Question 1

Nina the New Nurse has assessed a new client, admitted for sudden altered level of consciousness (ALOC). She also reviewed the current lab results, which are as follows: Na+ 156
CL- 100
K+ 4.0
HCO 21
BUN 86
Bld) Glucose 100
Nina the New Nurse is entering a nursing diagnosis on the care plan based on the information she has gathered. Which nursing diagnosis is most appropriate?

Accepted Answer

The lab results reveal an elevated Na+ and BUN, and decreased HCO. Na+ and BUN are increased when a client is dehydrated. When assessing findings, you must first determine if the results are normal or abnormal, then consider what your findings may indicate and how that affects the development of the nursing diagnosis.

Question 2

After a complete bowel rest, a client is prescribed a clear liquid diet. The nurse making the dietary plan for the client keeps in mind that a clear liquid diet consists of the following except:

Accepted Answer

Milk and dairy products are not included on a clear liquid diet. A clear liquid diet consists of foods that are transparent to light. A clear liquid diet includes water, bouillon, carbonated beverages, gelatin, popsicles, coffee, and tea.

Question 3

A nurse is assessing a newly-admitted client. Assessment reveals that the client has muscle weakness, muscle spasticity, and an unsteady gait. Based on the findings, which of the following is the most appropriate nursing diagnosis?

Accepted Answer

Based on the assessment findings, the client's mobility is impaired; therefore, the nursing diagnosis of Impaired physical mobility is most appropriate. This diagnosis is given to clients with limited independent physical movements.

Question 4

A high-fiber diet is thought to reduce the risk of colon cancer because it:

Accepted Answer

High-fiber diets are recommended to reduce the risk of colon cancer, because fiber promotes bile excretion and speeds up intestinal transit time so that carcinogens are eliminated quicker. Research studies are mixed regarding whether a high-fiber diet actually contributes to a lower incidence of colon cancer.

Question 5

Which of the following diets is suggested for the client with AIDS?

Accepted Answer

The suggested diet for the client with AIDS is one that is high calorie and high protein.

Question 6

Nina the New Nurse loves her job! She is working on the medical/surgical. unit, and has received reports on the clients she will care for from the off-going shift. She is prioritizing her first rounds of the day. Which of the following clients should Nina the New Nurse see first?

Accepted Answer

Client C is the least stable client; he is complaining of chills, a possible symptom of infection. His procedure puts him at risk for peritonitis, and further assessment is required. The least stable client is priority.

Question 7

Hank Smith, a 36-year-old bartender, was admitted for a total cystectomy with creation of an ileal conduit. Hank was diagnosed with a bladder tumor six months ago. While emptying and cleaning the stoma, the nurse is incorrect when she does which of the following?

Accepted Answer

The nurse is incorrect when she instructs the client to sit upright on the bed. Ideally, the client is placed in a low Fowler's position to keep the abdomen flat. This position prevents skin folding, which can cause the appliance to slip. A low Fowler's position allows the client to observe the procedure and encourages interest in performing the procedure themself. The nurse should maintain asepsis to avoid the transmission of harmful microorganisms. Timing is important; the appliance is changed during a period of low fluid intake (i.e., early morning).

Question 8

Nina the New Nurse was floated to a unit she was unfamiliar with. Wanting to be helpful and thought of as a team player, she accepted a very heavy assignment. According to the ICN Code of Ethics for Nurses, which of the four principle elements did Nina the New Nurse violate?

Accepted Answer

Nurses and practice is one of four principle elements of the ICN Code of Ethics for Nurses. Each element contains an outline of standards of ethical conduct. According to the principle element of nurse and practices, "A nurse is to use judgment regarding individual competence when accepting or delegating responsibility." Nina the New Nurse should have been honest with her supervisor (and, perhaps, herself) and not accepted a heavy assignment on an unfamiliar unit.

Question 9

A nurse is caring for Mr. Kline, a 56-year-old client who was admitted because of esophageal cancer. A gastrostomy tube (PEG) was inserted six weeks ago. During assessment, the nurse notes reddish color and swelling around the insertion site. The most appropriate action of the nurse is to:

Accepted Answer

Since these findings suggest irritation or inflammation of the insertion site, the appropriate action of the nurse is to notify the physician immediately. The insertion site of the PEG may be irritated because of constant contact with leaking gastric acid, exposure to feeding formula, or infection due to poor PEG care. To prevent this, the nurse should always do proper PEG care. Options C and D are incorrect; the nurse shouldn't attempt to manage this condition independently.

