<P> client has been admitted to the unit this afternoon for treatment of dehydr

<Q>A
<TYPE>single</TYPE>
ation. During the initial meeting of the client and nurse, which nursing action
is most appropriate?</Q>
<MC1>Evaluate
<MC2>Establish
<MC3>Tell client
client's
outcomes
that the
response
ofphysician
hospitalization
to treatment
will explain
forthus
client.</MC2>
what
far.</MC1>
to expect in the hospital.
<MC4>DetermineDischarge
</MC3>
<F>Rationale:
<CORRECT>4</CORRECT>
client needsplanning
upon should
discharge.</MC4>
begin on admission to the unit and shoul
d be an ongoing process (option 4). As a rule, clients are not ready to discuss
discharge plans on the day of admission; however, planning for appropriate follo
w-up and coordination of care frequently cannot be achieved on the morning of di
scharge. The client has just been admitted so there are no fully executed treatm
ents to evaluate (option 1). It is the nurse's responsibility to orient the clie
nt to the hospital and its routine (option 3). All outcomes should be mutually e
stablished
Cognitive
Client
Integrated
Content
Strategy:Need:
Area:
Level:
This
bySafe
Process:
the
Fundamentals
isApplication
client
Effective
theNursing
first
andmeeting
Care
Process:
nurseEnvironment:
(option
with
Planning
the2).client,
Management
so eliminate
of Care any distracter
s inconsistent with this timing. Differentiate the physician's role from the nur
se's role. Identify the distracter that is consistent with the goal of promoting
Reference:
independenceSmith,
and S.autonomy
F., Duell,
for theD. J.,
client.
& Martin, B. C. (2008). <i>Clinical nursi
ng skills: Basic to advanced skills</i> (7th ed.). Upper Saddle River, NJ: Pears
on Education,
<Q>The
<TYPE>single</TYPE>
<P>
</P> nurse would
pp. 113-114.</F>
do which of the following when using the evaluation phase of
the nursing process
<MC1>Ambulating
<MC2>Questioning
<MC3>Assessing
<MC4>Assigning
<F>Rationale:
<CORRECT>3</CORRECT>
The
aanursing
aevaluation
client's
client
client
duringdiagnosis
20progress
about
client
feet
stepfamily
down
care?</Q>
of
toward
to the
the
an
medical
identified
client's
ahallway</MC1>
desired
history</MC2>
plan
outcome</MC3>
need</MC4>
of care includes the asse
ssment of the client's progress toward a previously identified desired outcome/g
oal (option 3). The desired outcome would have been the result of assessment (op
tion 2), planning by establishing nursing diagnoses (option 4), and implementati
on of interventions
Cognitive
Client
Integrated
Content
Strategy:Need:
Area:
Level:
Eliminate
Process:
Safe
Fundamentals
Application
Effective
that promote
Nursing
distracters
Carethat
Process:
goalreflect
Environment:
Evaluation
achievement
any
Management
steps
(option
inofthe
3).Care
nursing process un
related to Smith,
Reference: evaluation.
S. F., Duell, D. J., & Martin, B. C. (2008). <i>Clinical nursi
ng skills: Basic to advanced skills</i> (7th ed.). Upper Saddle River, NJ: Pears
on Education,
<Q>The
<TYPE>multi</TYPE>
<P>
</P> nurse ispp.caring
24-27.</F>
for a client who was admitted from the operating room fol
lowing a traumatic amputation sustained during a motor vehicle accident. The cli
ent is awake upon arrival to the nursing unit and is hemodynamically stable at t
his time. The nurse monitors which elements of the complete blood count as indic
ators of blood
<MC1>White
<MC4>Red
<MC3>Eosinophils</MC3>
<MC2>Neutrophils</MC2>
<F>Rationale:
<CORRECT>[1,2,4]</CORRECT>
<MC5>Platelets</MC5>
potential
blood
The
cells
cell
risk
complications?
