Final 112

A college student visits the school's health center with vague complaints of anxiety and fatigue. The student tells the nurse, "Exams are right around the corner and all I feel like doing is sleeping." The student's vital signs are within normal parameters. What would be an appropriate question to ask in response to the student's verbalizations? "Are you worried about failing your exams?" "Have you been staying up late studying?" "Are you using any recreational drugs?" "Do you have trouble managing your time?"

"Are you worried about failing your exams?"

A nurse is caring for a 4-year-old child who had an incident of bedwetting during hospitalization. The child's parents expresses concern about the incident. Which of the following responses should the nurse make? "Children who are hospitalized often regress. The toileting skills will return when your child is feeling better." "I know this can be embarrassing. I have kids myself so I understand, and it doesn't bother me." "Why is she wetting the bed in the hospital? She must wet the bed at home." "I will discuss your child's loss of bladder control with the provider."

"Children who are hospitalized often regress. The toileting skills will return when your child is feeling better."

Which question about fluid balance would be appropriate when conducting a health history for a client? "Describe your usual urination habits." "Do you eat fruits and vegetables each day?" "How did you feel when your calcium was low?" "Describe your problems with constipation."

"Describe your usual urination habits."

A nurse teaches problem solving to a college student who is in a crisis situation. What statement best illustrates the student's understanding of the process? "I need to identify the problem first." "Listing alternatives is the initial step." "I will list alternatives after I develop the plan." "I do not need to evaluate the outcome of my plan."

"I need to identify the problem first."

A nurse is teaching a patient a relaxation technique. Which statement demonstrates the need for additional teaching? "I must breathe in and out in rhythm." "I should take my pulse and expect it to be faster." "I can expect my muscles to feel less tense." "I will be more relaxed and less aware."

"I should take my pulse and expect it to be faster."

A nurse facilitating a group therapy session is listening to clients discuss their coping strategies when feeling stressed. Which of the following statements indicate adaptive coping? (Select all that apply.) "I isolate myself in my room for a few hours when things get overwhelming." "I tense and release my muscles, starting with my feet." "I think about being on my favorite beach vacation." "I call a friend who makes me smile and laugh." "I sleep in in the mornings."

"I tense and release my muscles, starting with my feet." "I think about being on my favorite beach vacation." "I call a friend who makes me smile and laugh."

A nurse interviews a patient who was abused by her partner and is staying at a shelter with her three children. She tells the nurse, "I'm so worried that my husband will find me and try to make me go back home." Which data would the nurse most appropriately document? "Patient displays moderate anxiety related to her situation." "Patient manifests panic related to feelings of impending doom." "Patient describes severe anxiety related to her situation." "Patient expresses fear of her husband."

"Patient expresses fear of her husband."

What is the average adult fluid intake and loss in each 24 hours? 1,500 to 2,000 mL 500 to 1,000 mL 1,000 to 1,500 mL 1,500 to 3500 mL

1,500 to 3500 mL

A nurse is preparing to perform wound care and remove staples from a client's surgical incision following a hip replacement. Identify the sequence the nurse should follow from the following interventions. (All steps must be used.) 1) Clean the skin along the sides of the incision. 2) Remove remaining staples. 3) Remove the wound dressing. 4) Wipe cleansing solution directly over the surgical incision. 5) ​Remove every other staple. 3,4,5,2,1 3,4,1,5,2 3,1,4,5,2 3,1,5,2,4

3,4,1,5,2

A nurse monitoring the intake and output of fluids for a client with severe diarrhea knows that normally how much body fluid is lost via the gastrointestinal tract? 300 mL 1,000 mL 1,300 mL 2,600 mL

300mL

For which client would the application of a hydrocolloid dressing be most appropriate? A client with a sunburn affecting his back and torso A client who has a partial-thickness venous ulcer with moderate drainage A client whose surgical incision dehisced and became infected A client who has just undergone a cholecystectomy (gall bladder removal)

