Fundamentals of Nursing Practice Quiz 9

Answer: B – Prevent infection

Explanation: The client is at risk for infection because WBC count is dangerously low. Hb level and HCT are within normal limits; therefore, fluid balance, rest, and prevention of injury are inappropriate.

Answer: D – Side-lying

Explanation: Because of lethargy, the post tonsillectomy client is at risk for aspirating blood from the surgical wound. Therefore, placing the client in the side-lying position until he awake is best. The semi-Fowler’s, supine, and high-Fowler’s position don’t allow for adequate oral drainage in a lethargic post tonsillectomy client, and increase the risk of blood aspiration.

Answer: A – Anisocoria

Explanation: Unequal pupils are called anisocoria. Ataxia is uncoordinated actions of involuntary muscle use. A cataract is an opacity of the eye’s lens. Diplopia is double vision.

Answer: A – He may have a low threshold for pain

Explanation: People of Italian heritage tend to verbalize discomfort and pain. The pain was real to the client, and he may need medication when he wakes up.

Answer: D – Fluid overload

Explanation: Fluid overload causes the volume of blood within the vascular system to increase. This increase causes the vein to distend, which can be seen most obviously in the neck veins. A neck tumor doesn’t typically cause jugular vein distention. An electrolyte imbalance may result in fluid overload, but it doesn’t directly contribute to jugular vein distention.

Answer: A – Are important to use in nursing practice

Explanation: Nurses make many decisions: some require using the nursing process, whereas others are not client related but require critical thinking. The nursing process has specific steps; critical thinking does not. Neither is linear. Critical thinking applies to any discipline.

Answer: B – Diagnosis

Explanation: In the assessment phase, the nurse gathers data from many sources for analysis in the diagnosis phase. In the diagnosis phase, the nurse identifies the client’s health status. In the planning outcomes phase, the nurse formulates goals and outcomes. In the evaluation phase, which occurs after implementing interventions, the nurse gathers data about the client’s responses to nursing care to determine whether client outcomes were met.

Answer: D – Evaluation

Explanation: In the assessment phase, the nurse gathers data from many sources for analysis in the diagnosis phase. In the diagnosis phase, the nurse identifies the client’s health status. In the planning outcomes phase, the nurse and client decide on goals they want to achieve. In the intervention planning phase, the nurse identifies specific interventions to help achieve the identified goal. During the implementation phase, the nurse carries out the interventions or delegates them to other health care team members. During the evaluation phase, the nurse judges whether her actions have been successful in treating or preventing the identified client health problem.

Answer: A – Identify personal biases that may affect his thinking and actions

Explanation: The most basic reason is that self-knowledge directly affects the nurse’s thinking and the actions he chooses. Indirectly, thinking is involved in identifying effective interventions, communicating, and learning procedures. However, because identifying personal biases affects all the other nursing actions, it is the most basic reason.

Answer: C – A, E, C, D, B

Explanation: Logically, the steps are assessment, diagnosis, planning outcomes, planning interventions, and evaluation. Keep in mind that steps are not always performed in this order, depending on the patient’s needs, and that steps overlap.