Nursing Process and Client Care: Case Studies, Exams of Nursing

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NSG- 300

Foundations of Nursing

Comprehensive Exam Guide

Q & A

1. A nurse is assessing a client who has been admitted with heart failure. Which assessment finding would be most indicative of fluid volume excess? A. Weight loss and dry skin B. Distended neck veins and crackles in the lungs C. Flat neck veins and orthopnea D. Increased urinary output and dehydration Answer: B. Distended neck veins and crackles in the lungs Rationale: Distended neck veins and lung crackles are signs of fluid volume excess, often seen in heart failure due to the heart's inability to pump effectively, leading to fluid backup.
2. When planning care for a client with diabetes mellitus, which goal is most appropriate for the nurse to include? A. The client will experience no episodes of hypoglycemia. B. The client will adhere to a strict 1500 calorie diet. C. The client will demonstrate proper insulin injection technique. D. The client will verbalize the importance of foot care. Answer: C. The client will demonstrate proper insulin injection technique. Rationale: Ensuring the client can demonstrate proper insulin injection technique is crucial for the self-management of diabetes mellitus, preventing complications such as hypoglycemia or hyperglycemia.
3. A nursing student is learning about prioritizing client care. Which client should the nurse attend to first? A. A client who needs a dressing change for a wound that is healing as expected B. A client who is scheduled for routine medication administration

C. A client who is reporting chest pain and shortness of breath D. A client who is awaiting discharge instructions Answer: C. A client who is reporting chest pain and shortness of breath Rationale: Chest pain and shortness of breath may indicate a life-threatening condition such as myocardial infarction, requiring immediate intervention.

4. In teaching a client about managing hypertension, which statement by the nurse is most effective? A. "Monitor your blood pressure regularly and take medication as prescribed." B. "Avoid salty foods and try to exercise for at least 30 minutes a day." C. "Limit alcohol intake and avoid smoking to reduce your blood pressure." D. "All of the above are important in managing your hypertension." Answer: D. "All of the above are important in managing your hypertension." Rationale: Comprehensive management of hypertension includes regular monitoring, medication adherence, dietary modifications, exercise, and avoiding harmful substances.
5. A client with asthma is experiencing an acute exacerbation. What is the priority nursing intervention? A. Administering a bronchodilator B. Performing chest physiotherapy C. Encouraging deep breathing exercises D. Providing emotional support Answer: A. Administering a bronchodilator Rationale: During an acute asthma exacerbation, the priority is to open the airways and improve breathing, which is achieved by

administering a bronchodilator.

6. A nurse is caring for a postoperative client. Which action is most important to prevent postoperative complications? A. Encouraging the client to ambulate frequently B. Monitoring the client's vital signs every 4 hours C. Assisting the client with deep breathing and coughing exercises D. Keeping the head of the bed elevated at all times Answer: C. Assisting the client with deep breathing and coughing exercises Rationale: Deep breathing and coughing exercises help prevent atelectasis and pneumonia, common postoperative complications.
7. When evaluating a client's plan of care, which outcome indicates successful management of pain? A. The client reports a pain level of 2 on a scale of 0-10. B. The client is able to sleep through the night without waking. C. The client participates in physical therapy sessions. D. The client no longer requires pain medication. Answer: A. The client reports a pain level of 2 on a scale of 0-
8. Rationale: A low pain score indicates effective pain management, allowing the client to participate in care and activities comfortably.
9. A nurse is teaching a client about infection prevention at home. Which statement by the client indicates a need for further teaching? A. "I should wash my hands before preparing food." B. "It's okay to share personal items like a toothbrush with my spouse." C. "I need to clean and disinfect surfaces regularly."

D. "I should stay up-to-date with my vaccinations." Answer: B. "It's okay to share personal items like a toothbrush with my spouse." Rationale: Sharing personal items can spread infection; clients should be taught to avoid this practice to prevent infection.