A client who has a partial-thickness venous ulcer with moderate drainage

A nurse is discussing guided imagery with peers. Which of the following clients should the nurse identify as being a candidate for guided imagery? A client who has post-traumatic stress disorder A client who has schizophrenia A client who has pedophilia A client who has paranoid personality disorder

A client who has post-traumatic stress disorder

The nurse is caring for multiple adult clients in an acute care setting. The nurse should consider which client to be the most unlikely for an electrolyte imbalance? A client with third-degree burns to an estimated 30% of the body A client hospitalized for a temperature of 102 degrees after running a marathon A client with an estimated blood loss of 500 mL due to a traumatic injury A client experiencing uncontrollable vomiting and diarrhea for the past 3 days

A client with an estimated blood loss of 500 mL due to a traumatic injury

A nurse is discussing pressure ulcer staging with a newly licensed nurse. Which of the following statements should the nurse use to describe a stage 3 pressure ulcer? Unbroken skin with un-blancheable erythema Full-thickness tissue loss extending to underlying support structures A shallow, ruptured or intact skin blister without slough A deep crater without visible bone, tendon, or muscle

A deep crater without visible bone, tendon, or muscle

Which client will have more adipose tissue and less fluid? child man infant woman

A woman

A client has undergone abdominal surgery for the treatment of cancer and is recovering with a Hemovac drain in place. When caring for this device, which interventions should the nurse perform? Select all that apply. Administer analgesia before changing the dressing around the drain, if needed. Perform hand hygiene and put on goggles before emptying the drain. Use a gauze pad to clean the drain outlet after emptying it. Leave the drain open for 5 to 7 minutes to ensure full drainage. Fasten the drain to the client's gown using a safety pin after emptying and recompressing it.

Administer analgesia before changing the dressing around the drain, if needed. Use a gauze pad to clean the drain outlet after emptying it. Fasten the drain to the client's gown using a safety pin after emptying and recompressing it.

The nurse is admitting a client into the hospital with a diagnosis of dehydration related to vomiting. Which symptom of dehydration will the nurse expect during physical assessment? Unproductive cough Loss of appetite Alteration in body temperature Chronic pain

Alteration in body temperature

A nurse is assessing the developmental levels of patients in a pediatric office. Which person would a nurse document as experiencing developmental stress? An infant who learns to turn over A school-aged child who learns how to add and subtract An adolescent who is a "loner" A young adult who has a variety of friends

An adolescent who is a "loner"

A nurse is caring for a client who has urinary incontinence. Which of the following actions should the nurse take to prevent the development of skin breakdown? Apply a moisture barrier ointment to the skin. Clean the skin and perineum with hot water after each episode of incontinence. Check the client's skin every 8 hr for signs of breakdown. Request a prescription for the insertion of an indwelling urinary catheter.

Apply a moisture barrier ointment to the skin.

The nurse has received an order to apply a saline-moistened dressing to a client's wound. Which action should the nurse perform? Avoid using irrigation to clean the wound before changing the dressing. Apply dry gauze to the wound and carefully apply saline to saturate it. Exert firm pressure using forceps to pack the wound tightly with moistened dressing. Apply dry gauze pads over the wet gauze and place the abdominal pad over the gauzes.

Apply dry gauze pads over the wet gauze and place the abdominal pad over the gauzes.

A nurse has received an order to insert a urinary catheter into a female client. In preparation, the nurse asks if she has ever had an indwelling catheter and, if so, why and for how long. The nurse has performed which action? Assessed for the most appropriate size of catheter to insert Assessed the possibility that the client has urethral strictures Assessed the client's risk of hemorrhage during insertion Gauged the client's risk of developing a urinary tract infection

Assessed the possibility that the client has urethral strictures

A nurse is caring for a client who is 2 days postoperative after abdominal surgery. What nursing intervention would be important to promote wound healing at this time? Administer pain medications on a p.r.n. and regular basis. Assist in moving to prevent strain on the suture line. Tell the client that a mild fever is a normal response. If a scar forms over a joint, it may limit movement.

Assist in moving to prevent strain on the suture line.

