BSNlHESIl366lRNlExitlExamlV2l(Newl
Update)lQuestionslandlVerifiedlAnswers|
100%lCorrect|lGradelA-lNightingale
QUESTION
Alclientlwithlright-
sidedlweaknesslcallslforlassistancelwithlambulatingltolthelbathroom.lWhichlactionlshouldltheln
urselimplement?
AlBringlalbedsidelcommodeltolthelclient.
BlStandlonlthelclient'slrightlsidelwhilelwalking.
ClWalkldirectlylbehindlthelclientltolpreventlalfall.
DlGivelthelclientlalcaneltolholdlinlthelrightlhand.
Answer:
lBlStandlonlthelclient'slrightlsidelwhilelwalking.
-
Bylpositioninglthemselveslonlthelclient'slrightl(weaker)lsidelduringlambulation,lthelnurselcanlp
rovidelthelnecessarylsupport,lstability,landlguidanceltolpromotelsafelmobilitylandlpreventlfallsl
orlfurtherlinjury.
QUESTION
Alclientlwholrecentlylreceivedlalprescriptionlforlramelteonltoltreatlsleepldeprivationlreportslexp
eriencinglseverallsideleffectslsinceltakingltheldrug.lWhichlsideleffectlshouldlthelnurselreportltol
thelhealthlcarelprovider?
AlAlchangelinlthelsleep-wakelcycle.lBlMildlsedation.
ClSomnambulism.
DlDizzinesslreportedlafterlinitialldose.
Answer:
lClSomnambulism.l-
lSomnambulism,lalsolknownlaslsleepwalking,lislalpotentiallyldangerouslsideleffectlthatlneedsli
mmediatelattentionlfromlthelhealthcarelprovider.lThelclient'slsafetylislatlriskldueltolthelpotentia
llforlinjurylduringlsleepwalkinglepisodes.
QUESTION
Thelnurselislcaringlforlalclientlwholreceiveslalprescriptionlforlparenteralllidocaine.lPriorltoladm
inisteringlthelmedication,lthelnurselshouldlreviewlthelmedicallrecordlforlwhichlcondition?
,AlHeartlblock.
l
BlGlaucoma.
ClGastriclulcers.
DlDiabeteslmellitus.
Answer:
lAlHeartlblock.l-
lLidocainelislaslallocallanestheticlandlanlaslanlantiarrhythmic.lItlislcontraindicatedlandlclientsl
withlheartlblock.lWhenlusedlaslanlantiarrhythmic,lLidocainelworkslbylblockinglcertainlelectric
allsignalslinlthelheartlthatlcanlcauselanlirregularlheartbeat,llikelacutelventricularltachydysrhyth
mias.lHowever,linlpatientslwithlheartlblock,lalconditionlwherelthelelectricallsignalslinlthelheartl
arelpartiallylorlcompletelylblocked,lLidocainelcanlworsenlthelcondition.lThelotherlconditionslar
elnotldirectlylrelatedltoltheluseloflLidocaine.
QUESTION
Alclientlreceiveslalprescriptionlforlitraconazole.lWhichlstatementlmadelbylthelclientlrequireslad
ditionallinstructionlbylthelnurse?
AlIlshouldltakelthelmedicationlwithlantacids.
BlIflIlexperiencelanyldifficultylwithlbreathinglwilllreportlit.lClMonitoringlforlchangeslinlstoollc
olorlislimportant.
DlDrinkinglgrapefruitljuicelwilllreduceltheleffectsloflthelmedication.
Answer:
lAlIlshouldltakelthelmedicationlwithlantacids.
Bylprovidingladditionallinstructionltolavoidltakinglantacidslwithinl2lhoursloflitra-
lconazole,lthelnurselcanlensurelthelclientlunderstandslthelproperladministrationlandlmaximizeslt
heleffectivenessloflthislantifungallmedication.
QUESTION
Thelnurselislcaringlforlalclientlafterlthoracentesislthatldrainedl50lmL
oflclearlfluidlfromlthelleftllung.lWhichlassessmentlfindinglshouldlthelnurselreportltolthelhealthc
arelproviderlimmediately?
AlSerosanguinousldrainagelfromlthelchestltube.lBlDullnesslbilaterallylonlpercussion.
ClDiminishedlbreathlsoundslinlthelleftllowerllobe.
DlMediastinallshiftltolthelright.