9. A client with chronic kidney disease is undergoing hemodialysis. Which dietary modification should the nurse emphasize? A. Increase protein intake B. Limit fluid intake C. Increase consumption of potassium-rich foods D. Restrict sodium and phosphorus intake Answer: D. Restrict sodium and phosphorus intake Rationale: Clients undergoing hemodialysis need to restrict sodium and phosphorus to prevent complications associated with chronic kidney disease.
10. A nurse is caring for a client who has just undergone a mastectomy. Which intervention is most important for the nurse to include in the postoperative care plan? A. Encouraging the client to express feelings about body image changes B. Monitoring the surgical site for signs of infection C. Instructing the client on arm exercises to prevent lymphedema D. Providing information on breast reconstruction options Answer: C. Instructing the client on arm exercises to prevent lymphedema Rationale: Arm exercises are crucial after a mastectomy to prevent lymphedema, a common complication that can lead to significant discomfort and mobility issues.

11. A nurse is planning care for a client with a history of seizures. Which intervention should be included to ensure safety? A. Placing the client in a private room B. Keeping the bed in the lowest position with side rails up C. Avoiding the use of restraints D. Administering antiepileptic drugs as needed Answer: B. Keeping the bed in the lowest position with side rails up Rationale: This intervention helps prevent injury in case of a seizure by reducing the risk of falls and providing a barrier.
12. A client with bipolar disorder is experiencing a manic episode. What is the priority nursing action? A. Encouraging participation in group therapy B. Monitoring food and fluid intake C. Providing a quiet and structured environment D. Engaging the client in decision-making about care Answer: C. Providing a quiet and structured environment Rationale: During a manic episode, a quiet and structured environment can help reduce stimulation and promote safety.
13. A nurse is caring for a client with end-stage liver disease. Which symptom requires immediate intervention? A. Fatigue B. Jaundice C. Ascites D. Encephalopathy Answer: D. Encephalopathy Rationale: Encephalopathy can indicate a worsening of liver function and poses an immediate threat to the client's neurological status.

Question: A 45-year-old female patient presents with chest pain, shortness of breath, and diaphoresis. Which step of the nursing process should the nurse prioritize? A) Assessment B) Diagnosis C) Planning D) Implementation Answer: A) Assessment Rationale: Assessment is the first step in the nursing process and involves collecting data to identify the patient's health needs and concerns. Question: During the assessment phase, the nurse discovers that the patient has a history of hypertension and high cholesterol. Which nursing diagnosis is most appropriate? A) Ineffective Coping B) Risk for Infection C) Risk for Cardiovascular Disease D) Impaired Gas Exchange Answer: C) Risk for Cardiovascular Disease Rationale: Based on the patient's history of hypertension and high cholesterol, there is an increased risk for cardiovascular disease. Question: What is the next step after establishing the nursing diagnosis? A) Assessment B) Evaluation C) Planning D) Implementation Answer: C) Planning Rationale: Planning involves setting goals and developing a care plan to address the patient's nursing diagnosis.

Question: The nurse decides to implement interventions to reduce the patient's cardiovascular risk. Which intervention is most appropriate? A) Teaching the patient stress management techniques B) Administering antibiotics for infection prevention C) Providing oxygen therapy for shortness of breath D) Monitoring blood glucose levels Answer: A) Teaching the patient stress management techniques Rationale: Stress management can help reduce hypertension and cholesterol levels, thus lowering the risk of cardiovascular disease. Question: After implementing interventions, what is the nurse's next course of action? A) Assessment B) Evaluation C) Planning D) Diagnosis Answer: B) Evaluation Rationale: Evaluation involves assessing the effectiveness of the interventions in achieving the desired outcomes. Question: A diabetic patient is admitted with a foot ulcer. Which nursing diagnosis takes priority in this situation? A) Risk for Infection B) Impaired Skin Integrity C) Ineffective Tissue Perfusion D) Acute Pain Answer: B) Impaired Skin Integrity Rationale: The presence of a foot ulcer indicates impaired skin integrity, which requires immediate attention to prevent complications.

