Question

A nurse is assessing a client who has had diarrhea for several days. Which of the following findings should the nurse expect?

Answer 1

Correct Answers:

Dehydration

Rationale :

Diarrhea lasting for several days leads to excessive fluid loss, which can cause dehydration. Dehydration manifests with signs such as dry mucous membranes, decreased skin turgor, hypotension, tachycardia, and decreased urine output. Prolonged diarrhea can also lead to electrolyte imbalances, particularly the loss of sodium, potassium, and bicarbonate, increasing the risk of metabolic acidosis and further complications.

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Answer 2

Correct Answers:

Increase the client's fluid intake

Rationale :

Clients on bedrest are at increased risk for constipation due to reduced physical activity and slowed peristalsis. One of the most effective ways to manage constipation is by increasing fluid intake, which helps soften stool and promote bowel movements. Fluids, especially warm or room-temperature water, help maintain normal bowel function by preventing stool from becoming hard and difficult to pass.

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Answer 3

Correct Answers:

3.3

Rationale :

Total daily dose prescribed: 5 mg Doses per day: 3 (every 8 hours) Dose per administration:5mg/3=1.67 mg per dose Available tablet strength: 0.5 mg per tablet Tablets per dose:1.67 mg/0.5mg/tablet=3.34=3.3 tablets

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Answer 4

Correct Answers:

Planning

Rationale :

The planning phase of the nursing process involves setting goals and expected outcomes to address identified client problems. After assessing the client and diagnosing their condition, the nurse develops a plan that includes measurable and achievable objectives to guide interventions. This phase is crucial in ensuring patient-centered care, as it outlines specific actions to promote recovery or manage health conditions effectively.

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Answer 5

Correct Answers:

Ask the client to demonstrate walking with crutches

Rationale :

The psychomotor domain of learning involves physical skills and motor activities. When the nurse asks the client to demonstrate how to walk with crutches, it requires coordination, movement, and practical application of skills. This method ensures that the client has not only understood the instructions but can also perform the task correctly.

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Answer 6

Correct Answers:

The client reports dizziness when ambulating to the bathroom

Rationale :

Clinical judgment involves assessing the client's current condition before administering any medication, particularly antihypertensives, which lower blood pressure and can contribute to dizziness, lightheadedness, or orthostatic hypotension. Dizziness upon ambulation is a key sign that the client may already have low blood pressure, and administering the medication without further assessment could exacerbate the issue, potentially leading to falls or fainting. The nurse should check the client’s vital signs, particularly blood pressure and heart rate, and consider holding the medication if the blood pressure is already low or if the client is symptomatic.

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Answer 7

Correct Answers:

Uses a surface that is at waist height

Rationale :

A sterile field must be maintained at waist level or above to prevent contamination. Anything below waist level is considered non-sterile due to the increased risk of contact with unclean surfaces. By setting up the sterile field on a surface at waist height, the nurse ensures that all sterile items remain within the designated sterile zone and are easily accessible without contamination.

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Answer 8

Correct Answers:

Return demonstration

Rationale :

A return demonstration is a teaching strategy where the client performs a skill after being shown how to do it. This method helps reinforce learning by allowing the nurse to assess the client’s ability to correctly perform the task and provide feedback if needed. Return demonstration is especially effective for psychomotor skills, such as using assistive devices like walkers, administering insulin injections, or performing wound care.

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Answer 9

Correct Answers:

Place a perforated gauze pad around the drain to absorb drainage.

Rationale :

A Penrose drain is an open, passive drain used to remove excess fluid from a wound and prevent infection. Since it does not have a collection device, drainage seeps onto the dressing. The nurse should place a perforated gauze pad around the drain to help absorb the drainage while preventing skin maceration and irritation. The perforations allow drainage to be absorbed efficiently without sticking to the drain itself.

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Answer 10

Correct Answers:

Decreased blood pressure

Rationale :

Lisinopril is an angiotensin-converting enzyme (ACE) inhibitor, a medication primarily used to lower blood pressure in clients with hypertension or heart failure. It works by blocking the conversion of angiotensin I to angiotensin II, a substance that causes blood vessels to constrict. As a result, blood vessels remain dilated, reducing blood pressure and workload on the heart. A decrease in blood pressure is the expected therapeutic effect of this medication.

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RN 110 Fundamentals~Exam 1

No.

1 : A nurse is assessing a client who has had diarrhea for several days. Which of the following findings should the nurse expect?

2 : A nurse is caring for a client who is on bedrest and is experiencing constipation. Which of the following interventions should the nurse implement?

4 : A nurse is admitting a new client. Which of the followings steps of the nursing process is the nurse performing when formulating goals to address an identified problem?

5 : A nurse is teaching a client how to use crutches. Which of the following interventions uses the psychomotor domain of learning?

6 : A nurse is preparing to administer a client's antihypertensive medication. When using, clinical judgment, which of the following findings indicates the nurse should further assess the client before administering medication?

7 : A nurse is observing a newly licensed nurse set up a sterile field.

Which of the following actions by the newly licensed nurse indicates an understanding of the procedure?

8 : A nurse is teaching a client how to walk using a walker. After showing the client the procedure, the nurse asks the client to perform the skill. Which of the following types of teaching strategies is the nurse utilizing

9 : A nurse is caring for a client who has a Penrose drain. Which of the following actions should the nurse take?

10 : A nurse is caring for client who is taking lisinopril (ACE inhibitor).

Which of the following outcomes indicates a therapeutic effect of the medication?

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RN 110 Fundamentals~Exam 1

No.

1 : A nurse is assessing a client who has had diarrhea for several days. Which of the following findings should the nurse expect?

2 : A nurse is caring for a client who is on bedrest and is experiencing constipation. Which of the following interventions should the nurse implement?

4 : A nurse is admitting a new client. Which of the followings steps of the nursing process is the nurse performing when formulating goals to address an identified problem?

5 : A nurse is teaching a client how to use crutches. Which of the following interventions uses the psychomotor domain of learning?

6 : A nurse is preparing to administer a client's antihypertensive medication. When using, clinical judgment, which of the following findings indicates the nurse should further assess the client before administering medication?

7 : A nurse is observing a newly licensed nurse set up a sterile field.Which of the following actions by the newly licensed nurse indicates an understanding of the procedure?

8 : A nurse is teaching a client how to walk using a walker. After showing the client the procedure, the nurse asks the client to perform the skill. Which of the following types of teaching strategies is the nurse utilizing

9 : A nurse is caring for a client who has a Penrose drain. Which of the following actions should the nurse take?

10 : A nurse is caring for client who is taking lisinopril (ACE inhibitor).Which of the following outcomes indicates a therapeutic effect of the medication?

7 : A nurse is observing a newly licensed nurse set up a sterile field.

Which of the following actions by the newly licensed nurse indicates an understanding of the procedure?

10 : A nurse is caring for client who is taking lisinopril (ACE inhibitor).

Which of the following outcomes indicates a therapeutic effect of the medication?