Answer:
lDlMediastinallshiftltolthelright.l-
lAlmediastinallshiftltolthelrightlafterlalthoracentesislonlthelleftllunglcouldlindicatelalpotentiallc
omplicationlofltensionlpneumothoraxl(collapsedllung),lwhichlrequireslimmediatelmedicallattent
ion.
,QUESTION
Alclientlwholdeliveredlvaginallyl2ldayslagolstateslthatlshelwantsltolresumelusinglherldiaphrag
mlforlbirthlcontrol.lWhatlinformationlshouldlthelnurselsharelwithlher?
AlThelmostleffectivelformloflcontraceptionlislaldiaphragm.
BlTheldiaphragmlshouldlbelinsertedl2ltol4lhourslbeforelintercourse.lClVaselinellubricantlcanlbe
lusedlwhenlinsertingltheldiaphragm.
DlTheldiaphragmlmustlbelrefittedlafterlchildbirth.
Answer:
lDlTheldiaphragmlmustlbelrefittedlafterlchildbirth.l-
lItsleffectivenesslcanlbelcompromisedlbylchangeslinlthelanatomyloflthelvaginallcanal,lcervix,la
ndlpelviclstructures,lsuchlaslthoselthatloccurlafterlchildbirth.lAfterlvaginallchildbirth,lthelpelvic
lstructureslmaylundergolchanges,
l
includinglstretchinglandlpossiblellosslofltone.lTheselchangeslcanlaffectlthelfitlandlpositionloflth
eldiaphragm,lleadingltoldecreasedlcontraceptivelefficacy.lTherefore,lit'slimportantlforlwomenlw
holhavelgivenlbirthltolhaveltheirldiaphragmlrefittedlbylalhealthcarelproviderlbeforelresuminglits
luse.
QUESTION
Whichlclientlwilllbenefitlmostlfromlthelapplicationloflpneumaticlcompres-
lsionldevicesltolthellowerlextremities?lThelclientlwho:
Alhaslpressurelulcerslonlseveralltoes.lBlhasldiminishedlpedallpulselvolume.
Clislconfusedlandltriesltolclimbloutloflbed.
Dlislimmobilelonlprescribedlbedrest.
Answer:
lDlislimmobilelonlprescribedlbedrest.l-
lBeinglimmobilelonlprescribedlbedrestlsignificantlylincreaseslthelriskloflDVTldueltollackloflmo
vementlandlimpairedlbloodlflowlinlthellegs.lApplyinglpneumaticlcompressionldeviceslhelpslpro
motelcirculationlandlpreventlbloodlclotlformationlinlsuchlimmobilizedlpatients.
QUESTION
Whenlcaringlforlalclientlwithlfull-
thicknesslburnsltolbothllowerlextremities,lwhichlassessmentlfinding(s)lwarrantlimmediatelinterv
entionlbylthelnurse?lSelectlalllthatlapply.
AlLossloflsensationltolthelleftllowerlextremity.
BlChangelinlthelqualityloflthelperipherallpulses.lClComplaintloflincreasedlpainlandlpressure.
DlSloughingltissuelaroundlwoundledges.
ElWeepinglserosanguineouslfluidlfromlwounds.
Answer:
, lAlLossloflsensationltolthelleftllowerlextremity.-
lLossloflsensationlcouldlindicatelnerveldamagelorlcompromisedlbloodlflow,lbothloflwhichlrequ
irelimmediatelattention.
BlChangelinlthelqualityloflthelperipherallpulses.l-
lChangeslinlperipherallpulseslcanlindicatelcompromisedlcirculation,lwhichlislalmedicallemerge
ncy.lThislcouldlleadltoltissuelnecrosisliflnotladdressedlpromptly.
ClComplaintloflincreasedlpainlandlpressure.l-
lIncreasedlpainlandlpressurelcouldlindicatelcompartmentlsyndrome,lalseriouslconditionlthatlcan
lleadltolmusclelandlnerveldamageliflnotltreatedlimmediately.
QUESTION
Whichlnursinglresponsibilitylislrelatedltolhealthlpromotionlandlteachinglforlthelclientlwithlrheu
matoidlarthritis?
AlImmobilizationloflaffectedljoints.
BlAvoidanceloflfoodslcontaininglpurine.lClApplicationloflheatlandlcoldltherapy.
DlPreventionlthroughlnutritionlandlexercise.