A nurse has realized that he neglected to release the clamp from the drainage tubing of a client's indwelling urinary catheter after collecting a specimen. The nurse should promptly assess the client for what complication? Urinary tract infection Urinary stasis Acute kidney injury Bladder overdistention

Bladder overdistention

A nurse is assessing a patient who complains of migraines that have become "unbearable." The patient tells the nurse, "I just got laid off from my job last week and I have two kids in college. I don't know how I'm going to pay for it all." Which physiologic effects of stress would be expected findings in this patient? Select all that apply. Changes in appetite Changes in elimination patterns Increased pulse and respirations Use of ineffective coping mechanisms Withdrawal Attention-seeking behaviors

Changes in appetite Changes in elimination patterns Increased pulse and respirations

A nurse is providing hygiene care for a client who is immobilized. Which of the following actions should the nurse take? (Select all that apply.) Check the bed linens when removing them for personal items. Place a clean gown on the strongest arm first. Keep the bath water's temperature between 43.3°C (110° F) and 46.1° C (115° F). Shave the client's hair in the direction of the hair growth. Wash the client's extremities from proximal to distal.

Check the bed linens when removing them for personal items. Keep the bath water's temperature between 43.3°C (110° F) and 46.1° C (115° F). Shave the client's hair in the direction of the hair growth.

Urinalysis and urine culture testing have been ordered for a client who has an indwelling urinary catheter. The nurse observes that there is currently no urine in the client's catheter tube. What should the nurse do? Encourage the client to increase fluid intake for the next couple of hours Clamp the tube below to access the port to allow urine to accumulate. Reposition the client supine. Attach a syringe to the access port and aspirate until a sample is obtained.

Clamp the tube below to access the port to allow urine to accumulate.

A nurse is cleaning the wound of a client who has been injured by a gunshot. Which guideline is recommended for this procedure? Use clean technique to clean the wound. Clean the wound in a circular pattern, beginning on the perimeter of the wound. Clean the wound from the top to the bottom and from the center to outside. Once the wound is cleaned, gently dry the wound bed with an absorbent cloth.

Clean the wound from the top to the bottom and from the center to outside.

A nurse is caring for a client who has a wound infection. Which of the following actions should the nurse take when obtaining a wound drainage specimen for culture? Cleanse the wound with 0.9% sodium chloride irrigation before obtaining the specimen. Irrigate the wound with an antiseptic prior to obtaining the specimen. Include intact skin at the wound edges in the culture. Swab an area of skin away from the wound to identify normal flora.

Cleanse the wound with 0.9% sodium chloride irrigation before obtaining the specimen.

A nurse measures a client's 24-hour fluid intake and documents the findings. To be an accurate indicator of fluid status, what must the nurse also do with the information? -Compare the client's intake with the normal range of adult fluid intake. -Compare the total intake and output of fluids for the 24 hours. -Ensure that the information is included in the verbal end-of-shift report. -Report the exact milliliter of intake to the physician's office nurse.

Compare the total intake and output of fluids for the 24 hours.

A nurse is caring for a client who is 2 days postoperative following a right hemicolectomy. When the nurse enters the client's room, he states that, following a bout of coughing, "something popped in my belly." The nurse lifts the sheets and sees that the client's gown is bloody. After sending a coworker to get the charge nurse and call the surgeon, which of the following actions should the nurse take next? Position the client supine with his hips and knees bent. Prepare to administer an IV infusion of 0.9% sodium chloride. Cover the wound with moist sterile gauze. Measure the client's vital signs.

Cover the wound with moist sterile gauze.

A nurse in an urgent care clinic is preparing to remove skin sutures from a client. Which of the following actions should the nurse take? Remove loose sutures first Cut below the suture knot Use clean bandage scissors Lift sutures from the skin with a sterile needle.

