should focus on which area? A. Self-concept B. Health promotion C. Illness prevention D. Diagnosis of disease

B. Health promotion

A nurse is assessing clients across the lifespan for fluid and electrolyte balance. Which age group would the nurse identify as having the greatest risk for these imbalances? A. Toddlers B. Infants C. School-age children D. Adolescents

B. Infants

A nurse is caring for a client who is not able to take food orally for 1 week to 10 days. Which type of nutrition is the client likely receive? A. Total parenteral nutrition B. Peripheral parenteral nutrition C. Metabolizing nutrition D. Nasogastric feed

B. Peripheral parenteral nutrition

The nurse is preparing to talk to a local community group regarding chronic illness. The nurse informs the group that both external and internal factors influence a person's health. When discussing the fact that the male client has a higher chance of developing lung cancer due to his gender, which dimension is the nurse referring to? A. Intellectual dimension B. Physical dimension C. Emotional dimension D. Environmental dimension

B. Physical dimension

What level of prevention is represented by educating a group of clients on carseat safety? A. Educational prevention B. Primary prevention C. Tertiary prevention D. Secondary prevention

B. Primary prevention

The nurse is caring for a client who is a doctor in a general hospital. He complains about the stressful condition of his job. Lately, he has become increasingly susceptible to colds, headaches, muscular tension, excessive tiredness, and many other symptoms. At what stage of stress is the client? A. resistance stage B. exhaustion stage C. alarm stage D. secondary stage

B. exhaustion stage

A nurse is assessing a client who has recently lost her husband. During the interview the nurse realizes that the client is unable to cope with the loss. The client finds it difficult to organize daily tasks or solve problems effectively. Which suggestion would be most appropriate for the nurse to suggest as a crisis intervention? A. keep the home environment noise free B. seek assistance from family and friends C. tense and relax muscle groups systematically D. perform meditation to relax

B. seek assistance from family and friends

A nursing student is teaching a healthy adult client about adequate hydration. Which statement by the client indicates understanding of adequate hydration? A. "I need to drink no more than 1,000 mL/day" B. "I should drink more than 3,500 mL/day of fluid." C. "I should drink 2,500 mL/day of fluid." D. "I should drink 1,500 mL/day of fluid."

C. "I should drink 2,500 mL/day of fluid."

What commonly used intravenous solution is hypotonic? A. 0.9% NaCl B. 0% dextrose in water C. 0.45% NaCl D. lactated Ringer's

C. 0.45% NaCl

A health care provider orders an infusion of 250 mL of NS in 100 minutes. The set is 20 gtt/ml What is the flow rate? A. 40 gtt/min B. 20 gtt/min C. 50 gtt/min D. 30 gtt/min

C. 50 gtt/min

A nurse is caring for a client who received naloxone to reverse respiratory depression due to opioid therapy. The client is now complaining of pain and wishes to receive the newly prescribed pain medication. What is the correct action by the nurse? A. Administer the medication when the client's heart rate is > 80. B. Administer the medication when the client's heart rate is < 90. C. Administer the medication if respiratory rate is > 9. D. Administer the medication when the client's blood pressure is > 140/90.

C. Administer the medication if respiratory rate is > 9.

What is the definition of wellness? A. Being without disease B. A desire to be without disease C. An active state of being healthy D. Maximizing the state in which you live

C. An active state of being healthy

The nurse is caring for a client who frequently comes to the emergency department (ED) reporting a headache that is an 8 or 9 on a pain scale of 1 to 10. The client is noted to be laughing while on the phone and chatting with staff after reporting a headache that is a 10. Which action will the nurse perform prior to initiating treatment? A. Contact the pain clinic for further assessment B. Discuss observations with the client C. Assess for nonverbal cues to pain D. Request a lower dose of medication from the health care provider

C. Assess for nonverbal cues to pain

Risk factors for illness are divided into six categories. Working with carcinogenic chemicals is an example of which type of risk factor? A. Physiologic risk factor B. Health habits risk factor C. Environmental risk factor D. Lifestyle risk factor