Question: What is the rationale behind prioritizing the nursing diagnosis of Impaired Skin Integrity? A) To prevent sepsis B) To promote wound healing C) To address pain management D) To improve mobility Answer: A) To prevent sepsis Rationale: Impaired skin integrity can lead to infections like sepsis, making it crucial to address promptly. Question: Which intervention is essential in caring for a patient with Impaired Skin Integrity? A) Administering pain medication B) Applying a sterile dressing C) Encouraging ambulation D) Providing emotional support Answer: B) Applying a sterile dressing Rationale: Proper wound care, such as applying a sterile dressing, is crucial in promoting wound healing and preventing infections. Question: How does the nurse evaluate the effectiveness of wound care interventions? A) Assessing vital signs B) Monitoring blood glucose levels C) Documenting wound appearance and healing progress D) Administering antibiotics Answer: C) Documenting wound appearance and healing progress Rationale: Documenting the wound's appearance and healing progress allows the nurse to track the effectiveness of interventions.

Question: A patient with chronic obstructive pulmonary disease (COPD) presents with increased dyspnea. Which nursing diagnosis should be prioritized? A) Impaired Gas Exchange B) Ineffective Airway Clearance C) Activity Intolerance D) Impaired Verbal Communication Answer: A) Impaired Gas Exchange Rationale: Increased dyspnea in a patient with COPD indicates impaired gas exchange, requiring immediate attention. Question: What is the rationale for prioritizing the nursing diagnosis of Impaired Gas Exchange in a patient with COPD? A) To prevent respiratory infections B) To promote oxygenation C) To improve lung function D) To decrease anxiety Answer: B) To promote oxygenation Rationale: Improving gas exchange is essential for optimizing oxygenation and respiratory function in patients with COPD. Question: Which intervention is crucial in addressing Impaired Gas Exchange in a patient with COPD? A) Administering bronchodilators B) Providing pain management C) Encouraging deep breathing exercises D) Ensuring adequate hydration Answer: A) Administering bronchodilators Rationale: Bronchodilators help dilate the airways, improve airflow, and enhance gas exchange in patients with COPD. Question: How does the nurse assess the effectiveness of

bronchodilator therapy in a patient with COPD? A) Monitoring blood pressure B) Auscultating lung sounds C) Checking blood glucose levels D) Measuring urine output Answer: B) Auscultating lung sounds Rationale: Auscultating lung sounds allows the nurse to evaluate the patient's respiratory status and the effectiveness of bronchodilator therapy. Question: A post-operative patient reports severe incisional pain. Which nursing diagnosis should be addressed first? A) Impaired Physical Mobility B) Acute Pain C) Risk for Infection D) Impaired Skin Integrity Answer: B) Acute Pain Rationale: Severe incisional pain requires immediate attention to ensure the patient's comfort and well-being. Question: What is the rationale for prioritizing the nursing diagnosis of Acute Pain in a post-operative patient? A) To prevent deconditioning B) To promote wound healing C) To improve quality of life D) To enhance patient comfort Answer: D) To enhance patient comfort Rationale: Addressing acute pain is essential to enhance patient comfort and promote recovery after surgery. Question: Which intervention is crucial in managing acute pain in a post-operative patient? A) Encouraging early ambulation