Cut below the suture knot

A nurse is interviewing a patient who just received a diagnosis of pancreatic cancer. The patient tells the nurse "I would never be the type to get cancer; this must be a mistake." Which defense mechanism is this patient demonstrating? Projection Denial Displacement Repression

Denial

What is the movement of solute molecules from an area high concentration to an area of low concentration? Facilitated Transport Diffusion Active Transport Passive Transport Osmosis

Diffusion

A nurse is caring for a client who has generalized anxiety disorder. The client is consistently late for appointments and ignores household chores. The client states, "I'm just too stressed. I need to be taken care of." The nurse should identify this behavior as the maladaptive use of which of the following defense mechanisms? Dissociation ​Introjection Regression Repression

Dissociation

A nurse is caring for a female client with an indwelling urinary catheter. Which action should the nurse take into consideration to reduce the client's risk of developing a urinary tract infection (UTI)? Use clean technique when inserting the catheter. Ensure that the catheter is removed as soon as possible. Irrigate the catheter with sterile water once per shift. Administer prophylactic antibiotics, as ordered.

Ensure that the catheter is removed as soon as possible.

A physician writes an order to "force fluids." What will be the first action the nurse will take in implementing this order? Tell the client and family to increase oral intake. Explain to the client why this is needed. Divide the intake so the largest amount is at night. Decide how much fluid to increase every 8 hours.

Explain to the client why this is needed.

A nurse is caring for a client with an external condom catheter. Which guideline should be implemented when applying and caring for this type of catheter? Remove the catheter every 8 hours, or more often in humid weather. Wipe the penis thoroughly with an alcohol swab and dry thoroughly before application. Fasten the condom securely enough to prevent leakage without constricting blood flow. Ensure the tip of the tubing is touching the tip of the client's penis.

Fasten the condom securely enough to prevent leakage without constricting blood flow.

A nurse is assessing a client with a stage IV pressure ulcer. What assessment of the ulcer would be expected? Full-thickness skin loss Skin pallor Blister formation Eschar formation

Full-thickness skin loss

A health care provider orders a dressing to cover a newly developed partial-thickness wound with minimal drainage. What would be the best type of dressing for this wound? Saline-moistened dressing Dressing secured with Montgomery straps Hydrocolloid dressing Foam dressing

Hydrocolloid dressing

A nurse is collecting data on a client who is experiencing chronic stress. Which of the following is an expected finding? Hypotension Viral infection ​Increased energy ​Increased cognitive awareness

Hypotension

What intervention should be included on a plan of care to prevent pressure ulcer development in health care settings? Change position at least once each shift. Implement a turning schedule every 2 hours. Use ring cushions for heels and elbows. Do not turn; use pressure-relieving support surface.

Implement a turning schedule every 2 hours.

A nurse identifies a pressure ulcer after a client had a long, extensive recovery following a surgical procedure. When completing an incident report about the pressure ulcer, which of the following actions should the nurse take? Document what the nurse believes was the cause of ulcer development. Include any relevant statements the client made about the incident. Document in the client's medical record that she completed an incident report. Question the charge nurse about care deficits that might have contributed to the incident.

Include any relevant statements the client made about the incident.

A nurse is collecting data from a client who underwent a stressful event and is experiencing fight-or-flight syndrome. Which of the following findings should the nurse expect as an immediate response in the client? Increased fluid retention Increased basal metabolic rate Decreased gastrointestinal motility Decreased immune response

Increased basal metabolic rate

A nurse witnesses a street robbery and is assessing a patient who is the victim. The patient has minor scrapes and bruises, and tells the nurse, "I've never been so scared in my life!" What other symptoms would the nurse expect to find related to the fight-or-flight response to stress? Select all that apply. Increased heart rate Decreased muscle strength Increased mental alertness Increased blood glucose levels Decreased cardiac output Decreased peristalsis

Increased heart rate Increased mental alertness Increased blood glucose levels

A nurse is caring for a patient in the shock or alarm reaction phase of the GAS (General Adaptation Syndrome). Which response by the patient would be expected? Decreasing pulse Increasing sleepiness Increasing energy levels Decreasing respirations

Increasing energy levels

A nurse is collecting data from a client who has posttraumatic stress disorder (PTSD) following a sexual assault. Which of the following is an expected finding? Sleeping 12 hr or more each day ​Increasing sense of attachment to others Constant need to talk about the event ​Increasing feelings of anger

Increasing feelings of anger

Which individual with diarrhea for three days is most likely to suffer from fluid and electrolyte imbalance? Young adult School-age child Infant Adolescent

Infant

Based on knowledge of total body fluids, a nurse is especially watchful for a fluid volume deficit in an infant. Why would the nurse do this? Infants have more total body fluid and ECF than adults. Infants have less total body fluid and ECF than adults. Infants drink less fluid than adults. Infants lose more fluids through output than adults.