C. Environmental risk factor

Which needs are being met when a nurse recommends a senior citizen community center for an older client who is living alone? A. Emotional needs B. Spiritual needs C. Sociocultural needs D. Intellectual needs

C. Sociocultural needs

An older adult client who is being treated in the hospital was given a hypnotic medication at bedtime. Which of the following possible consequences would indicate a paradoxical effect of this drug? A. The client is unable to sleep without medication the following night. B. The client experiences respiratory depression after the drug takes effect. C. The client exhibits restless, uncharacteristic behavior after receiving the drug. D. In the morning, the client is unable to identify his location or the day of the week.

C. The client exhibits restless, uncharacteristic behavior after receiving the drug.

When the male client on his first postoperative day after chest surgery appears stoic and does not ask for any pain medication, the nurse should: A. document the client's lack of medication. B. assume the client does not need medication. C. actively solicit information about the client's pain level. D. ask the client's family if he ever uses pain medicines.

C. actively solicit information about the client's pain level.

A client who recently had surgery is bleeding. What blood product does the nurse anticipate administering for this client? A. albumin B. cryoprecipitate C. platelets D. granulocytes

C. platelets

The nurse is planning to discontinue a peripherally inserted central catheter (PICC) for a client who is prescribed warfarin therapy. Which intervention will individualize care for this client? A. Apply petroleum-based ointment and sterile occlusive dressing. B. Ask client to perform Valsalva maneuver. C. Instruct client to remain flat for 30 minutes. D. Apply pressure to insertion site for at least 3 minutes.

D. Apply pressure to insertion site for at least 3 minutes. Explanation: The nurse recognizes that the client prescribed warfarin is at risk for bleeding and individualizes care by applying pressure to the insertion site for longer than the minimum recommended 1 minute.

Meeting which type of needs is essential for physiological health and survival? A. Educational needs B. Spiritual needs C. Monetary needs D. Basic human needs

D. Basic human needs

When caring for a client who has just been diagnosed with a chronic illness, the nurse understands the importance of promoting health by highlighting which concept? A. Focus on the altered functioning. B. Focus on why the client has the illness. C. Focus on what can no longer be. D. Focus on what is possible.

D. Focus on what is possible.

Which is an example of tertiary health promotion? A. Pap tests B. Family counseling C. Water treatment D. Rehabilitation

D. Rehabilitation

During a blood transfusion of a client, the nurse observes the appearance of rash and flushing in the client, although the vital signs are stable. Which intervention should the nurse perform for this client first? A. Infuse saline at a rapid rate. B. Prepare to give an antihistamine. C. Administer oxygen. D. Stop the transfusion immediately.

D. Stop the transfusion immediately.

The nurse writes a a problem-based care plan, citing the client's excess fluid volume. What risk factor does the nurse expect to assess in this client? A. diaphoresis B. increased cardiac output C. excessive use of laxatives D. acute kidney injury

D. acute kidney injury

The body's attempt to restore balance through self-regulatory mechanisms is termed: A. equilibration. B. self-conception. C. biofeedback. D. homeostasis.

D. homeostasis.

The nurse is caring for a client, who was admitted after falling from a ladder. The client has a brain injury which is causing the pressure inside the skull to increase that may result in a lack of circulation and possible death to brain cells. Considering this information, which intravenous solution would be most appropriate? A. hypotonic B. isotonic C. plasma D. hypertonic

D. hypertonic

A client is admitted to the facility after experiencing uncontrolled diarrhea for the past several days. The client is exhibiting signs of a fluid volume deficit. When reviewing the client's laboratory test results, which electrolyte imbalance would the nurse likely to find? A. hyperphosphatemia B. hypomagnesemia C. hyperchloremia D. hypokalemia

