Question

17. After reviewing the medical record for a client who has an oral herpes simplex infection following chemotherapy, which nursing diagnosis will you address as the priority? a. Social Isolation related to anxiety about herpes infection b. Acute Pain related to the presence of extensive herpes simplex lesions c. Imbalanced Nutrition: Less than Body Requirements related to decreased oral intake d. Disturbed Body Image related to the appearance of oral lesions 18. You have just received the change-of-shift report in the burn unit. Which client would you check on first? a. 22-year-old admitted 4 days previously with facial burns due to a house fire who has been crying since recent visitors left b. 34-year-old who returned from skin-graft surgery 3 hours ago and is reporting level 8 pain (ona scale of 0 to 10) c. 45-year-old with partial thickness leg burns who has a temperature of 102.6°F (39.2°C) and a blood pressure of 98/46 mm Hg d. 57-year-old who was admitted with electrical burns 24 hours ago and has a blood potassium level of 5.1 mEq/L 19. You are providing nursing care for a 24-year-old female patient admitted to the unit with a diagnosis of cystitis. Which intervention should you delegate to the UAP? a. Teaching the patient how to secure a clean-catch urine sample b. Assessing the patient's urine for color, odor, and sediment c. Reviewing the nursing care plan and add nursing interventions d. Providing the patient with a clean-catch urine sample container 20. As charge nurse, you would assign the nursing care of which patient to an LPN/LVN, working under the supervision of an RN? a. 48-year-old with cystitis who is taking oral antibiotics b. 64-year-old with kidney stones who has a new order for lithotripsy C. 72-year-old with urinary incontinence who needs bladder training d. 52-year-old with pyelonephritis who has severe acute flank pain 21. You are providing care for a patient with reflex urinary incontinence. Which action could be appropriately delegated to a new LPN/LVN? a. Teaching the patient bladder emptying by the Crede method b. Demonstrating how to perform intermittent self-catheterization c. Discussing the side effects of bethanechol chloride (Urecholine) d. Reinforcing the importance of proper hand washing to prevent infection 22. The nursing diagnosis of Constipation related to compression of the intestinal tract has been identified in a patient with polycystic kidney disease. Which nursing care action should you delegate to a newly-trained LPN/LVN? a. Instructing the patient about foods that are high in fiber b. Teaching the patient about foods that assist in promoting bowel regularity c. Assessing the patient for previous bowel problems and bowel routine d. Administering docusate sodium (Colace) 100 mg by mouth twice a day

Answer 1

Question 17: B

Question 18: B

Question 19: D

Question 20: B

Question 21: D

Question 22: C