Infants have more total body fluid and ECF than adults.

Concentration of the solutes on both sides of the cell membrane are equal; at osmotic equilibrium? Hypertonic Solution Plain Water Solution Hypotonic Solution Isotonic Solution

Isotonic Solution

The nurse has inserted a woman's urinary catheter, but obtained no urine backflow. Closer examination reveals that the catheter is in the woman's vagina and not in her meatus. What should the nurse do? Remove the catheter, document this event, and reattempt insertion in 30 to 60 minutes. Gently aspirate with a syringe to confirm that the catheter is in the vagina. Remove the catheter, cleanse it thoroughly with antiseptic, and reattempt insertion. Leave the catheter in the woman's vagina and reattempt the sterile insertion of a new catheter.

Leave the catheter in the woman's vagina and reattempt the sterile insertion of a new catheter.

The client has an infected nonhealing wound in which negative-pressure wound therapy (NPWT) has been applied. What actions would the nurse employ for this client? Select all that apply. Measure and record the amount of drainage each shift. Empty or replace the canister on the machine when full or nearly full. Assess for a problem if the machine alarms. Disconnect the machine for 2 hours daily to allow the client to bathe and ambulate. Change the wound dressing every day.

Measure and record the amount of drainage each shift. Empty or replace the canister on the machine when full or nearly full. Assess for a problem if the machine alarms.

A nurse is caring for an older adult in a long-term care facility who has a spinal cord injury affecting his neurologic reflex arc. Based on the patient's condition, what would be a priority intervention for this patient? Monitoring food and drink temperatures to prevent burns Providing adequate pain relief measures to reduce stress Monitoring for depression related to social isolation Providing meals high in carbohydrates to promote healing

Monitoring food and drink temperatures to prevent burns

A nurse is maintaining a client's continuous bladder irrigation. When appraising the effectiveness of this therapy, the nurse should prioritize what assessment? Calculating the flow rate of urinary output Monitoring the characteristics of the urinary output Assessing PVR using a bladder scanner Palpating the client's bladder region

Monitoring the characteristics of the urinary output

A visiting nurse is performing a family assessment of a young couple caring for their newborn who was diagnosed with cerebral palsy. The nurse notes that the mother's hair and clothing are unkempt and the house is untidy, and the mother states that she is "so busy with the baby that I don't have time to do anything else." What would be the priority intervention for this family? Arrange to have the infant removed from the home. Inform other members of the family of the situation. Increase the number of visits by the visiting nurse. Notify the care provider and recommend respite care for the mother.

Notify the care provider and recommend respite care for the mother.

During a dressing change, the nurse assesses protrusion of intestines through an opened wound. What would the nurse do after covering the wound with towels moistened with sterile 0.9% sodium chloride solution? Document the assessments and intervention. Reinforce the dressing with additional layers. Administer pain medications intramuscularly. Notify the physician and prepare for surgery.

Notify the physician and prepare for surgery.

The nurse has received an order to catheterize a female client. What action should the nurse perform? Lubricate 3 to 4 in of the catheter tip before insertion. Using both hands, hold the catheter near the tip and insert slowly into the urethra. Advance the catheter until slight resistance is felt. Once urine begins to drain, advance the catheter another 1 to 2 inches.

Once urine begins to drain, advance the catheter another 1 to 2 inches.