D. hypokalemia

A nurse is reviewing the client's serum electrolyte levels which are as follows: Sodium: 138 mEq/L (138 mmol/L) Potassium: 3.2 mEq/L (3.2 mmol/L) Calcium: 10.0 mg/dL (2.5 mmol/L) Magnesium: 2.0 mEq/L (1.0 mmol/L) Chloride: 100 mEq/L (100 mmol/L) Phosphate: 4.5 mg/dL (2.6 mEq/L) Based on these levels, the nurse would identify which imbalance? A. hyponatremia B. hypercalcemia C. hypermagnesemia D. hypokalemia

D. hypokalemia

During a counseling session a client states, "I just try to forget about my spouse hitting me." Which coping mechanism should the nurse document on the basis of this client's statement? A. regression B. reaction formation C. rationalization D. repression

D. repression

Prior to the client's scheduled bone marrow biopsy, the nurse has devoted time to educating him about the rationale and the specific details of the procedure. The nurse's actions constitute what stress management technique? A. Anticipatory guidance B. Relaxation C. Guided imagery D. Normalization

A. Anticipatory guidance

Which nursing intervention is an example of tertiary preventive care? A. Assisting with speech therapy a client with a traumatic brain injury B. Administration of immunizations to a 6-month-old child C. Blood pressure screenings at a senior center D. Teaching stress reduction classes at a wellness center

A. Assisting with speech therapy a client with a traumatic brain injury

A nurse is performing a venipuncture on an older client. The client has visible veins that appear to roll. What nursing technique is most appropriate? A. Avoid use of a tourniquet. B. Consider venipuncture in the foot where veins are less visible. C. Select a large-gauge needle. D. Use the client's nondominant hand to hold the vein in place.

A. Avoid use of a tourniquet.

When performing a pain assessment on a client, the nurse observes that the client guards his arm, which was fractured in a car accident, and he refuses to move out of his chair. The nurse notes this reaction as what type of pain response? A. Behavioral B. Physiologic C. Affective D. Psychosomatic

A. Behavioral

The nurse is reviewing relaxation techniques with the client who has chronic back pain that radiates to the legs. What information does the nurse include? A. Close your eyes while practicing the relaxation exercises. B. Sit in a wood chair with a straight back. C. Tighten and relax muscles starting with the upper body. D. Take shallow abdominal breaths.

A. Close your eyes while practicing the relaxation exercises.

A client who suffered multiple trauma in a motor vehicle accident is receiving care in an orthopedic trauma unit. The client has a documented history or opioid addiction and the hospital's advanced pain control team has become involved in his pain control plan. Which of the following are aspects of addiction? Select all that apply. A. Compulsive use of a particular drug B. The need to use opioids for purposes other than pain reliefterm-6 C. The need for increasing size or frequency of opioid doses to achieve pain relief D. The use of more than 30 mg of morphine or 15 mg of hydromorphone in a 24 hour period

A. Compulsive use of a particular drug Presence of an unusually low pain threshold B. The need to use opioids for purposes other than pain relief

A nurse is caring for a client who requires intravenous (IV) therapy. The nurse understands that which actions are the nurse's responsibilities related to this therapy? Select all that apply. A. Deciding the location of the IV catheter. B. Determining the amount of IV solution. C. Prescribing the kind of IV solution. D. Deciding the size of the IV catheter. E. Administering the IV solution.

A. Deciding the location of the IV catheter. D. Deciding the size of the IV catheter. E. Administering the IV solution.

The young female client had emergency surgery for appendicitis. She is a cigarette smoker, is breast-feeding her infant, and expressed a desire to continue to breast-feed when discharged from the hospital. The surgeon has prescribed acetaminophen/oxycodone for pain relief at home. What instructions would the nurse include when providing discharge teaching? Select all that apply. A. Do not drive a vehicle while taking this medication. B. For better absorption, take your pain medication on an empty stomach. C. Client is allowed to have one drink of alcohol each day. D. You may smoke cigarettes during the day but not at night. E. Keep a diary to record level of pain and time medication is taken. F. You must check with your primary care provider before breast-feeding your infant.

A. Do not drive a vehicle while taking this medication. E. Keep a diary to record level of pain and time medication is taken. F. You must check with your primary care provider before breast-feeding your infant.