(RBCs)</MC4>
count
for postoperative
(WBCs)</MC1>
Select infection
all that apply.</Q>
is high in a traumatic amputa
tion so the WBCs should be monitored as an indication of the presence of a wound
infection. The neutrophil count would be monitored as part of the WBC, since th
ese cells respond to pathogens. Because the client has come directly from the op
erating room, the client could have a low red blood cell count from blood loss a
t the time of the amputation and during surgery. There is no information about b
lood transfusions, so the RBC count should be monitored for anemia. Eosinophils
and basophils are other types of WBCs that do not respond to acute infection. A
low platelet count would put the client at risk for bleeding but the client is h
emodynamically
Cognitive
Client
Integrated
Content
Strategy:Need:
Area:
Level:
The
Process:
Physiological
Adult
keys
stable
Analysis
toHealth:
Nursing
so this
answering
Integrity:
Process:
Hematological
isthis
not item
aPhysiological
Assessment
primary
are that
concern.
the
Adaptation
client has undergone surg
ery and that there was a traumatic amputation. Select the distracters that refle
ct the greatest
Reference: LeMone,
dangers
P., &ofBurke,
bloodK.loss
(2008).
and infection.
<i>Medical-surgical nursing: Critical
thinking in client care</i> (4th ed.). Upper Saddle River, NJ: Pearson Educatio
n, pp. nurse
<Q>The
<TYPE>single</TYPE>
<P>
</P> 1078-1079.</F>
is preparing a client for a magnetic resonance imaging (MRI) proced
ure. Prior to sending the client to radiology, the nurse does which of the follo
wing that is urinary
<MC1>Empties unique tocatheter
this test?</Q>
so drainage is not obstructed during the test</MC1
><MC2>Determines
<MC3>Remove
<MC4>Send
<F>Rationale:
<CORRECT>3</CORRECT>
anclient's
extra
MRIthat
testing
blanket
the plastic
partialinvolves
anddental
pillow
name
the
plate</MC3>
band
for
userepositioning
is ainmagnetic
of place</MC2>
during
field and
the radiofrequenc
test</MC4>
y waves. Any object that contains metal (option 3) of any kind will be attracted
to the magnetic field, which will affect the diagnostic ability of the test and
can potentially harm the client. Plastic (option 2) and the urinary catheter (o
ption 1) are not attracted to the magnetic field. In addition, it is standard pr
ocedure (not unique) to be sure that clients are wearing an identification brace
let. The MRI suite has devices for positioning that completely immobilize the cl
ient, so sending blankets and pillow for repositioning (option 4) are unnecessar
Cognitive
y.
Client
Integrated
Content
Strategy:
Need:
Area:
ALevel:
Process:
critical
Physiological
Fundamentals
Application
Nursing
word toIntegrity:
Process:
guide youPlanning
Reduction
in this question
of Risk is
Potential
<i>unique</i>. Review
the basis of the MRI and the risks associated with the use of a magnet. Then us
e the process of elimination to discard any option that does not focus on this r
Reference: Berman, A., Snyder, S., Kozier, B., & Erb, G. (2008). <i>Fundamentals
isk.
of nursing: Concepts, process, and practice</i> (8th ed.). Upper Saddle River,
NJ: Pearson
<Q>The
<TYPE>single</TYPE>
<P>
</P> nurseEducation,
is caring forpp. a818-819.</F>
client admitted with a diagnosis of rule out acute
myocardial infarction (AMI). When reviewing the client's laboratory data, the nu
rse concludes Elevations
<MC1>Elevations
<MC2>Elevated
<MC3>Elevated
<MC4>Decrease
<F>Rationale:
<CORRECT>1</CORRECT>
that
total
in inmyoglobin</MC4>
which
troponin
cholesterol</MC2>
creatine
of troponin
in Tthe
kinase</MC3>
andfollowing
I</MC1>
T andwould
I arebenotdiagnostic
found in healthy
for an AMI?</Q>
individual
s, so any elevation is indicative of an acute cardiac event (option 1). While th
e elevation in the total cholesterol (option 2) places the client at risk for an
AMI, it is not diagnostic. The total creatine kinase (option 3) is nonspecific
and may indicate brain (CK-BB), myocardial (CK-MB), or skeletal damage (CK-MM).
The isoenzyme CK-MB is specific for an AMI as is an elevation in myoglobin level
s (option
Cognitive
Client
Integrated
Content
Strategy: Need:
Area:
4).