A client has an order to restrict fluids. What is one comfort measure nurses can implement for this client to alleviate a common problem? Oral hygiene Chewing gum Back rubs Hair care

Oral hygiene

What is the diffusion of water across a selectively permeable membrane? Diffusion Capillary Filtration Osmosis Metabolic Acidosis

Osmosis

A process that requires NO energy to move molecules down their concentration gradient(from high to low concentration). Active Transport Passive Transport (Diffusion) Facilitated Transport Osmosis

Passive Transport (Diffusion)

A client who has a bacterial infection develops an abscess that needs to be drained. What drainage system would most likely be used in this situation? Jackson--Pratt drain Penrose drain Hemovac drain Wound pouching

Penrose drain

The nurse would recognize which of these devices as an open drainage system? Penrose drain Jackson-Pratt drain Hemovac Negative pressure dressing

Penrose drain

When measuring the size, depth, and wound tunneling of a client's stage IV pressure ulcer, what action should the nurse perform first? Perform hand hygiene. Insert a swab into the wound at 90 degrees. Measure the width of the wound with a disposable ruler. Assess the condition of the visible wound bed.

Perform hand hygiene

___________________ is the process of cells to ingest extracellular fluids or the surrounding fluid."Also known as Cell Drinking"

Pinocytosis

A nurse will use a bladder scanner to assess a client with urinary frequency. How should the nurse best prepare the client for this procedure? Position the client in a supine position. Administer a diuretic, as ordered. Have the client rest for 15 minutes before the assessment. Assess the client's need for analgesia.

Position the client in a supine position.

A nurse is collecting data from a client whose husband died during a hurricane one year ago. The client reports having nightmares about the hurricane, persistent thoughts of blaming herself for her husband's death, and has stopped participating in her usual activities. The nurse should identify that the client is experiencing which of the following disorders? Dependent personality disorder Post traumatic stress disorder Histrionic personality disorder Obsessive personality disorder

Post traumatic stress disorder

The nurse needs to be aware of the functions of water in the body. Which presented function is untrue? Maintains body temperature Lubricates body joints and digestive tract Protects the brain and spinal cord tissue Prevents replication and growth of pathogens

Prevents replication and growth of pathogens

A certified nurse midwife is teaching a pregnant woman techniques to reduce the pain of childbirth. Which stress reduction activities would be most effective? Select all that apply. Progressive muscle relaxation Meditation Anticipatory socialization Biofeedback Rhythmic breathing Guided imagery

Progressive muscle relaxation Meditation Biofeedback Rhythmic breathing Guided imagery

A nurse is caring for an adolescent on an inpatient mental health unit who is undergoing detoxification for a substance use disorder. He tells the nurse that he first began using illicit drugs when his parents wouldn't allow him to get a tattoo. Which of the following defense mechanisms is the client demonstrating? Suppression Intellectualization Projection Dissociation

Projection

Upon assessment of a client's wound, the nurse notes the formation of granulation tissue. The tissue easily bleeds when the nurse performs wound care. What is the phase of wound healing characterized by the nurse's assessment? Proliferation phase Hemostasis Inflammatory phase Maturation phase

Proliferation phase

A nurse is caring for an older adult client who is at risk for skin breakdown. Which of the following interventions should the nurse use to help maintain the client's skin integrity? Reposition the client every 3 hr. Massage bony prominences to promote circulation. Provide the client with a diet high in protein. Apply cornstarch to keep the skin dry.

Provide the client with a diet high in protein.

A nurse is assessing a young adult client who has a new diagnosis of idiopathic juvenile arthritis. The client states, "The pain in my joints is just a temporary thing. If I keep eating right and exercising, it'll go away." The nurse should identify that the client is using which of the following defense mechanisms? Denial Displacement Rationalization

Rationalization

A client in a long-term care facility says to the nurse, "I really can't stand my roommate. Is there anything you can do to get me a bed in another room?" When the roommate comes back into the room, the client offers to share the box of cookies her family brought her with the roommate. Which of the following defense mechanisms is the client demonstrating? Denial ​Displacement Rationalization Reaction formation

Reaction formation

The nurse is caring for a client who has two Jackson--Pratt drains following her bilateral mastectomy. When emptying a Jackson--Pratt drain, the nurse should prioritize what action? Don sterile gloves before manipulating the cap of the drain. Cleanse the area around the cap with alcohol for 30 seconds before removing it. Pin the drain to the client's gown after pulling the tubing taut. Recompress the drain before replacing the cap.