Answer:
lDlPreventionlthroughlnutritionlandlexerciselislthelmostlcomprehensivelapproachlthatlalignslwit
hlhealthlpromotion
andlteachinglforlclientslwithlrheumatoidlarthritis.lItlincludesleducatinglclientslonlalbalancedldie
tlandlphysicallactivityltolmanagelsymptomslandlimproveloveralllhealth.
l
Incorrect:
AlApplicationloflheatlandlcoldltherapylcanlhelplmanagelsymptomslbutldoeslnotlencompasslthel
broaderlaspectsloflhealthlpromotionlandlteaching.
BlAvoidanceloflfoodslcontaininglpurinelislmorelspecificltolconditionsllikelgoutlratherlthanlrheu
matoidlarthritis,landlwhileldietlislimportant,litldoeslnotlfullylrepresentlhealthlpromotionlandltea
ching.
ClImmobilizationloflaffectedljointslislnotlalhealthlpromotionlstrategylandlcanlactuallylworsenls
ymptomsloverltime.lActivelandlpassivelrange-of-motionlexerciseslarelrecommendedlinstead.
QUESTION
Afterlreceivinglshiftlreport,lthelnurselworkinglonlalpostpartumlunitlshouldlassesslwhichlclientlf
irst?
AlCesareanlbirthlofltwinsltodaylwholislnowlcomplainingloflpain.lBlPost-
cesareanlbirthltodaylwithlfunduslatlthelumbilicus.
ClVaginallbirthltodaylwhoselinfantlislrefusingltolbreastfeed.
DlMultiparalvaginallbirthlyesterdaylwholislsaturatingltwolpads/hour.
Answer:
Update)lQuestionslandlVerifiedlAnswers|
100%lCorrect|lGradelA-lNightingale
QUESTION
Alclientlwithlright-
sidedlweaknesslcallslforlassistancelwithlambulatingltolthelbathroom.lWhichlactionlshouldltheln
urselimplement?
AlBringlalbedsidelcommodeltolthelclient.
BlStandlonlthelclient'slrightlsidelwhilelwalking.
ClWalkldirectlylbehindlthelclientltolpreventlalfall.
DlGivelthelclientlalcaneltolholdlinlthelrightlhand.
Answer:
lBlStandlonlthelclient'slrightlsidelwhilelwalking.
-
Bylpositioninglthemselveslonlthelclient'slrightl(weaker)lsidelduringlambulation,lthelnurselcanlp
rovidelthelnecessarylsupport,lstability,landlguidanceltolpromotelsafelmobilitylandlpreventlfallsl
orlfurtherlinjury.
QUESTION
Alclientlwholrecentlylreceivedlalprescriptionlforlramelteonltoltreatlsleepldeprivationlreportslexp
eriencinglseverallsideleffectslsinceltakingltheldrug.lWhichlsideleffectlshouldlthelnurselreportltol
thelhealthlcarelprovider?
AlAlchangelinlthelsleep-wakelcycle.lBlMildlsedation.
ClSomnambulism.
DlDizzinesslreportedlafterlinitialldose.
Answer:
lClSomnambulism.l-
lSomnambulism,lalsolknownlaslsleepwalking,lislalpotentiallyldangerouslsideleffectlthatlneedsli
mmediatelattentionlfromlthelhealthcarelprovider.lThelclient'slsafetylislatlriskldueltolthelpotentia
llforlinjurylduringlsleepwalkinglepisodes.
QUESTION
Thelnurselislcaringlforlalclientlwholreceiveslalprescriptionlforlparenteralllidocaine.lPriorltoladm
inisteringlthelmedication,lthelnurselshouldlreviewlthelmedicallrecordlforlwhichlcondition?
,AlHeartlblock.
l
BlGlaucoma.
ClGastriclulcers.
DlDiabeteslmellitus.
Answer:
lAlHeartlblock.l-
lLidocainelislaslallocallanestheticlandlanlaslanlantiarrhythmic.lItlislcontraindicatedlandlclientsl
withlheartlblock.lWhenlusedlaslanlantiarrhythmic,lLidocainelworkslbylblockinglcertainlelectric
allsignalslinlthelheartlthatlcanlcauselanlirregularlheartbeat,llikelacutelventricularltachydysrhyth
mias.lHowever,linlpatientslwithlheartlblock,lalconditionlwherelthelelectricallsignalslinlthelheartl
arelpartiallylorlcompletelylblocked,lLidocainelcanlworsenlthelcondition.lThelotherlconditionslar
elnotldirectlylrelatedltoltheluseloflLidocaine.
QUESTION
Alclientlreceiveslalprescriptionlforlitraconazole.lWhichlstatementlmadelbylthelclientlrequireslad
ditionallinstructionlbylthelnurse?
