Final Exam NUR 2214C | LATEST VERSION

Final Exam NUR 2214C 1. A client is admitted with a large draining wound on the leg. What action does the nurse take first? a.Administer ordered antibiotics. b.Insert an intravenous line. c.Give pain medications if needed. d.Obtain cultures of the leg wound. ANS: D The nurse first obtains wound cultures prior to administering broad-spectrum antibiotics. The nurse would need to start the IV prior to giving the antibiotics as they will most likely be parenteral. Pain should be treated but that is not the priority. 2. A client is going to be admitted for a scheduled surgical procedure. Which action does the nurse explain is the most important thing the client can do to protect against errors? a.Bring a list of all medications and what they are for. b.Keep the doctor's phone number by the telephone. c.Make sure all providers wash hands before entering the room. d.Write down the name of each caregiver who comes in the room. ANS: A Medication errors are the most common type of health care mistake. The Joint Commission's Speak Up campaign encourages clients to help ensure their safety. One recommendation is for clients to know all their medications and why they take them. This will help prevent medication errors. 3. A client with chronic osteomyelitis is being discharged from the hospital. What information is important for the nurse to teach this client and family? (Select all that apply.) a.Adherence to the antibiotic regimen b.Correct intramuscular injection technique c.Eating high-protein and high-carbohydrate foods d.Keeping daily follow-up appointments e.Proper use of the intravenous equipment ANS: A, C, E The client going home with chronic osteomyelitis will need long-term antibiotic therapy—first intravenous, then oral. The client needs education on how to properly administer IV antibiotics, care for the IV line, adhere to the regimen, and eat a healthy diet to encourage wound healing. The antibiotics are not given by IM injection. The client does not need daily follow-up. 4. Which nursing action is the best example of the ethical principle of veracity? 1. Supporting the patient's right to refuse any part of planned nursing care 2. Informing the patient that the pain medication to be given is not the same as what was administered the previous day 3. Maintaining the privacy of the patient's personal medical information. 4. Supporting the patient when ambulating and instructing the patient on the use of a walker 2 Explanation: 1. This is an example of autonomy. 2. Veracity is truth telling, which is essential for effective communication and trust. 3. This illustrates confidentiality. 4. This illustrates beneficence or "do no harm." 5. A new graduate nurse is working with an experienced nurse to chart assessment findings. The new nurse notes that the physical therapist wrote on the chart that the patient is lazy and did not want to participate in assigned therapies this AM. The experienced nurse asks the new nurse what may be going on here. What is the best explanation for this statement? a. Data on the chart can sometimes be documented in a biased manner. b. Data on the chart changes as the patient’s condition changes. c. Data on the chart is usually accurate and can be verified from the patient. d. Reading the chart is not a wise use of time as this can be time consuming and tedious. ANS: A It is important that the nurse records only what is assessed, without adding judgments or interpretations to the record. Data do indeed change (and need to be charted) as the patient’s condition changes, but this would not be the best