Recompress the drain before replacing the cap.

Negative pressure wound therapy (NPWT) has been ordered for a client who is being treated for a chronic wound. What should be included in this client's nursing care plan? To facilitate adequate rest, disconnect NPWT each night between 2200 and 0700. Record the quantity of drainage once per shift and document on the intake and output record. Change the wound dressing daily, or more frequently if excessive output is noted. Remove the transparent dressing if a leak is noted.

Record the quantity of drainage once per shift and document on the intake and output record.

What nursing diagnosis would be a priority for a client who has a large wound from colon surgery, is obese, and is taking corticosteroid medications? Self-care Deficit Risk for Imbalanced Nutrition Anxiety Risk for Infection

Risk for Infection

A nurse is removing the staples from a client's surgical incision, as ordered. After removing the first few staples, the nurse notes that the edges of the wound pull apart as each staple is removed. What is the nurse's best action? Stop removing staples and inform the surgeon. Apply adhesive wound closure strips after each staple is removed. Apply an occlusive pressure dressing after removing the staples. Stop removing staples and apply an abdominal pad over the incision.

Stop removing staples and inform the surgeon.

A nurse is assessing a client who has multiple injuries from a motor vehicle crash as a result of driving while under the influence of alcohol. The client tells the nurse," I had a few drinks after my boss fired me, but it's okay. Everything will work out somehow next week." Which of the following defense mechanisms is the client demonstrating? Suppression Intellectualization Projection Dissociation

Suppression

The nurse is counseling a young female client who is a long-distance runner. Which factor does the nurse recognize as the greatest risk for this client to develop dehydration? Excessive physical activity can cause vomiting and diarrhea. Sweating and hard breathing will cause fluid loss. Long distance runners lack the availability of fluids. Females will lose extra fluid volume due to menses.

Sweating and hard breathing will cause fluid loss.

The nurse is transferring a client to the intensive care unit (ICU) and reports the client is experiencing "third spacing." Which manifestation will the ICU nurse expect to see? Elevated body temperature High blood pressure Large amounts of dilute urine Swelling in the extremities

Swelling in the extremities

The nurse has received an order to remove a client's indwelling urinary catheter. Which actions are appropriate when carrying out this order? Select all that apply. The nurse may delegate this task to unlicensed assistive personnel (UAP). Strict aseptic technique must be used when removing the client's catheter. The nurse may delegate this task to a licensed practical/vocational nurse (LPN/LVN). The nurse should remove the water from the balloon by withdrawing it with a syringe. Limit the client's fluid intake for 2 to 4 hours prior to removal.

The nurse may delegate this task to a licensed practical/vocational nurse (LPN/LVN). The nurse should remove the water from the balloon by withdrawing it with a syringe.

A nurse caring for patients in a hospital setting uses anticipatory guidance to prepare them for painful procedures. Which nursing intervention is an example of this type of stress management? The nurse teaches a patient rhythmic breathing to perform prior to the procedure. The nurse tells a patient to focus on a pleasant place, mentally place himself in it, and breathe slowly in and out. The nurse teaches a patient about the pain involved in the procedure and describes methods to cope with it. The nurse teaches a patient to create and focus on a mental image during the procedure in order to be less responsive to the pain.

The nurse teaches a patient about the pain involved in the procedure and describes methods to cope with it.

Phagocytosis is the process in which certain living cells ingest or engulf other cells or particles. TRUE or FALSE

True

The higher the temperature, the faster the rate of diffusion. True False

True

The health care provider orders for the T-Tube to be clamped for 1 hour before and after meals. The client suddenly develops right upper quadrant pain, and nausea. Which priority action should the nurse provide? Obtain vital signs. Report findings to the surgeon. Assess for signs of obstructed bile flow. Unclamp the T-Tube.