Level:
Eliminate
Process:
Physiological
Adult
Analysis
NursingIntegrity:
Health:
componentsProcess:
Cardiovascular
that are Assessment
Reduction
nonspecificof Risk
for myocardial
Potential injury. Revie
w the items secreted from the injured myocardial cell. Any item secreted from th
e cell intoLeMone,
Reference: the serum
P.,will
& Burke,
increase K. (2008).
the serum <i>Medical-surgical
level of that component.
nursing: Critical
thinking in client care</i> (4th ed.). Upper Saddle River, NJ: Pearson Educatio
n, pp. nurse
<Q>The
<TYPE>single</TYPE>
<P>
</P> 975-976.</F>
is caring for a client with a diagnosis of acute renal failure. The
nurse would expect the arterial blood gases to resemble which of the following?
<MC1>pH 7.48, pCO₂ 37 mmHg, HCO₃² 29 mEq/L</MC1
</Q>
><MC2>pH 7.28, pCO₂ 32 mmHg, HCO₃^- 24 mEq/L</MC2
><MC3>pH 7.46,
<MC4>pH 7.27, pCO₂ 30 38 mEq/L,
mmHg, HCO₃
HCO₃^-
19 mEq/L</MC3>25 mEq/L</MC
<F>Rationale: Clients in acute renal failure have an accumulation of uric acid i
<CORRECT>3</CORRECT>
4>
n the blood that makes them acidotic, and thus the acidosis is of metabolic orig
in, not respiratory origin. The bicarbonate (HCO₃²) level
is low because it is used trying to neutralize body acid (option 3). A low pH (n
ormal 7.35-7.45) would indicate an acidosis (options 2 and 3), while a high pH i
ndicates alkalosis (options 1 and 4). An elevated bicarbonate level (normal 22-2
6 mEq/L), as in option 1, indicates a metabolic cause for alkalosis. A low pCO<s
ub>2</sub>
Cognitive
Client
Integrated
Content
Strategy:
Need:
Area:
Level:
The
(normal
Process:
Physiological
Adult
kidneys
Analysis
35-45)
Nursing
Health:
eliminate
should
Integrity:
Process:
Renal anindicate
and
acid,
Assessment
Reduction
Genitourinary
soa if
respiratory
they
of Risk
are not
alkalosis
Potential
functioning,
(optionacid
4). ac
cumulates in the blood making it acidic. Eliminate all pHs that are not acidotic
. Then differentiate
Reference: LeMone, P.,respiratory
& Burke, K.acidosis
(2008).from<i>Medical-surgical
metabolic acidosis.nursing: Critical
thinking in client care</i> (4th ed.). Upper Saddle River, NJ: Pearson Educatio
n, p. 1217.</F>
<Q>The
<TYPE>single</TYPE>
<P>
</P> nurse is caring for a client with a new diagnosis of renal failure. What
serum laboratory value is the most specific indicator that treatment for the cli
ent's renalspecific
<MC1>Potassium
<MC2>Blood
<MC3>Creatinine
<MC4>Urine
<F>Rationale:
<CORRECT>3</CORRECT>
urea
disorder
Creatinine
level
nitrogen
level gravity
has
5.0
3.2levels
not
mEq/L</MC1>
(BUN)
mg/dL</MC3>
1.010</MC4>
yet40(normal
been
mg/dL</MC2>
managed
0.8-1.6adequately?</Q>
mg/dL) are more sensitive and sp
ecific for renal function (option 3) than the BUN (normal 8-22 mg/dL). Although
the BUN (option 2) is used to assess renal function, it can also be affected by
diet and fluid status and is therefore not the most specific indicator available
. The potassium level (option 1) can be affected by many factors as well, such a
s tissue damage and adrenal insufficiency; this level is normal, however (range
3.5-5.1 mEq/L). Specific gravity is not a blood test, but rather is performed on
Cognitive
Client
Integrated
Content
Strategy:
the urine
Need:
Area:
Level:
The
itself
Process:
Physiological
Adult
critical
Analysis
andHealth:
Nursing
the
wordvalue
Integrity:
Process:
Renal
in the
ofand
1.010
question
Assessment
Reduction
Genitourinary
is is
within
<i>specific</i>.
of Risk
normalPotential
range Eliminate
(1.010-1.025).
