Question

The nurse is caring for an older adult client who is receiving intravenous fluids at 150 mL/hr. Upon assessment, the nurse notes crackles, shortness of breath, and jugular vein distention.

Based on this data, which complication of IV fluid therapy does the nurse anticipate?

Answer 1

Correct Answers:

Fluid volume excess

Rationale :

Signs of fluid volume excess include crackles in the lungs, shortness of breath, and jugular vein distention, indicating fluid overload. This can result from rapid or excessive IV fluid administration. The nurse should slow or stop the infusion and notify the provider.

Distractor Analysis :

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Answer 2

Correct Answers:

To help people to become empowered to take care of their health

Rationale :

The primary goal of nursing education is to enable clients to take control of their health and make informed decisions. Education promotes independence and improves health outcomes. This approach aligns with patient-centered care.

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Answer 3

Correct Answers:

Juanita, who smokes two packs of cigarettes a day

Rationale :

Smoking is a modifiable risk factor for osteoporosis as it decreases bone density and calcium absorption. Unlike genetics, age, or menopause, smoking can be changed through behavioral intervention. Stopping smoking can reduce osteoporosis risk.

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Answer 4

Correct Answers:

I work with the LPN and nursing assistant on dividing up patientcare tasks

Rationale :

Effective delegation and collaboration maximize efficiency and ensure appropriate task distribution. Nurses should assign tasks based on team members' skills while maintaining accountability. This approach optimizes time management in patient care.

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Answer 5

Correct Answers:

Psychomotor

Rationale :

The psychomotor domain involves physical skills and coordination, such as demonstrating inhaler use. It differs from cognitive learning (knowledge-based) and affective learning (emotions/attitudes). Hands-on practice ensures skill mastery.

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Answer 6

Correct Answers:

Stabilize the object

Rationale :

Removing a penetrating object can cause further damage, bleeding, or loss of eye contents. The priority is to stabilize the object and prevent movement while seeking emergency care. Immediate removal should only be performed by an ophthalmologist.

Distractor Analysis :

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Answer 7

Correct Answers:

Explore other options for pain relief

Rationale :

If the prescribed medication is not effective, the nurse should assess alternative pain management strategies such as repositioning, ice, relaxation techniques, or notifying the provider. Pain relief is a priority in post-surgical care. Addressing pain promptly improves comfort and recovery.

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Answer 8

Correct Answers:

Paralytic ileus

Rationale :

Paralytic ileus occurs when the intestines temporarily stop moving after surgery, leading to absent bowel sounds and delayed digestion. It is a common post-operative complication, especially after abdominal surgery. Treatment includes bowel rest and monitoring for improvement.

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Answer 9

Correct Answers:

I can schedule this elective surgery without an evaluation by the surgeon prior to the procedure

Rationale :

Bariatric surgery requires a thorough preoperative evaluation, including medical, psychological, and nutritional assessments. The client must undergo screening to ensure they are a good candidate. This statement indicates a misunderstanding that needs correction.

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Answer 10

Correct Answers:

Analyze cues

Rationale :

After collecting assessment data, the next step in the nursing process is analyzing cues to identify patterns and potential health issues. This step helps guide clinical judgment and intervention planning. Nursing interventions and SMART goals come later.

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RN 144 Exam 1 Fundamental Concepts of Nursing Practice

No.

1 : The nurse is caring for an older adult client who is receiving intravenous fluids at 150 mL/hr. Upon assessment, the nurse notes crackles, shortness of breath, and jugular vein distention.

Based on this data, which complication of IV fluid therapy does the nurse anticipate?

2 : What is the main goal for the RN as a teacher?

3 : Which of the following clients has a modifiable risk factor for osteoporosis?

4 : Which statement suggests that the RN understands delegation in the concept of time management?

5 : The RN asks the client to demonstrate proper use of his inhaler.

This is an example of which domain of learning?

6 : A client presents in the emergency room with a penetrating eye injury. The object is still present in the eye. Which nursing action is priority?

7 : A client continues to report post-surgical incision pain at a level of 9 out of IO after pain medication is given. The next dose of pain medicine is not due for another hour. What should the critically thinking nurse do first?

8 : A client is 24 hours post-op after having a colon resection (part of the colon is removed and the healthy ends are sewn back together). His abdominal incision is dry and intact, but the nurse notes that bowel sounds have not returned. What condition is this client likely experiencing?

9 : A nurse is educating a client about bariatric surgery. Which of the following statements by the client indicate a need for further teaching?

10 : The RN has completed an assessment on a client. What should the nurse do next?

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RN 144 Exam 1 Fundamental Concepts of Nursing Practice

No.

1 : The nurse is caring for an older adult client who is receiving intravenous fluids at 150 mL/hr. Upon assessment, the nurse notes crackles, shortness of breath, and jugular vein distention.Based on this data, which complication of IV fluid therapy does the nurse anticipate?

2 : What is the main goal for the RN as a teacher?

3 : Which of the following clients has a modifiable risk factor for osteoporosis?

4 : Which statement suggests that the RN understands delegation in the concept of time management?

5 : The RN asks the client to demonstrate proper use of his inhaler.This is an example of which domain of learning?

6 : A client presents in the emergency room with a penetrating eye injury. The object is still present in the eye. Which nursing action is priority?

7 : A client continues to report post-surgical incision pain at a level of 9 out of IO after pain medication is given. The next dose of pain medicine is not due for another hour. What should the critically thinking nurse do first?

8 : A client is 24 hours post-op after having a colon resection (part of the colon is removed and the healthy ends are sewn back together). His abdominal incision is dry and intact, but the nurse notes that bowel sounds have not returned. What condition is this client likely experiencing?

9 : A nurse is educating a client about bariatric surgery. Which of the following statements by the client indicate a need for further teaching?

10 : The RN has completed an assessment on a client. What should the nurse do next?

1 : The nurse is caring for an older adult client who is receiving intravenous fluids at 150 mL/hr. Upon assessment, the nurse notes crackles, shortness of breath, and jugular vein distention.

Based on this data, which complication of IV fluid therapy does the nurse anticipate?

5 : The RN asks the client to demonstrate proper use of his inhaler.

This is an example of which domain of learning?