MULTIPLE CHOICE Question Preview (ID: 54035)


Mrs. dela Riva is in her first trimester of pregnancy. She has been lying all day because her OB-GYN requested her to have a complete bed rest. Which nursing intervention is appropriate when addressing the client’s need to maintain skin integrity?
a) Monitoring intake and output accurately
b) Instructing the client to cough and deep-breathe every 2 hours
c) Keeping the linens dry and wrinkle free
d) Using a foot board to maintain correct anatomic position

Mang Rogelio, a 32-year-old patient, is about to be discharged from the acute care setting. Which nursing intervention is the most important to include in the plan of care?
a) Stress-reduction techniques
b) Home environment evaluation
c) Skin-care measures
d) Participation in activities of daily living

Lisa, a client with altered urinary function, is under the care of nurse Tine. Which intervention is appropriate to include when developing a plan of care for Lisa who is experiencing urinary dribbling?
a) Inserting an indwelling Foley catheter
b) Having the client perform Kegel exercisesvv
c) Keeping the skin clean and dry
d) Using pads or diapers on the client

Jeron is admitted in the hospital due to bacterial pneumonia. He is febrile, diaphoretic, and has shortness of breath and asthma. WHich goal is the most important for the client?
a) Prevention of fluid volume excess
b) Maintenance of adequate oxygenation
c) Education about infection prevention
d) Pain reduction

A 22-year-old lady is displaying facial grimaces during her treatment in the hospital due to burn trauma. Which nursing intervention should be included for reducing pain due to cellular injury?
a) Administering anti-inflammatory agents as prescribed
b) Elevating the injured area to decrease venous return to the heart
c) Elevating the injured area to decrease venous return to the heart
d) Applying warm packs initially to reduce edema

Mr. McPartlin suffered abrasions and lacerations after a vehicular accident. He was hospitalized and was treated for a couple of weeks. When planning care for a client with cellular injury, the nurse should consider which scientific rationale?
a) Nutritional needs remain unchanged for the well-nourished adult.
b) Age is an insignificant factor in cellular repair.
c) The presence of infection may slow the healing process.
d) The presence of infection may slow the healing process.

A 12-year-old boy was admitted in the hospital two days ago due to hyperthermia. His attending nurse, Dennis, is quite unsure about his plan of care. Which of the following nursing intervention should be included in the care of plan for the client?
a) Room temperature reduction
b) Fluid restriction of 2,000 ml/day
c) Axillary temperature measurements every 4 hours
d) Antiemetic agent administration

A 36-year-old male client is about to be discharged from the the hospital after 5 days due to surgery. Which intervention should be included in the home health care nurse’s instructions about measures to prevent constipation?
a) Discouraging the client from eating large amounts of roughage-containing foods in the diet.
b) Encouraging the client to use laxatives routinely to ensure adequate bowel elimination.
c) Instructing the client to establish a bowel evacuation schedule that changes every day.
d) Instructing the client to fill a 2-L bottle with water every night and drink it the next day.

Khaleesi is admitted in the hospital due to having lower than normal potassium level in her bloodstream. Her medical history reveals vomiting and diarrhea prior to hospitalization. Which foods should the nurse instruct the client to increase?
a) Whole grains and nuts
b) Milk products and green, leafy vegetables
c) Pork products and canned vegetables
d) Orange juice and bananas

Patient X is diagnosed with constipation. As a knowledgeable nurse, which nursing intervention is appropriate for maintaining normal bowel function?
a) assessing dietary intake
b) decreasing fluid intake
c) providing limited physical activity
d) turning, coughing and deep breathing

Tom is ready to be discharged from the medical-surgical unit after 5 days of hospitalization. Which client statement indicates to the nurse that Tom understands the discharge teaching about cellular injury?
a) “I do not have to see my doctor unless i have problems.”
b) “I can stop taking my antibiotics once I am feeling better.”
c) “If I have redness, drainage, or fever, I should call my healthcare provider.”
d) “I can return to my normal activities as soon as I go home.”

On morning assessment of your patient in room 2502 who has severe burns. You notice that fluid is starting to accumulate in his abdominal tissue. You note that his weight has not changed and his intake and output is equal. What do you suspect?
a) Third spacing
b) This is normal and expected after a burn and it is benign
c) Document this finding as non-pitting abdominal edema.
d) Intravascular compartment syndrome

Which patient is at more risk for an electrolyte imbalance?
a) An 8 month old with a fever of 102.3 'F and diarrhea
b) A 55 year old diabetic with nausea and vomiting
c) A 5 year old with RSV
d) A healthy 87 year old with intermittent episodes of gout

A patient is admitted to the ER with the following findings: heart rate of 110 (thready upon palpation), 80/62 blood pressue, 25 ml/hr urinary output, and Sodium level of 160. What interventions do you expect the medical doctor to order for this pati
a) Restrict fluid intake and monitor daily weights
b) Administer hypertonic solution of 5% Dextrose 0.45% Sodium Chloride and monitor urinary output
c) Administer hypotonic IV fluid and administer sodium tablets.
d) No interventions are expected

After obtaining an EKG on a patient you notice that ST depression is present along with an inverted T wave and prominent U wave. What lab value would be the cause of this finding?
a) Magnesium level of 2.2
b) Potassium level of 5.6
c) Potassium level of 2.2
d) Phoshorus level of 2.0

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