any di
stracters that are not directly related to abnormal renal function, including th
e potassium level at the high end of normal and the normal urine specific gravit
y. Then eliminate the distracters that can be abnormal from other causes, which
is the BUN.LeMone, P., & Burke, K. (2008). <i>Medical-surgical nursing: Critical
Reference:
thinking in client care</i> (4th ed.). Upper Saddle River, NJ: Pearson Educatio
n, p.client
<Q>A
<TYPE>single</TYPE>
<P>
</P> 835.</F>
is scheduled for a colonoscopy and asks the nurse what will be deter
mined fromwill
<MC1>"It theevaluate
test. Whatwhether
wouldtherebe theisnurse's
a tumorbestor other
response?</Q>
problem in the large in
<MC2>"It will determine whether there is any blood in the abdominal cavity."</MC
testine."</MC1>
<MC3>"It will evaluate the presence of esophageal varices and provide opportunit
2>
y to sclerose
<MC4>"It will assess
them."</MC3>
the effectiveness of the treatment you had for the peptic u
<F>Rationale: A colonoscopy is the insertion of a flexible tube into the lower G
<CORRECT>1</CORRECT>
lcer."</MC4>
I tract for evaluation and treatment of conditions of the lower bowel. An evalua
tion of the esophagus and stomach would require an approach from the upper GI tr
act such as an esophagogastroduodenoscopy (EGD). The presence of blood in the ab
dominalNeed:
Cognitive
Client
Integrated
Content
Strategy:cavity
Area:
Level:
Recall
Process:
Physiological
Adult
would
Application
thatTeaching/Learning
Health:
require
colonoscopy
Integrity:
Gastrointestinal
an abdominal
meansReduction
direct
ultrasound
visualization
of Risk
or Potential
otherofx-ray
the colon.
procedure.
Elimi
nate any distracters
Reference: LeMone, P.,unrelated
& Burke,toK.this (2008).
definition.
<i>Medical-surgical nursing: Critical
thinking in client care</i> (4th ed.). Upper Saddle River, NJ: Pearson Educatio
n, p. 745.</F>
<Q>The
<TYPE>single</TYPE>
<P>
</P> nurse reviews the nursing database to determine specific client needs. Th
is represents
<MC1>Client
<MC2>Team
<MC4>Developing
<MC3>Diagnosing</MC3>
<F>Rationale:
<CORRECT>3</CORRECT>
collaboration</MC2>
teaching</MC1>
which
Diagnosing
a clinical
step is
inpathway</MC4>
athespecific
nursingstep
process?</Q>
of the nursing process that utilizes
the information collected during the client-specific database collection. Clien
t teaching is a nursing intervention. Team collaboration is important in all asp
ects of the nursing process. The utilization of a previously developed clinical
pathwayNeed:
Cognitive
Client
Integrated
Content
Strategy:includes
Area:
Level:
Review
Process:
Safe
Fundamentals
components
Comprehension
the
Effective
Nursing
definitionof all
Care
Process:
ofEnvironment:
steps
each
Planning
ofofthe
theManagement
steps
nursing
in the
process.
of nursing
Care process and
compare theSmith,
Reference: definitions
S. F.,toDuell,
each D. of J.,
the &distracters.
Martin, B. C. (2008). <i>Clinical nursi
ng skills: Basic to advanced skills</i> (7th ed.). Upper Saddle River, NJ: Pears
on Education,
<Q>A
<TYPE>single</TYPE>
<P>
</P> client presents
pp. 23-24.</F>
to the Emergency Department reporting left arm pain followi
ng a fall. The first physical examination technique the nurse utilizes would be:
<MC1>Palpation for
</Q>
<MC2>Inspection forany
anydeformities
deformities,ordiscoloration,
areas of tenderness.</MC1>
or obvious bone protrusion.<
<MC3>PalpationThe
/MC2>
<MC4>Information
<F>Rationale:
<CORRECT>2</CORRECT>
ofgathering
distalnursing
first pulses.</MC3>
aboutassessment
the circumstances
techniqueofutilized
the injury.</MC4>
to gather data is
inspection of the area (option 2). Palpation of any of the area would be attempt
ed after the inspection (options 1 and 3). Obtaining the client history (option
4) is not
Cognitive
Client
Integrated
Content
Strategy:
Need:
Area:
aProcess:
Level:
Always
component
Health
Adult
Application
look
Promotion
Nursing
Health:
of theMusculoskeletal
at Process:
physical
area
and of
Maintenance
Assessment
complaint
examination.
first for visible signs of an abn
Reference: LeMone, P., & Burke, K. (2008). <i>Medical-surgical nursing: Critical
ormality.
thinking in client care</i> (4th ed.). Upper Saddle River, NJ: Pearson Educatio
n, p. 1407.</F>
</P>