Question 10

In an upper respiratory tract infection, secretion of copious amounts of mucus can affect a client's appetite. Which of the following interventions can best help increase the palatability of food for a client with an upper respiratory infection?

Accepted Answer

The other options are correct, but drinking citrus juice prior to eating is the best intervention to help cleanse the palate of the sputum taste. This intervention increases the palatability of the food. The taste of sputum in the mouth decreases the appetite, so frequent oral care should be reinforced. In addition, the nurse can help the client select preferred foods that are within the nutritional recommendations given to the client.

Question 11

A 20-year-old male client with a BMI of 33 has been admitted for recurrent chest pains and difficulty breathing. During the assessment, it is found that his father and mother both suffered from myocardial infarction before the age of 50. Which of the following nursing actions is the first step to prevent the client from having a myocardial infarction?

Accepted Answer

A sedentary lifestyle and poor diet are associated with obesity and myocardial infarction; however, the client must be willing and committed to participate in a weight reduction program. Therefore, assessment of interest in reducing weight is the first step in prevention of these diseases.

Question 12

What is meant by the term values?

Accepted Answer

The term values refers to experiences, culture, religion and education that form principles or beliefs influencing behavior and/or decisions.

Question 13

After receiving the client assignments for the day, which client should the nurse assess first?

Accepted Answer

Airway should be the nurse's highest priority. The client having difficulty with breathing should be seen by the nurse first. The other clients have intermediate needs.

Question 14

A nurse assesses the cranial nerves of a client with head trauma. The nurse assesses cranial nerve VIII by performing which of the following?

Accepted Answer

The nurse assesses cranial nerve VIII, or the acoustic nerve, by observing balance and assessing the client's ability to hear. Option A checks cranial nerve II, or the optic nerve; option B assesses cranial nerve IX, or the glossopharyngeal nerve; and option D checks cranial nerve X, or the vagus nerve.

Question 15

A nurse is teaching a 75-year-old client how to use an aluminum walker appropriately. Which of the following techniques are accurate?

Accepted Answer

The client must lift-not push or glide-the walker forward 8 to 10 inches. The client should move forward with the affected leg first, followed by the good leg.

Question 16

During a staffing crisis, the nurse manager decides that the most efficient nursing modality to implement is:

Accepted Answer

During a staffing crisis, functional nursing is the most efficient way to maximize the skills of the staff in a timely manner. In functional nursing, a specific nursing function is assigned to each member of the staff. This method allows the most work to be accomplished in the shortest time possible.

Question 17

A nurse is on the elevator when she overhears a group of medical interns discussing the case of a male client who was found to be positive for human immunodeficiency virus. The nurse knows that which client right might have been breached?

Accepted Answer

The right to confidentiality of client information might have been breached if the client's diagnosis is discussed in public areas. The other rights listed were not breached.

Question 18

A client has an indwelling urinary catheter. Which of the following nursing interventions is best to prevent bladder infections?

Accepted Answer

Tub baths can cause bacterial contamination of the urinary meatus and catheter, and allow easier entry of bacteria into the urinary tract. Fluid intake is encouraged to prevent infection. Irrigation is mainly done to keep the catheter patent.

Question 19

An elderly client with a swallowing disorder is at increased risk for aspiration. Which of the following is an inappropriate nursing action?

Accepted Answer

Full-fat milk products should be limited or avoided, as they can thicken the secretions, which may increase the client's risk for aspiration. The other options are appropriate actions to prevent choking or aspiration.

Question 20

Nina the New Nurse is preparing to receive a client who will be transferred from the recovery room to her unit. The recovery room nurse reports the client is awake and alert after colon surgery and vital signs are stable. The patient has no complaints of pain or nausea and has an NG tube to low suction draining serosanguineous fluid. Nina the New Nurse's team is very busy now; she is trying to determine which task can safely be delegated to the nursing assistant on her team. Which of the following tasks can safely be delegated to the nursing assistant?

Accepted Answer

A nursing assistant can safely measure and record vital signs, however, it is the nurse's responsibility to assess the readings and evaluate the client's status. The nursing assistant can also safely provide mouth care and skin care around the NG tube. The remaining tasks require the advance skills of an LPN or RN.

Quiz 1: American Association of Colleges of Nursing (AACN) Clinical Nurse Specialist