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FUNDAMENTALS OF NURSING PRACTICE TESTBANK

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Fundamentals of Nursing Testbank Kozier
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    FUNDAMENTALS OF NURSING PRACTICE TESTBANK Kozier Erb    FUNDAMENTALS OF NURSING PRACTICE TESTBANK Barbara Timbey    VITAL SIGNS 1. The client’s temperature of 8:00am using an oral electronic thermometer is 36.1C (97.2F). If the respiration, pulse and blood pressure were within normal range, what would the nurse do next?  A. Wait 15 minutes and retake it B. Check what the client’s temperature was the last time it was taken  C. Retake it using different thermometer D. Chart the temperature; it is normal Rationale: Answer 2  Although temperature is slightly lower than expected for the morning, it would be best to determine the client‟s previous temperature range next. This may be a normal range for this client. Depending on that finding, the nurse might want to retake it in a few minutes-no need to wait 15 minutes (option 3) or with another thermometer to see if the initial thermometer was functioning properly. Chart after determining that the temperature has been measured properly. 2. When the nurse enters the room to measure vital signs in preparing the client for diagnostic test, the client is on the phone. What technique should the nurse use to determine the respiratory rate?  A. Count the respirations during conversational pauses. B. Ask the client to end the phone call now and resume it a later time. C. Wait at the client’s bedside until the phone call is completed and then count respirations D. Since there is no evidence of distress or urgency, defer the measurement. RATIONALE: Answer 4 Since the client‟s needs are always considered   first, the measurement should be delayed unless the client is in distress or there are other urgent reasons. Option A: Respirations should be measured for 30 seconds to 1 minute and are affected by talking. Option B: There are needs to be an important reason for interrupting the client. Option C: It is inappropriate to wait and listen to the client‟s conversation.   DIAGNOSTIC TESTING 1. A 78-year old male client need to complete a 24 hour urine specimen. In planning his care, the nurses realizes that which measures is most important?   A. Instruct the client to empty his bladder and save this voiding to start the urine collection B. Instruct the client to use sterile individual containers to collect the urine. C. Post a sign stating “Save All Urine” in the bathroom  D. Keep the urine specimen in the refrigerator. Rationale: Answer C Option C is the most important nursing measure. This will inform the staff that the client is on a 24 hour urine collection. Option A is not appropriate since the first voided is to be discarded. Option B is not appropriate nursing measure since the specimen container is clean and not sterile, and one container is need  – not individual container. 2. The nurse practitioner requests a laboratory blood test to determine how well a client has controlled her diabetes during the past 3 months. Which blood tests will provide this information?  A. Fasting Blood glucose B. Capillary Blood specimen C. Glycosylated Hemoglobin D. GGT (Gamma-glutamyl transferase) Rationale: Answer C  A Glycosylated Hemoglobiin will indicate the glucose levels for a period of time, which is indicated by the nurse practitioner. Option A and B will provide information about the current blood glucose and not the past history. Option D is used to assess liver disease. MEDICATIONS 1. T he client tells the nurse, “This pill is a different color than the one that I usually take at home”. Which is the best response by the nurse?   A. “Go ahead and take your medicine”  B. “I will recheck your medication orders”  C. “Maybe the doctor ordered a different medication”  D. “I’ll leave the pill here while I check with the doctors”   RATIONALE: Answer B IF there is any doubt . the medication process should be interrupted until the question is clarified. Listen to the client. Find out any other information the client may have about that certain
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