A client has been admitted to the hospital for the treatment of diabetic ketoacidosis, with a random blood glucose reading of 575 mg/dL (31.91 mmol/L), vomiting, and shortness of breath. This client has experienced which phenomenon? A. Exacerbation B. Infection C. Risk factor D. Morbidity

A. Exacerbation

The nurse that ascribes to the gate control theory of pain would be most likely to prescribe which of the following for the relief of pain? (Select all that apply.) A. Massage B. Pressure C. Acetaminophen D. Percocet E. Heat

A. Massage B. Pressure E. Heat

The nurse is preparing to initiate an infusion of packed red blood cells (PRBCs). While observing the information on the blood bag, it is essential to verify which information with another nurse? Select all that apply. A. Number on the client's identification band B. Client's room number C. Name on the client's identification band D. Client's vital signs E. Patency of the client's venous access device

A. Number on the client's identification band C. Name on the client's identification band

A nurse refers an HIV-positive client to a local support group. This is an example of what level of preventive care? A. Tertiary B. Primary C. Chronic D. Secondary

A. Tertiary

What is the priority goal for the activity in which the nurse is engaging, related to the administration of a prescribed IV solution? A. To assure the IV solution is appropriate for this administration B. To demonstrate effective nursing care in the administration of the prescribed IV solution C. To assure effective administration of the prescribed IV solution D. To provide for effective time management in the administration of the prescribed IV solution

A. To assure the IV solution is appropriate for this administration

Upon assessment of a client's peripheral intravenous site, the nurse notices the area is red and warm. The client complains of pain when the nurse gently palpates the area. These signs and symptoms are indicative of: A. phlebitis. B. rapid fluid administration. C. a systemic blood infection. D. an infiltration.

A. phlebitis.

The primary extracellular electrolytes are: A. sodium, chloride, and bicarbonate. B. magnesium, sulfate, and carbon. C. potassium, phosphate, and sulfate. D. phosphorous, calcium, and phosphate.

A. sodium, chloride, and bicarbonate.

A group of nursing students is learning about the body's response to stress. Which system is responsible for initiating the fight-or-flight response to stress? A. sympathetic nervous system B. parasympathetic nervous system C. respiratory system D. endocrine system

A. sympathetic nervous system

The nurse is taking a history for a pregnant client who has been seen for chronic headaches for 2 years. Today, the client reports a headache that feels different than the normal headaches she has experienced in the past. Which assessment question helps the nurse assess quality of pain? A. "When did your pain begin?" B. "Can you describe the type of pain you are having?" C. "Could you please rate your pain on a 1-10 scale?" D. "How long have you experienced this pain?"

B. "Can you describe the type of pain you are having?"

A client has just been started on opioid analgesia for pain control. The nurse assesses the client's level of sedation using a sedation scale and notes that the client is awake and alert. The nurse would assign which rating? A. S B. 1 C. 2 D. 3

B. 1

A health care provider has asked the nurse to use microdrip tubing to administer a prescribed dosage of IV solution to a client. What is the standard drop factor of microdrip tubing? A. 120 drops/mL B. 60 drops/mL C. 30 drops/mL D. 90 drops/mL

B. 60 drops/mL

A client with protracted nausea and vomiting has been receiving intravenous solution at 125 ml/h for the past several hours. The administration of this solution has resulted in an increase in blood pressure because the water in the solution has passed through the semipermeable membrane of blood cells, causing them to swell. What type of solution has the client been receiving? A. A hypertonic solution B. A hypotonic solution C. An isotonic solution D. Packed red blood cells

B. A hypotonic solution

Upon arrival to the emergency room, the mother of a client involved in a motor vehicle accident becomes upset when she learns her son is unconscious and unstable. The mother begins to yell at the emergency room staff in unintelligible words, and she is trembling. She becomes short of breath and yells she can't breathe. What is the mother likely experiencing? A. Mild anxiety B. A panic attack C. Moderate anxiety D. Severe anxiety

