Concept Based Nursing Practice Questions

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A client with disseminated intravascular coagulation (DIC) has a nursing diagnosis of Impaired Gas Exchange. Which action is appropriate when providing care based on this nursing diagnosis?

  • A. Place the client in low-Fowler position to improve gas exchange
  • B. Monitor the client's oxygen saturation intermittently
  • C. Encourage frequent amulation
  • D. Use continuous endotracheal suctioning instead of coughing and deep breathing
Correct Answer: B

Rationale: Monitoring the client's oxygen saturation intermittently is the most appropriate action when providing care for a client with disseminated intravascular coagulation (DIC) who has a nursing diagnosis of Impaired Gas Exchange. DIC can lead to a variety of complications, including inadequate oxygenation of tissues due to abnormal clotting and bleeding. By monitoring the client's oxygen saturation levels, the healthcare team can assess the effectiveness of gas exchange and adjust interventions as needed to optimize oxygenation. This action helps in early detection of worsening gas exchange and guides appropriate interventions to address any respiratory issues promptly. Placing the client in a low-Fowler position may not be suitable for all patients with DIC, encouraging frequent ambulation could be risky due to the increased bleeding tendency, and using continuous endotracheal suctioning is not recommended as it can lead to aggravation of respiratory issues and increase the risk of further complications.

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During the physical examination of a client who took a fall that fractured his hip, the nurse notices an impairment of the client's hearing, but that the client's visual acuity and motor function do not seem to be impaired. The client answers questions very precisely and readily grasps the meaning of everything the nurse says when the client can face the nurse. When teaching this client, the nurse should make it a priority to

  • A. make verbal instructions face to face with the client.
  • B. provide only written instructions.
  • C. use only visual media.
  • D. use only physical demonstrations with written instructions.
Correct Answer: A

Rationale: The client in this scenario has an impairment of hearing, so it is essential to ensure effective communication by facing the client when providing verbal instructions. By facing the client, the nurse can help the client by making it easier to lip-read and pick up verbal cues, improving the client's ability to understand the instructions clearly. This approach demonstrates sensitivity to the client's needs and promotes better communication during teaching sessions. Providing written instructions alone (option B), using only visual media (option C), or relying solely on physical demonstrations with written instructions (option D) may not be as effective for this particular client with impaired hearing.

The nurse is teaching a group of community members about measures to reduce the risk of bladder cancer. What should the nurse include when providing these instructions? Select all that apply.

  • A. Empty the bladder every 2 hours
  • B. Do not start smoking; if you smoke, stop
  • C. Increase the intake of fluids and vegetables
  • D. Avoid using hair dyes and pesticides in the home e. Limit the intake of coffee and other caffeinated beverages
Correct Answer: A

Rationale: A. Empty the bladder every 2 hours: Regularly emptying the bladder helps reduce the exposure of the bladder to potentially harmful substances that can increase the risk of developing bladder cancer.

A client with peripheral vascular disease (PVD) has symptoms of intermittent claudication. Which should the nurse include when teaching the client about intermittent claudication?

  • A. It causes pain that occurs during periods of inactivity.
  • B. It causes pain that increases when the legs are elevated and decreases when the legs are dependent.
  • C. It causes cramping or aching pain in the lower extremities and the buttocks that occurs with a predictable level of activity.
  • D. It is often described as a burning sensation in the lower legs.
Correct Answer: C

Rationale: Intermittent claudication is a symptom of peripheral vascular disease (PVD) characterized by cramping or aching pain in the lower extremities and buttocks that occurs with a predictable level of activity, such as walking a certain distance. This pain typically resolves with rest. The pain is due to inadequate blood flow to the muscles during activity, causing a buildup of lactic acid, which leads to muscle pain. This symptom is an important indicator of decreased arterial blood flow and is a common presentation in individuals with PVD. Therefore, when teaching the client about intermittent claudication, the nurse should emphasize the predictable nature of the pain related to activity and the relief experienced with rest.

Which assessment findings support the nurse's concern that a client is experiencing hypovolemic shock? Select all that apply.

  • A. Slight increase in pulse
  • B. Dry, warm skin
  • C. Increased urine output
  • D. Normal respirations
Correct Answer: A

Rationale: A. A slight increase in pulse is a common finding in hypovolemic shock. The body compensates for the decreased blood volume by increasing the heart rate to maintain adequate perfusion.

During an assessment, the nurse determines that a patient with knee pain is at risk for osteoarthritis. What did the nurse assess in this patient?

  • A. Having a history of falls
  • B. Eating a diet high in calcium
  • C. Walking 30 minutes each day
  • D. Being overweight by 30 pounds
Correct Answer: D

Rationale: Osteoarthritis is a condition where the protective cartilage that cushions the ends of bones wears down over time. Excess weight puts extra stress on the joints, particularly weight-bearing joints like the knees. Being overweight by 30 pounds increases the risk of developing osteoarthritis in the knees because the added weight can accelerate the breakdown of cartilage. Therefore, the nurse identified the patient as at risk for osteoarthritis due to being overweight by 30 pounds.

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