Unclamp the T-Tube

During a health history interview, a male client tells the nurse that he does not feel that he completely empties his bladder when he voids. He has been diagnosed with an enlarged prostate. What is the name of this symptom? Urinary incontinence Urinary retention Involuntary voiding Urinary frequency

Urinary retention

A health care provider orders irrigation with normal saline for the treatment of a client's wound. What should the nurse do when performing this intervention? Use clean technique instead of sterile technique if the wound is closed. Apply petroleum jelly to the periwound skin to protect it from the irrigation solution. Stop irrigating when the solution from the wound turns light pink. If new bleeding is noted, continue irrigation cautiously and then notify the health care provider.

Use clean technique instead of sterile technique if the wound is closed.

A nurse who is right-handed is inserting a woman's indwelling urinary catheter. The nurse will use cotton balls and antiseptic solution to cleanse the woman's meatus and perineum. Which of the nurse's actions is most appropriate? Grasp a cotton ball with forceps in her left hand and spread the woman's labia with her right hand. Use her left hand to spread the woman's labia and keep them spread until the catheter is inserted. Perform hand hygiene between cleansing the woman's labia and inserting the catheter. Insert the catheter with her left hand while supporting the woman with her right hand.

Use her left hand to spread the woman's labia and keep them spread until the catheter is inserted.

A nurse is caring for a client who has a large surgical wound healing by secondary intention. The nurse should recommend a diet high in protein and which of the following nutrients? Vitamin C Niacin Iron Potassium

Vitamin C

The nurse applies the principles of anatomy and physiology to client care. Which factor does the nurse understand as having the most affect on fluid movement in the body? Water intake Potassium balance Age Percentage of body fat

Water intake

A nurse is caring for a client who wants information about a complementary or alternative healing modality to help her reduce stress. The nurse should suggest which of the following modalities in which the client can practice poses and meditation to achieve wellness? Reiki Aromatherapy Acupuncture Yoga

Yoga

What is the most accurate definition of a wound? a disruption in normal skin and tissue integrity a change in the function of internal organs any injury that results in changes in nervous tissue any trauma resulting in serious damage and pain

a disruption in normal skin and tissue integrity

After surgery, a postoperative client has not voided for 8 hours. Where would the nurse assess the bladder for distention? between the symphysis pubis and the umbilicus over the costovertebral region of the flank in the left lower quadrant of the abdomen between ribs 11 and 12 and the umbilicus

between the symphysis pubis and the umbilicus

Upon responding to the client's call bell, the nurse discovers the client's wound has dehisced. Initial nursing management includes calling the physician and: covering the wound area with sterile towels moistened with sterile 0.9% saline. closing the wound area with Steri-Strips. pouring sterile hydrogen peroxide into the abdominal cavity and packing with gauze. holding the wound together until the physician arrives.

covering the wound area with sterile towels moistened with sterile 0.9% saline.

A home care nurse makes the following assessments of a wound: increased drainage and pain, increased body temperature, red and swollen wound, and purulent wound drainage. What wound complication do these assessments indicate? evisceration infection dehiscence fistula

infection

Which body fluid is the fluid within the cells, constituting about 70% of the total body water? interstitial fluid intravascular fluid extracellular fluid (ECF) intracellular fluid (ICF)

intracellular fluid (ICF)

The diffusion of water across a selectively permeable membrane is known as _________________

osmosis

Which condition is an indication for the use of negative pressure wound therapy? bone infections malignant wounds wounds with fistulas to body cavities pressure ulcers

pressure ulcers

When clients are pulled up in bed rather than lifted, they are at increased risk for the development of a decubitus ulcer. What is the name given to the factor responsible for this risk? friction necrosis of tissue ischemia shearing force

shearing force

Of the many topics that may be taught to clients or caregivers about home wound care, which one is the most significant in preventing wound infections? taking medications as prescribed proper intake of food and fluids thorough hand hygiene adequate sleep and rest

thorough hand hygiene

A nurse assessing a client's wound documents the finding of purulent drainage. What is the composition of this type of drainage? clear, watery blood large numbers of red blood cells mixture of serum and red blood cells white blood cells, debris, bacteria

white blood cells, debris, bacteria