Concepts for Nursing Practice Test Bank

Correct Answer: A

Rationale: Impaired Gas Exchange is the nursing diagnosis that should take the highest priority for implementing client education in a client with chronic obstructive pulmonary disease (COPD). Since COPD directly affects the ability of the lungs to take in oxygen and eliminate carbon dioxide, impaired gas exchange is a critical concern for these patients. By educating the client on proper breathing techniques, medication adherence, smoking cessation, and environmental triggers, the nurse can help in improving gas exchange and overall respiratory function. Addressing Impaired Gas Exchange as a priority can significantly impact the client's quality of life and prevent respiratory complications.

Correct Answer: B

Rationale: Option B, "Demonstrates care of the vascular access device for dialysis," indicates that the patient understands how to care for their vascular access device, which is important for receiving dialysis treatment. This action shows adequate comprehension and competency in managing this aspect of their care. Therefore, additional teaching is not necessary in this area. On the other hand, options A, C, and D present actions that may require further clarification or reinforcement in the teaching provided to the patient with acute glomerulonephritis.

Correct Answer: B

Rationale: A decreased urinary output from 50 mL/hour to 40 mL/hour indicates a worsening of the client's condition with preeclampsia. A decreased urinary output can be a sign of reduced kidney function, which is a serious complication in preeclampsia. Monitoring urinary output is crucial in assessing kidney function and overall fluid balance in clients with preeclampsia. It is important to promptly address any reduction in urinary output to prevent further deterioration in the client's condition. The other options do not specifically indicate a worsening of the condition in this context.

Correct Answer: B

Rationale: The gland that encircles the male urethra at the base of the bladder is the prostate gland. The prostate is an important organ in the male reproductive system that produces fluid to nourish and protect sperm. It also plays a role in ejaculation. A nurse focusing on the prostate gland during the health history of an older male patient is particularly important because issues related to the prostate, such as benign prostatic hyperplasia (BPH) or prostate cancer, commonly affect older men. Regular assessment and screening of the prostate gland are crucial for early detection and management of any potential prostate problems.

Correct Answer: B

Rationale: B. Coach in nonpharmacologic pain management techniques: The client's vital signs indicate they may be experiencing pain as evidenced by an elevated heart rate (P 119), which can be addressed initially with nonpharmacologic pain management techniques. This approach can help reduce pain and anxiety without the immediate need for medication.