Fundamentals of Nursing Practice Quiz 8

Answer: D – Suggest referral to a sex counselor or other appropriate professional

Explanation: The nurse should refer this client to a sex counselor or other professional. Making appropriate referrals is a valid part of planning the client’s care. The nurse doesn’t normally provide sex counseling. Therefore, providing time for privacy and providing support for the spouse or significant other are important, but not as important as referring the client to a sex counselor.

Answer: B – Elimination

Explanation: According to Maslow, elimination is a first-level or physiological need, and therefore takes priority over all other needs. Security and safety are second-level needs; belonging is a third-level need. Second- and third-level needs can be met only after a client’s first-level needs have been satisfied.

Answer: B – Inadequate protein intake

Explanation: A client on bed rest suffers from a lack of movement and a negative nitrogen balance. Therefore, inadequate protein intake impairs wound healing. Inadequate vitamin D intake and low calcium levels aren’t factors in poor healing for this client. A pressure ulcer should never be massaged.

Answer: D – Risk for aspiration related to anesthesia

Explanation: Risk for aspiration related to anesthesia takes priority for thins client because general anesthesia may impair the gag and swallowing reflexes, possibly leading to aspiration. The other options, although important, are secondary.

Answer: C – Petechiae

Explanation: Petechiae are small hemorrhagic spots. Extravasation is the leakage of fluid in the interstitial space. Osteomalacia is the softening of bone tissue. Uremia is an excess of urea and other nitrogen products in the blood.

Answer: B – Patient’s Bill of Rights

Explanation: The Patient’s Bill of Rights addresses the client’s right to information, informed consent, timely responses to requests for services, and treatment refusal. A legal document, it serves as a guideline for the nurse’s decision making. Standards of Nursing Practice, the Nurse Practice Act, and the Code for Nurses contain nursing practice parameters and primarily describe the use of the nursing process in providing care.

Answer: B – Produce a false-high measurement

Explanation: Using an undersized blood pressure cuff produces a falsely elevated blood pressure because the cuff can’t record brachial artery measurements unless it’s excessively inflated. The sciatic nerve wouldn’t be damaged by hyperinflation of the blood pressure cuff because the sciatic nerve is located in the lower extremity.

Answer: A – Baked beans, hamburger, and milk

Explanation: Baked beans, hamburger, and milk are all excellent sources of protein. The spaghetti-broccoli-tea choice is high in carbohydrates. The bouillon-spinach-soda choice provides liquid and sodium as well as some iron, vitamins, and carbohydrates. Chicken provides protein but the chicken-spinach-soda combination provides less protein than the baked beans-hamburger-milk selection.

Answer: A – Assess the client’s airway

Explanation: The first priority is to evaluate airway patency before assessing for signs of obstruction, sternal retraction, stridor, or wheezing. Airway management is always the nurse’s first priority. Pain management and splinting are important for the client’s comfort, but would come after airway assessment. Coughing and deep breathing may be contraindicated if the client has internal bleeding and other injuries.

Answer: B – Unexpected feeling and emotions among the staff

Explanation: The usual or most prevalent reason for lack of productivity in a group of competent nurses is inadequate communication or a situation in which the nurses have unexpected feeling and emotions. Although the other options could be contributing to the problematic situation, they’re less likely to be the cause.