B. A panic attack

A hospital client's pain is being treated with epidural analgesia. Which nursing action would pose a threat to the client's safety? A. Feeding the client food and fluids while in a semi-Fowler's (partially upright) position B. Administering an oral dose of morphine to treat the client's breakthrough pain C. Administering a glycerin suppository to treat the client's constipation D. Palpating the client's abdomen during a head-to-toe assessment

B. Administering an oral dose of morphine to treat the client's breakthrough pain

A neonatal nurse is caring for a 2-day-old infant who experienced shoulder subluxation during delivery. What pain assessment scale should the nurse use to assess this client's pain? A.Wong-Baker B. CRIES Pain Scale C. FLACC Scale D. PAINAD Scale

B. CRIES Pain Scale

When caring for a client who is on intravenous therapy, the nurse observes that the client has developed redness, warmth, and discomfort along the vein. Which intervention should the nurse perform for this complication? A. Apply antiseptic and a dressing. B. Restart infusion in another vein and apply a warm compress. C. Elevate the client's head. D. Position the client on the left side.

B. Restart infusion in another vein and apply a warm compress.

A community health nurse arranges for a dentist to teach local children in the school district how to properly brush their teeth. Which goal will the nurse set for this event? A. illness prevention B. health promotion C. high-level wellness D. reversal of self-care deficit

B. health promotion

A client is on a stress management program. She states that she is open to trying a guided meditation class. When helping her get started, a nurse tells her that which of the following is not important? A. a focus of attention B. soft music C. an open attitude D. a quiet environment

B. soft music

A client with a diagnosis of colon cancer has opted for a treatment plan that will include several rounds of chemotherapy. What vascular access device is most likely to meet this client's needs? A. A midline peripheral catheter B. A peripheral venous catheter inserted to the cephalic vein C. An implanted central venous access device (CVAD) D. A peripheral venous catheter inserted to the antecubital fossa

C. An implanted central venous access device (CVAD)

The nurse is caring for a client with chronic pain. Which long-term coping strategies may be helpful in this situation? A. Accepting the pain will never go away B. Take a tepid sponge bath during pain episodes C. Deep breathing and meditation D. Smoking and walking briskly

C. Deep breathing and meditation

A nurse is providing care for client who experienced a stroke. Which nursing intervention reflects the tertiary level of prevention? A. assess blood pressure every 4 hours B. discuss family history of hypertension C. provide care transition at discharge for speech therapy D. conduct mental status assessment every 2 hours

C. provide care transition at discharge for speech therapy

A client is taking a diuretic such as furosemide. When implementing client education, what information should be included? A. Decreased oxygen levels B. Increased potassium levels C. Increased sodium levels D. Decreased potassium levels

D. Decreased potassium levels

Three days after surgery, a client continues to have moderate to severe incisional pain. Based on the gate-control theory, what action should the nurse take? A. Decrease external stimuli in the room during painful episodes. B. Advise the client to try to sleep following administration of pain medication. C. Administer pain medications in smaller doses but more frequently. D. Reposition the client and gently massage the client's back.

D. Reposition the client and gently massage the client's back. Explanation: The nurse would reposition the client and gently massage the client's back using the gate-control theory of pain. The gate-control theory provides the most practical model regarding the concept of pain. It describes the transmission of painful stimuli and recognizes a relationship between pain and emotions. Nursing measures, such as massage or a warm compress to a painful lower back area, stimulate large nerve fibers to close the gate, thus blocking pain impulses from that area. Decreasing the dosage of the pain medication—but giving the doses more frequently—does not follow this theory. Decreasing external stimuli in the room during painful episodes would not address the gate-control theory. Advise the client to sleep following administration of pain medication does not address the gate-control theory.

A client informs the nurse that headaches started when marital problems began. The client reports that each time they have a fight, a headache develops and loss of appetite occurs for several days. What does the nurse identify as the physiologic symptoms? fear a somatic disorder a coping mechanism anxiety

a somatic disorder