Question: A nurse is assessing a client with a stage 4 pressure injury. What assessment of the injury would be expected?
Answer Choices:
A blister formation
B full-thickness skin loss
C eschar formation
D skin pallor
Answer: B – full-thickness skin loss.
Question: Which body fluid is the fluid within the cells, constituting about 70% of the total body water?
Answer Choices:
A. Extracellular fluid (ECF)
B. Intracellular fluid (ICF)
C. Intravascular fluid
D. Interstitial fluid
Answer: B. Intracellular fluid (ICF)
Question: Upon assessment of a client’s wound, the nurse notes the formation of granulation tissue. The tissue bleeds easily when the nurse performs wound care. What is the phase of wound healing characterized by the nurse’s assessment?
Answer Choices:
A hemostasis
B inflammatory phase
C maturation phase
D proliferation phase
Answer: D – proliferation phase.
Question: A client is taking a diuretic that increases urinary output. What nursing concern is appropriate to base an educational plan?
Answer Choices:
A altered skin integrity
B decreased fluid volume risk
C altered urinary elimination
D urinary retention
Answer: B – decreased fluid volume risk.
Question: What is the average adult fluid intake and loss in each 24 hours?
Answer Choices:
A. 500 to 1,000 mL
B. 1,000 to 1,500 mL
C. 1,500 to 2,000 mL
D. 1,500 to 3,500 mL
Answer: D. 1,500 to 3,500 mL
Question: A health care provider writes a prescription to “force fluids.” What will be the first action the nurse will take in implementing this prescription?
Answer Choices:
A Tell the client and family to increase oral intake.
B Explain to the client why this is needed.
C Divide the intake so the largest amount is at night.
D Decide how much fluid to increase every 8 hours.
Answer: B – Explain to the client why this is needed.
Question: A nurse is caring for a client with phlebitis. The nurse notices that the client’s forearm, which has the tubing, has become red and slightly warm. Which actions should the nurse perform to avoid further complications and provide relief to the client?
Answer Choices:
A. Administer oxygen
B. Call for help
C. Discontinue the IV promptly
D. Elevate the affected arm
Answer: C. Discontinue the IV promptly
Question: The client is admitted to the nurse’s unit with a diagnosis of heart failure. His heart is not pumping effectively, which is resulting in edema and coarse crackles in his lungs. The term for this condition is:
Answer Choices:
A myocardial infarction.
B fluid volume excess.
C atelectasis.
D fluid volume deficit.
Answer: B – fluid volume excess.
Question: The wound care clinical nurse specialist has been consulted to evaluate a wound on the leg of a client with diabetes. The wound care nurse determines that damage to the subcutaneous tissues has occurred. How would the nurse document this wound?
Answer Choices:
A stage 1 pressure injury
B stage 4 pressure injury
C stage 2 pressure injury
D stage 3 pressure injury
Answer: D – stage 3 pressure injury.
Question: Which client will have more adipose tissue and less fluid?
Answer Choices:
A A woman
B A child
C An infant
Answer: A – A woman.
Question: While obtaining a health history from a client, which question is most appropriate for the nurse to ask the client to assess fluid balance?
Answer Choices:
A. “How much do you typically urinate during the day?”
B. “How often do you usually have a bowel movement?”
C. “How often do you experience leg cramps?”
D. “How much coffee do you drink during a typical day?”
Answer: A. “How much do you typically urinate during the day?”
Question: Which statement is an appropriate nursing concern for an 80-year-old client diagnosed with heart failure, with symptoms of edema, orthopnea, and confusion?
Answer Choices:
A. Excess extracellular volume related to heart failure, manifested as edema and orthopnea
B. Heart failure related to edema
C. Excess fluid volume related to loss of sodium and potassium
D. Deficient fluid volume related to congestive heart failure, manifested as shortness of breath
Answer: A. Excess extracellular volume related to heart failure, manifested as edema and orthopnea