Which of the following women who made significant contributions to the nursing care of soldiers during the Civil War? Select all that apply. a. Harriet Tubman b. Florence Nightingale c. Fabiola d. Dorothea Dix e. Sojoumer Truth

used her wealth to provide houses of caring and healing during the Roman Empire . Fabiola. contributed to the nursing care of soldiers in the Crimean War.Answer: 1. 4. and 5 Florence Nightingale.

´it is normal to feel frustrated about the discomfortµ. Genuineness c.A nurse tells a client who is struggling with cancer pain. Which of the following is most representative of the skills associated with the working phase of the helping relationship? a. Respect b. Confrontation . Concreteness d.

The nurse is not confronting but supporting through respect for the client·s feelings.Answer: a. Respect is correct because the nurse is validating the client·s feeling. Concreteness is giving an example. . Its not genuineness because the nurse is giving information versus being genuine.

The sum of the systolic and diastolic pressure c. Half of the systolic pressure . The inverse of the blood pressure d. Difference between the systolic and diastolic pressure b.€ Pulse pressure (pp) is considered the _____. a.

a. Difference between the systolic and diastolic pressure .

which of the following tests would be performed to assess the ability to ambulate? a. Kernig's b. Romberg's c. Hoffmann's . Riley-Day's d.For a client who has ataxia.

Kernig's sign. a reflex contraction.Answer: b Rationale: Romberg's test is the ability to maintain an upright position without swaying when standing with feet close together and eyes closed. . is pain in the hamstring muscle when attempting to extend the leg after flexing the thigh.

Not administer oxygen unless ordered by the physician c. Administer oxygen at 2 liters flow per minute d. Wait until the client's lab work is done b. the first nursing action would be to a. Administer oxygen at 10 liters flow per minute and check the client's nail beds .A cyanotic client with an unknown diagnosis is admitted to the emergency room. In relation to oxygen.

Answer: c Rationale: Administer oxygen at 2 liters per minute and no more. for if the client is emphysemic and receives too high a level of oxygen. he will develop CO2 narcosis and the respiratory system will cease to function .

a friend sustains a snake bite from a poisonous snake. Elevate the bite area above the level of the heart c.While on a camping trip. The most effective initial intervention would be to a. Immobilize the limb . Place a restrictive band above the snake bite b. Position the client in a supine position d.

Answer: a Rationale: A restrictive band 2 to 4 inches above the snake bite is most effective in containing the venom and minimizing lymphatic and superficial venous return. Elevation of the limb or immobilization would not be effective interventions. .

and his PaO2 is less than 45 mmHg. His arterial blood gases show that his pH is less than 7. the nurse would conclude that a.A 24-year-old male is admitted with a possible head injury. Edema has resulted from a low pH state b. Evaluating this ABG panel. Acidosis has caused vasoconstriction of cerebral arterioles c. his PaCO2 is elevated above 60 mmHg.3. Cerebral edema has resulted from a low oxygen state d. Cerebral blood flow has decreased € .

Hypoxia also causes cerebral vasodilatation particularly in response to a decrease in the PaO2 below 60 mmHg. .Answer: c Rationale: Hypoxic states may cause cerebral edema.

the one the nurse would expect to see in the client with acute renal failure is a. PCO2 30 . PCO2 46 b. HCO3 24.Of the following blood gas values. pH 7. pH 7. HCO3 14. HCO3 14. pH 7.26. PCO2 30 c. HCO3 24.49. PCO2 46 d.49.26. pH 7.

Answer: d Rationale: The client with acute renal failure would be expected to have metabolic acidosis (low HCO3) resulting in acid blood pH (acidemia) and respiratory alkalosis (lowered PCO2) as a compensating mechanism. HCO3 23 to 27 mEg. and PCO2 35 to 45 mmHg.45. .35 to 7. Normal values are pH 7.

P 100. Suction the nose gently with a bulb syringe and send specimen to the laboratory d. The nurse observes bleeding from the client's nose. Obtain a culture of the specimen using sterile swabs and send to the laboratory b. T 98F. Allow the drainage to drip on a sterile gauze and observe for a halo or ring around the blood c.€ A 24-year-old client is admitted to the hospital following an automobile accident. Insert sterile packing into the nares and remove in 24 hours . She was brought in unconscious with the following vital signs: BP 130/76. Which of the following interventions will assist in determining the presence of cerebrospinal fluid? a. R 16.

The nurse understands that the rationale for this therapy is to a. Force potassium into the cells to prevent arrhythmias . Provide calories to prevent tissue catabolism and azotemia d.A client in acute renal failure receives an IV infusion of 10% dextrose in water with 20 units of regular insulin. Correct the hyperglycemia that occurs with acute renal failure b. Facilitate the intracellular movement of potassium c.

in this case KC1 is also added to the infusion.Answer: b Rationale: Dextrose with insulin helps move potassium into cells and is immediate management therapy for hyperkalemia due to acute renal failure. . This type of infusion is often administered before cardiac surgery to stabilize irritable cells and prevent arrhythmias. An exchange resin may also be employed.

In preparation for discharge of a client with arterial insufficiency and Raynaud's disease. Walking several times each day as a part of an exercise routine b. client teaching instructions should include a. Using hydrotherapy for increasing oxygenation . Wearing TED hose during the day d. Keeping the heat up so that the environment is warm c.

and socks will also be useful in preventing vasoconstriction.Answer: b Rationale: The client's instructions should include keeping the environment warm to prevent vasoconstriction. warm clothes. Wearing gloves. Walking will most likely increase pain. . but TED hose would not be therapeutic.

Movement of the head .Which one of the following conditions could lead to an inaccurate pulse oximetry reading if the sensor is attached to the client's ear? a. Hypothermia d. Vasodilation c. Artificial nails b.

Answer: c Rationale: Hypothermia or fever may lead to an inaccurate reading. . Vasoconstriction can cause an inaccurate reading of oxygen saturation. Arterial saturations have a close correlation with the reading from the pulse oximeter as long as the arterial saturation is above 70 percent. Artificial nails may distort a reading if a finger probe is used.

Check that the balloon is deflated on a regular basis . Regularly assess respiratory status d.A client being treated for esophageal varices has a Sengstaken-Blakemore tube inserted to control the bleeding. Check that a hemostat is at the bedside b. Monitor IV fluids for the shift c. The most important assessment is for the nurse to a.

Answer: c Rationale: The respiratory system can become occluded if the balloon slips and moves up the esophagus. . putting pressure on the trachea. This is a safety intervention. Scissors should be kept at the bedside to cut the tube if distress occurs. This would result in respiratory distress and should be assessed frequently.