a nurse is completing an admission assessment for a client who reports vomiting and diarrhea for the past 3 days which of the following findings shoul

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1. A nurse is completing an admission assessment for a client who reports vomiting and diarrhea for the past 3 days. Which of the following findings should the nurse expect?

A. Blood pressure 144/82 mm Hg
B. Urine specific gravity 1.03
C. Neck vein distention
D. Urine specific gravity 1.01

Correct answer: A

Rationale: In a client experiencing vomiting and diarrhea, the nurse should expect findings such as dehydration, which can lead to hypovolemia and subsequent increased heart rate and decreased blood pressure. A blood pressure of 144/82 mm Hg is indicative of possible dehydration in this client. Urine specific gravity is typically increased in dehydrated individuals, so choices B and D are incorrect. Neck vein distention is not a typical finding associated with vomiting and diarrhea; therefore, choice C is also incorrect.

2. A nurse is caring for a client who has a nasogastric (NG) tube and is receiving intermittent feedings through an open system. Which of the following actions should the nurse take first?

A. Make sure the enteral formula is at room temperature.
B. Wipe the top of the formula can with alcohol.
C. Rinse the feeding bag with water between feedings.
D. Tell the client to keep the head of the bed elevated at least 30�

Correct answer: B

Rationale:

3. Which of the following is a key component of patient-centered care?

A. Provider-centered decision making
B. Timely discharge
C. Respect for patient preferences
D. Focusing on clinical outcomes

Correct answer: C

Rationale: The correct answer is C: Respect for patient preferences. Patient-centered care focuses on involving patients in their care decisions and respecting their preferences. Choice A, provider-centered decision making, goes against the concept of patient-centered care as it prioritizes the provider over the patient. Timely discharge, choice B, is important but not a defining component of patient-centered care. Focusing on clinical outcomes, choice D, is essential in healthcare but does not solely represent patient-centered care, which is more about personalized care and involving patients in decision-making.

4. An RN enters a patient�s room to place an indwelling urinary catheter, as ordered by the health-care professional. The client is alert and oriented and tells the RN he wants to leave the hospital now and not receive further treatment. Which of the following actions by the RN would be considered false imprisonment?

A. The RN tells the client he is not allowed to leave until the physician has released him.
B. The RN asks the client why he wishes to leave.
C. The RN asks the client to explain what he understands about his medical diagnosis.
D. The RN asks the client to sign an against medical advice discharge form.

Correct answer: A

Rationale: The RN tells the client he is not allowed to leave until the physician has released him would be considered false imprisonment.

5. A client is discussing the use of herbal supplements for health promotion with a nurse. Which of the following client statements indicates an understanding of herbal supplement use?

A. I can take echinacea to improve my immune system.
B. I can take feverfew to reduce my level of anxiety.
C. I can take ginger to improve my memory.
D. I can take ginkgo biloba to relieve nausea.

Correct answer: D

Rationale: The correct answer is D. Ginkgo biloba is commonly used to improve blood circulation and relieve symptoms of cognitive disorders like dementia. The other choices are incorrect because echinacea is used to boost the immune system, feverfew is used for migraines and headaches, and ginger is known for its anti-inflammatory properties and aiding digestion, not memory improvement.