Fundamentals Practice Practice B : A nurse receives a report about a client

Q 1 A nurse receives a report about a client who has0/9% sodium chlorideinfusing IV at 125 mL/hr. When the nurse performs the initial assessment, he notes that the client has received only 80 ml over the last 2 hr. Which of the following action should the nurse take first?

1.  Check the cord routinely for frays or tearing
2.  Consider purchasing a generator for power backup
3.  Observe for signs of hypoxia
4.  Check the IV tubing for obstruction

Q2 What is the rationale for using the nursing process in planning care for clients?

1.  As a scientific process to identify nursing diagnoses of a clients’ healthcare problems.
2.  To establish a nursing theory that incorporates the biopsychosocial nature of humans.
3.  As a tool to organize thinking and clinical decision making about clients’ healthcare needs.
4.  To promote the management of client care in collaboration with other healthcare professionals.

Q3  What activity should the nurse use in the evaluation phase of the nursing process?

1.  Ask a client to evaluate the nursing care provided.
2.  Document the nursing care plan in the progress notes.
3.  Determine whether a client’s health problems have been alleviated.
4.  Examine the effectiveness of nursing interventions toward meeting client outcomes.

Q4  Which statement is an example of a correctly written nursing diagnosis statement?

1.  Altered tissue perfusion related to congestive heart failure.
2.  Altered urinary elimination related to urinary tract infection.
3.  The risk for impaired tissue integrity related to the client’s refusal to turn.
4.  Ineffective coping is related to response to positive biopsy test results.

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