B) Administering pain medication as prescribed C) Offering emotional support D) Providing distraction techniques Answer: B) Administering pain medication as prescribed Rationale: Administering pain medication as prescribed helps alleviate pain and improve the patient's comfort level. Question: How does the nurse evaluate the effectiveness of pain management strategies in a post-operative patient? A) Monitoring oxygen saturation B) Assessing incision site for signs of infection C) Asking the patient to rate pain on a scale D) Checking for adequate fluid intake Answer: C) Asking the patient to rate pain on a scale Rationale: Patient self-report of pain is a valuable indicator of the effectiveness of pain management strategies. Question: A patient with end-stage renal disease is experiencing fatigue and weakness. Which nursing diagnosis should be the focus of care? A) Risk for Impaired Skin Integrity B) Activity Intolerance C) Impaired Gas Exchange D) Ineffective Coping Answer: B) Activity Intolerance Rationale: Fatigue and weakness in a patient with end-stage renal disease indicate activity intolerance, necessitating interventions to improve mobility. Question: What is the rationale for prioritizing the nursing diagnosis of Activity Intolerance in a patient with end-stage renal disease? A) To prevent falls

B) To promote rest and relaxation C) To improve quality of life D) To enhance functional ability Answer: D) To enhance functional ability Rationale: Addressing activity intolerance helps improve the patient's ability to perform activities of daily living and maintain independence. Question: Which intervention is essential in addressing Activity Intolerance in a patient with end-stage renal disease? A) Encouraging frequent naps throughout the day B) Providing passive range of motion exercises C) Administering iron supplements D) Offering nutritional counseling Answer: B) Providing passive range of motion exercises Rationale: Passive range of motion exercises help maintain joint mobility, prevent contractures, and improve circulation in patients with activity intolerance.

1. During the assessment phase of the nursing process, the nurse collects data through: A. Observation, interview, and physical examination B. Diagnostic tests and laboratory results C. Review of the client's medical history D. All of the above Answer: A. Observation, interview, and physical examination Rationale: During the assessment phase, it is important for the nurse to gather data through observation, interview, and physical examination to obtain a comprehensive view of the client's health status.
2. Which of the following statements best describes the planning phase of the nursing process?

A. Developing short-term and long-term goals for the client B. Identifying nursing interventions to achieve client goals C. Evaluating the effectiveness of nursing interventions D. Implementing nursing interventions to meet client needs Answer: A. Developing short-term and long-term goals for the client Rationale: The planning phase involves setting specific, measurable goals for the client to achieve optimal health outcomes.

3. When developing a nursing care plan, what is the nurse's priority consideration? A. Client preferences and cultural beliefs B. The nurse's personal beliefs and values C. Hospital policies and procedures D. The physician's orders Answer: A. Client preferences and cultural beliefs Rationale: It is essential for the nurse to consider the client's preferences and cultural beliefs when developing a care plan to provide client-centered care.
4. What is the purpose of the evaluation phase of the nursing process? A. To assess the client's health status B. To develop a nursing care plan C. To determine the effectiveness of nursing interventions D. To establish short-term and long-term goals Answer: C. To determine the effectiveness of nursing interventions Rationale: The evaluation phase involves assessing the outcomes of nursing interventions to determine if the client's goals have been met.

5. A nurse is caring for a client with a pressure ulcer on the sacrum. What is the priority nursing diagnosis for this client? A. Impaired Skin Integrity B. Impaired Mobility C. Risk for Infection D. Acute Pain Answer: A. Impaired Skin Integrity Rationale: The priority nursing diagnosis for a client with a pressure ulcer is impaired skin integrity, as the client is at risk for further skin breakdown and complications.
6. Which of the following nursing interventions is appropriate for a client with impaired skin integrity? A. Administering pain medication B. Providing a pressure-relieving mattress C. Ambulating the client every 2 hours D. Applying heat to the affected area Answer: B. Providing a pressure-relieving mattress Rationale: Providing a pressure-relieving mattress helps to reduce pressure on the affected area and prevent further skin breakdown in clients with impaired skin integrity.
7. A nurse is caring for a client with diabetes who has a blood sugar level of 300 mg/dL. Which nursing intervention is appropriate for this client? A. Administering insulin as prescribed B. Encouraging the client to eat a high-carbohydrate meal C. Monitoring the client's blood sugar level every 4 hours D. Encouraging the client to increase fluid intake Answer: A. Administering insulin as prescribed Rationale: Administering insulin as prescribed helps to lower the client's blood sugar level and manage diabetes effectively.

