In which step of the nursing process does the nurse analyze data and identify client problems? A. Assessment B. Diagnosis C. Planning outcomes D. Evaluation Correct Answer: B. Diagnosis In the diagnosis phase, the nurse identifies the client’s health status. The North American Nursing Diagnosis Association (NANDA)… Read More »
A nurse must measure the intake and output (I&O) for a patient who has a urinary retention catheter. Which equipment is most appropriate to use to accurately measure urine output from a urinary retention catheter? A. Urinal B. Graduate C. Large syringe D. Urine collection bag Correct Answer: B.… Read More »
Sterile technique is used whenever: A. Strict isolation is required B. Terminal disinfection is performed C. Invasive procedures are performed D. Protective isolation is necessary Correct Answer: C. Invasive procedures are performed All invasive procedures, including surgery, catheter insertion, and administration of parenteral therapy, require a sterile… Read More »
Which nursing intervention would be a priority during the care of a 2-month-old after surgery? A. Minimize stimuli for the infant. B. Restrain all extremities. C. Encourage stroking of the infant. D. Demonstrate to the mother how she can assist with her infant’s care. Correct Answer: C.… Read More »
Tywin has come to the nursing clinic for a comprehensive health assessment. Which statement would be the best way to end the history interview? A. “What brought you to the clinic today?” B. “Would you describe your overall health as good?” C. “Do you understand what is happening?” D. “Is there anything else… Read More »
When providing care for a female client with Addison disease, the nurse should be alert for which of the following laboratory values? A. Potassium level of 3.2 mEq/L. B. Calcium level of 3.3 mEq/L. C. Sodium level of 150 mg/dL. D. Hematocrit level of 25%. Correct Answer:… Read More »
A health care issue often becomes an ethical dilemma because: A. A client’s legal rights coexist with a health professional’s obligation. B. Decisions must be made quickly, often under stressful conditions. C. Decisions must be made based on value systems. D. The choices involved do not appear to be clearly right… Read More »
A female patient who speaks a little English has emergency gallbladder surgery, during discharge preparation, which nursing action would best help this patient understand wound care instruction? A. Asking frequently if the patient understands the instruction. B. Asking an interpreter to replay the instructions to the patient. C. Writing out the instructions and having… Read More »
In which phase of the nursing process does the nurse decide whether her actions have successfully treated the client’s health problem? A. Assessment B. Diagnosis C. Planning outcomes D. Evaluation Correct Answer: D. Evaluation During the implementation phase, the nurse carries out the interventions or delegates them… Read More »
A patient’s urine is cloudy, is amber, and has an unpleasant odor. What problem may this information indicate that requires the nurse to make a focused assessment? A. Urinary retention B. Urinary tract infection C. Ketone bodies in the urine D. High urinary calcium level Correct Answer:… Read More »