A male patient is admitted to the healthcare facility for treatment of chronic obstructive

pulmonary disease. Which nursing diagnosis is most important for this patient?

Impaired gas exchange related to airflow obstruction

The purpose of respiration is: To maintain an adequate oxygen level in the blood to support
cellular life. By providing oxygen and eliminating carbon dioxide, respiration assists in the rapid

 is the process of analyzing health data and drawing conclusions to identify diagnoses.
diagnostic reasoning

Chronological record of seeking care, from the time the symptoms appear until now history of
present illness

Cancer can cause changes in what component of Virchow’s triad? Blood coagulability

This indicates the patient’s exact words. Ex. “Chest pain for 3 hours”; “Difficulty of breathing for 2
days” chief complaint

The pulse may be palpated in any place that allows an artery to be compressed near the
surface of the body
Neck area
Carotid artery

The following 5 stages of Sigmund Freud's stages of psychosexual development are correct
except:

b.The fecal stage

A male adult patient hospitalized for treatment of a pulmonary embolism develops respiratory
alkalosis. Which clinical findings commonly accompany respiratory alkalosis? Lightheadedness or
paresthesia

The carotid arteries .

All of the above

Often referred to as the father of psychotherapy, developed the concepts of id, ego and
superego, the psychological defense mechanisms such as sublimation and suppression

Sigmund Freud
Involves determining beforehand the strategies or course of actions to be taken
before implementation of nursing care. Planning

This must be done before performing any procedures. Observe other appropriate infection
prevention procedures. Hand washing
A client arrives at the emergency room with a foreign body in the left ear that has been
determined to be an insect. Which intervention would the nurse anticipate to be prescribed
initially? Instillation of diluted alcohol

Osteogenesis imperfect is also known as brittle bone disease

A male client with psoriasis visits the dermatology clinic. When inspecting the affected areas, the
nurse expects to see which type of secondary lesion? Scale

The most important factor in regulating the caliber of blood vessels, which determines
resistance to flow, is: The sympathetic nervous system

Planning has guide to follow, acronym SMART: "S" is for Specific

Two nurses are taking an apical-radial pulse and note a difference in pulse rate of 8 beats per
minute. The nurse would document this difference as which of the following? pulse deficit

The nursing process is a sequential method of problem solving that nurses use and includes
which steps: Assessment. Diagnosis, outcome identification, planning, implementation, &
evaluation

An oxygen delivery system is prescribed for a male client with chronic obstructive pulmonary
disease to deliver a precise oxygen concentration. Which of the following types of oxygen
delivery systems would the nurse anticipate to be prescribed? Venturi mask

This reveals the sounds produced by the body, usually from movement of organs and tissues.
Auscultation

Which structure is located in the left lower quadrant of the abdomen? sigmoid colon

Excessive fast heart rate above normal. Tachycardia

Which nursing intervention can help a client maintain healthy skin? Keep the client well hydrated

Before doing any procedures, the nurse must: Hand wash before the procedure

When planning care for a male client with burns on the upper torso, which nursing diagnosis
should take the highest priority? Ineffective airway clearance related to edema of the respiratory
passages
Body temperature fluctuates minimally but always remains above normal. Constant fever
This applies sense of touch to assess the following factors: texture, temperature, moisture, organ
location and size, any swelling, vibration or pulsation, rigidity or spasticity, crepitation, presence
of lumps or masses, presence of tenderness and pain. Palpation

This reveals the sounds produced by the body, usually from movement of organs and tissues.
Auscultation

Tapping of the patient’s skin with short, sharp strokes to assess underlying structures, the
characteristic sound produced during percussion depicts the location, size and density of
underlying organ. Percussion

Ryan underwent an open reduction and internal fixation of the left hip. One day after the
operation, the client is complaining of pain. Which data would cause the nurse to refrain from
administering the pain medication and to notify the health care provider instead? Left foot cold
to touch; no palpable pedal pulse

Buerger’s disease is characterized by all of the following except: Lipid deposits in the arteries

Data are gathered through the senses – sight, smells, touch and hearing. Objective data

This is complex, with multiple definitions, and the term is often used interchangeably with other
terms such as race, ethnicity, and nationality. Culture
This is constructed of the sternum, 12 pairs of ribs, 12 thoracic vertebrae, muscles, and cartilage.
It provides support and protection for many important organs including those of the lower
respiratory system. Thoracic cage

The costochondral junctions are not palpable. True

When planning care for a male client with burns on the upper torso, which nursing diagnosis
should take the highest priority Ineffective airway clearance related to edema of the respiratory
passages

It is a term with many definitions, often used interchangeably with the terms ethnicity and
culture race

Nurse Tara is teaching a community group about substance abuse. She explains that a genetic
component has been implicated in which of the following commonly abused substances?
Alcohol

This is a non-invasive technique to measure the percent to which Haemoglobin is filled with

oxygen of arterial blood. It does not replace measurement of arterial blood gases for assessment
of abnormalities. Pulse oxymetry

The client’s vision is tested with a Snellen’s chart. The results of the tests are documented as
20/60. The nurse interprets this as:
The client can read only at a distance of 20 feet what a client with normal vision can read at 60
feet.

It is a process which result to a diagnostic statement. It is an act to identify problems Nursing

Diagnosis

Chuck, who is in the hospital, complains of abdominal pain that ranks 9 on a scale of 1 (no pain)
to 10 (worst pain). Which interventions should the nurse implement Assessing the client’s bowel
sounds

A nurse is assessing a client with an abdominal aortic aneurysm. Which of the following
assessment findings by the nurse is probably unrelated to an aneurysm? Hyperactive bowel
sounds in that area

The general sequence of performing physical examination techniques is as follows: Inspection,

Palpation, Percussion, Auscultation.

The different Pulse sites :

Temporal
carotid 
brachial 
radial 
femoral 
popliteal
dorsalis pedis
posterior tibal
This abuse includes pushing, shoving, slapping, kicking, choking, punching and burning. It may
also involve holding, tying or other methods of restraint. The victim may be left in a dangerous
place without resources. The abuser may refuse to help the victim when sick, injured or in need.
Physical abuse

The following are Mechanisms of breathing, except Internal respiration, or ventilation, is the
mechanical act of breathing

When measuring a patients body temperature, the nurse keeps in mind that body temperature i
s influenced by: diurnal cycle