8. Which of the following nursing diagnoses is appropriate for a client experiencing difficulty breathing and chest pain? A. Ineffective Breathing Pattern B. Impaired Gas Exchange C. Acute Pain D. Anxiety Answer: B. Impaired Gas Exchange Rationale: Impaired gas exchange is a priority nursing diagnosis for a client experiencing difficulty breathing and chest pain, as it indicates a potential respiratory problem that needs to be addressed.
9. A nurse is caring for a client with a history of depression. Which of the following nursing interventions is appropriate for this client? A. Encouraging the client to isolate themselves B. Providing emotional support and active listening C. Administering sedatives as prescribed D. Limiting the client's access to visitors Answer: B. Providing emotional support and active listening Rationale: Providing emotional support and active listening helps to address the client's emotional needs and promote mental health in clients with depression.
10. Which of the following nursing actions demonstrates the application of critical thinking skills in the nursing process? A. Following physician orders without questioning B. Collaborating with the interdisciplinary team to develop a care plan C. Administering medications without verifying client identity D. Ignoring the client's concerns and preferences Answer: B. Collaborating with the interdisciplinary team to develop a care plan

Rationale: Collaborating with the interdisciplinary team demonstrates critical thinking skills by incorporating input from various healthcare professionals to provide comprehensive care for the client.

11. A nurse is assessing a client's cultural beliefs and preferences. Which cultural factor is the nurse considering in this situation? A. Ethnicity B. Religion C. Language D. Socioeconomic status Answer: A. Ethnicity Rationale: Ethnicity refers to a group of people who share a common cultural background, heritage, or ancestry, which can influence their beliefs and preferences.
12. Which of the following nursing diagnoses is appropriate for a client with a language barrier? A. Impaired Communication B. Risk for Falls C. Impaired Mobility D. Risk for Infection Answer: A. Impaired Communication Rationale: Impaired communication is a priority nursing diagnosis for a client with a language barrier, as it can affect the client's ability to understand and express their needs effectively.
13. A nurse is caring for a client from a different cultural background. Which nursing action promotes culturally sensitive care? A. Using medical jargon to communicate with the client B. Repositioning the client without explaining the procedure C. Respecting the client's cultural beliefs and practices

D. Ignoring the client's preferences and values Answer: C. Respecting the client's cultural beliefs and practices Rationale: Respecting the client's cultural beliefs and practices promotes culturally sensitive care by acknowledging and honoring the client's values and preferences.

14. Which of the following nursing interventions is appropriate for a client with a physical disability? A. Providing assistive devices to promote independence B. Restraining the client to prevent falls C. Minimizing social interactions with the client D. Administering sedatives to keep the client calm Answer: A. Providing assistive devices to promote independence Rationale: Providing assistive devices helps clients with physical disabilities maintain independence and enhance their quality of life.
15. A nurse is caring for a client with a feeding tube. Which nursing intervention is essential for ensuring safe care? A. Flushing the feeding tube with water after medications B. Using tape to secure the feeding tube in place C. Providing tube feeding at room temperature D. Administering medications directly into the feeding tube Answer: A. Flushing the feeding tube with water after medications Rationale: Flushing the feeding tube with water after medications helps prevent clogging and ensure proper administration of medications through the tube.
16. A nurse is caring for a client with dementia. Which nursing intervention is appropriate for promoting client safety? A. Restraining the client to prevent wandering B. Providing a structured daily routine

C. Administering sedatives to keep the client calm D. Minimizing social interactions with the client Answer: B. Providing a structured daily routine Rationale: Providing a structured daily routine helps clients with dementia feel secure and reduces confusion by establishing a predictable schedule.

17. What is the purpose of the nursing process in clinical practice? A. To promote evidence-based practice B. To provide a framework for nursing care C. To ensure safe and quality client care D. All of the above Answer: D. All of the above Rationale: The nursing process serves as a systematic framework for delivering evidence-based, safe, and quality client care in clinical practice.
18. Which of the following components is essential for effective communication in the nursing process? A. Active listening B. Interrupting the client while speaking C. Using medical terminology D. Providing one-way communication Answer: A. Active listening Rationale: Active listening involves fully engaging with the client, understanding their perspective, and responding appropriately to facilitate effective communication in the nursing process.
19. A nurse is caring for a client with a new colostomy. Which nursing intervention is appropriate for supporting the client emotionally? A. Ignoring the client's concerns about body image

B. Providing emotional support and empathy C. Avoiding discussions about the colostomy D. Pressuring the client to accept the colostomy Answer: B. Providing emotional support and empathy Rationale: Providing emotional support and empathy helps clients adjust to changes in body image and cope with emotional challenges related to a new colostomy.

20. Which of the following nursing interventions is appropriate for a client with impaired mobility? A. Encouraging bed rest to prevent falls B. Providing assistive devices for mobility C. Limiting the client's physical activity D. Avoiding physical therapy sessions Answer: B. Providing assistive devices for mobility Rationale: Providing assistive devices for mobility helps clients with impaired mobility maintain independence and improve their quality of life.
21. A nurse is caring for a client with an anxiety disorder. Which nursing intervention is appropriate for promoting relaxation? A. Administering sedatives as prescribed B. Encouraging the client to engage in deep breathing exercises C. Avoiding conversations about anxiety triggers D. Providing high-stress environments for the client Answer: B. Encouraging the client to engage in deep breathing exercises Rationale: Encouraging the client to engage in deep breathing exercises helps promote relaxation and reduce anxiety symptoms in clients with anxiety disorders.
22. Which of the following nursing diagnoses is appropriate for a client with a urinary tract infection?

A. Acute Pain B. Risk for Infection C. Impaired Skin Integrity D. Impaired Mobility Answer: B. Risk for Infection Rationale: Risk for infection is a priority nursing diagnosis for a client with a urinary tract infection, as it indicates a potential risk of complications related to the infection.

23. A nurse is caring for a client with a wound infection. Which nursing intervention is appropriate for managing infection? A. Administering pain medication B. Changing the dressing daily C. Applying heat to the wound D. Avoiding wound assessment Answer: B. Changing the dressing daily Rationale: Changing the dressing daily helps to prevent infection spread, promote wound healing, and maintain a clean wound environment in clients with wound infections.
24. A nurse is caring for a client with chronic pain. Which nursing intervention is appropriate for managing pain? A. Administering pain medication as needed B. Encouraging the client to endure the pain silently C. Providing physical therapy sessions D. Limiting pain assessment frequency Answer: A. Administering pain medication as needed Rationale: Administering pain medication as needed helps to alleviate pain and improve the client's comfort level in managing chronic pain effectively.
25. Which of the following nursing actions demonstrates cultural competence in the nursing process?

A. Stereotyping clients based on their cultural background B. Imposing the nurse's values and beliefs on clients C. Respecting and valuing diversity in client care D. Avoiding interactions with clients from diverse backgrounds Answer: C. Respecting and valuing diversity in client care Rationale: Cultural competence involves respecting and valuing diversity in client care by recognizing and appreciating individual differences in beliefs, values, and customs.

26. A nurse is caring for a client with limited English proficiency. Which nursing intervention is appropriate for promoting effective communication? A. Using complex medical terminology B. Speaking loudly to the client C. Using interpreters and translation services D. Avoiding eye contact with the client Answer: C. Using interpreters and translation services Rationale: Using interpreters and translation services helps to bridge communication barriers and ensure effective communication with clients with limited English proficiency.
27. What is the role of the nurse in advocating for client rights in the nursing process? A. Limiting client involvement in care decisions B. Respecting client autonomy and preferences C. Withholding information from clients D. Disregarding client concerns and complaints Answer: B. Respecting client autonomy and preferences Rationale: Advocating for client rights involves respecting client autonomy and preferences, involving clients in care decisions, and supporting their rights to make informed choices in the nursing process.

28. A nurse is caring for a client who refuses a prescribed medication. How should the nurse respond to the client's decision? A. Administering the medication forcefully B. Providing information about the medication benefits and risks C. Ignoring the client's preferences and concerns D. Disregarding the client's decision and administering the medication Answer: B. Providing information about the medication benefits and risks Rationale: Providing information about the medication benefits and risks helps clients make informed decisions about their care and collaborate with the healthcare team in the nursing process.
29. Which of the following nursing actions demonstrates professionalism in the nursing process? A. Failing to communicate with the interdisciplinary team B. Being disrespectful to clients and colleagues C. Respecting confidentiality and privacy D. Ignoring safety protocols and guidelines Answer: C. Respecting confidentiality and privacy Rationale: Professionalism in the nursing process involves respecting confidentiality and privacy, upholding ethical standards, and maintaining trust and integrity in client care.
30. A nurse is caring for a client with a history of substance abuse. Which nursing intervention is appropriate for promoting client safety? A. Allowing the client access to alcohol and drugs B. Monitoring the client's vital signs regularly C. Ignoring substance abuse issues D. Limiting the client's involvement in care decisions Answer: B. Monitoring the client's vital signs regularly

Rationale: Monitoring the client's vital signs regularly helps to assess the client's health status, identify potential complications related to substance abuse, and ensure client safety in the nursing process.

31. A nurse is caring for a client with a pressure injury. Which nursing intervention is appropriate for promoting wound healing? A. Applying heat to the wound B. Avoiding wound assessment C. Changing the dressing daily D. Limiting physical activity Answer: C. Changing the dressing daily Rationale: Changing the dressing daily helps to maintain a clean wound environment, prevent infection spread, and promote wound healing in clients with pressure injuries.
32. Which of the following nursing diagnoses is appropriate for a client experiencing shortness of breath? A. Impaired Gas Exchange B. Acute Pain C. Impaired Skin Integrity D. Risk for Infection Answer: A. Impaired Gas Exchange Rationale: Impaired gas exchange is a priority nursing diagnosis for a client experiencing shortness of breath, as it indicates potential respiratory problems that need to be addressed.
33. A nurse is caring for a client with congestive heart failure. Which nursing intervention is appropriate for managing fluid retention? A. Restricting fluid intake B. Encouraging high-sodium foods C. Administering diuretics as prescribed

D. Limiting physical activity Answer: C. Administering diuretics as prescribed Rationale: Administering diuretics helps to manage fluid retention, reduce edema, and improve cardiac function in clients with congestive heart failure.

34. A nurse is caring for a client with diabetes. Which nursing intervention is appropriate for promoting blood sugar control? A. Encouraging high-sugar snacks B. Monitoring blood sugar levels daily C. Administering insulin only as needed D. Limiting physical activity Answer: B. Monitoring blood sugar levels daily Rationale: Monitoring blood sugar levels daily helps to assess the client's glycemic control, adjust diabetes management strategies, and prevent complications related to diabetes in the nursing process.
35. A nurse is caring for a client with a surgical wound. Which nursing intervention is appropriate for preventing infection? A. Appplying heat to the wound B. Changing the dressing every other day C. Administering pain medication as needed D. Washing hands before and after wound care Answer: D. Washing hands before and after wound care Rationale: Washing hands before and after wound care helps to prevent infection transmission, maintain aseptic technique, and ensure client safety in the nursing process.
36. A nurse is caring for a client with a history of falls. Which nursing intervention is appropriate for promoting client safety? A. Limiting the client's physical activity B. Ignoring fall risk assessment