AlIlshouldltakelthelmedicationlwithlantacids.
BlIflIlexperiencelanyldifficultylwithlbreathinglwilllreportlit.lClMonitoringlforlchangeslinlstoollc
olorlislimportant.
DlDrinkinglgrapefruitljuicelwilllreduceltheleffectsloflthelmedication.
Answer:
lAlIlshouldltakelthelmedicationlwithlantacids.
Bylprovidingladditionallinstructionltolavoidltakinglantacidslwithinl2lhoursloflitra-
lconazole,lthelnurselcanlensurelthelclientlunderstandslthelproperladministrationlandlmaximizeslt
heleffectivenessloflthislantifungallmedication.
QUESTION
Thelnurselislcaringlforlalclientlafterlthoracentesislthatldrainedl50lmL
oflclearlfluidlfromlthelleftllung.lWhichlassessmentlfindinglshouldlthelnurselreportltolthelhealthc
arelproviderlimmediately?
AlSerosanguinousldrainagelfromlthelchestltube.lBlDullnesslbilaterallylonlpercussion.
ClDiminishedlbreathlsoundslinlthelleftllowerllobe.
DlMediastinallshiftltolthelright.
Answer:
lDlMediastinallshiftltolthelright.l-
lAlmediastinallshiftltolthelrightlafterlalthoracentesislonlthelleftllunglcouldlindicatelalpotentiallc
omplicationlofltensionlpneumothoraxl(collapsedllung),lwhichlrequireslimmediatelmedicallattent
ion.
,QUESTION
Alclientlwholdeliveredlvaginallyl2ldayslagolstateslthatlshelwantsltolresumelusinglherldiaphrag
mlforlbirthlcontrol.lWhatlinformationlshouldlthelnurselsharelwithlher?
AlThelmostleffectivelformloflcontraceptionlislaldiaphragm.
BlTheldiaphragmlshouldlbelinsertedl2ltol4lhourslbeforelintercourse.lClVaselinellubricantlcanlbe
lusedlwhenlinsertingltheldiaphragm.
DlTheldiaphragmlmustlbelrefittedlafterlchildbirth.
Answer:
lDlTheldiaphragmlmustlbelrefittedlafterlchildbirth.l-
lItsleffectivenesslcanlbelcompromisedlbylchangeslinlthelanatomyloflthelvaginallcanal,lcervix,la
ndlpelviclstructures,lsuchlaslthoselthatloccurlafterlchildbirth.lAfterlvaginallchildbirth,lthelpelvic
lstructureslmaylundergolchanges,
l
includinglstretchinglandlpossiblellosslofltone.lTheselchangeslcanlaffectlthelfitlandlpositionloflth
eldiaphragm,lleadingltoldecreasedlcontraceptivelefficacy.lTherefore,lit'slimportantlforlwomenlw
holhavelgivenlbirthltolhaveltheirldiaphragmlrefittedlbylalhealthcarelproviderlbeforelresuminglits
luse.
QUESTION
Whichlclientlwilllbenefitlmostlfromlthelapplicationloflpneumaticlcompres-
lsionldevicesltolthellowerlextremities?lThelclientlwho:
Alhaslpressurelulcerslonlseveralltoes.lBlhasldiminishedlpedallpulselvolume.
Clislconfusedlandltriesltolclimbloutloflbed.
Dlislimmobilelonlprescribedlbedrest.
Answer:
lDlislimmobilelonlprescribedlbedrest.l-
lBeinglimmobilelonlprescribedlbedrestlsignificantlylincreaseslthelriskloflDVTldueltollackloflmo
vementlandlimpairedlbloodlflowlinlthellegs.lApplyinglpneumaticlcompressionldeviceslhelpslpro
motelcirculationlandlpreventlbloodlclotlformationlinlsuchlimmobilizedlpatients.
QUESTION
Whenlcaringlforlalclientlwithlfull-
thicknesslburnsltolbothllowerlextremities,lwhichlassessmentlfinding(s)lwarrantlimmediatelinterv
entionlbylthelnurse?lSelectlalllthatlapply.
AlLossloflsensationltolthelleftllowerlextremity.
BlChangelinlthelqualityloflthelperipherallpulses.lClComplaintloflincreasedlpainlandlpressure.
DlSloughingltissuelaroundlwoundledges.
ElWeepinglserosanguineouslfluidlfromlwounds.
Answer:
, lAlLossloflsensationltolthelleftllowerlextremity.-
lLossloflsensationlcouldlindicatelnerveldamagelorlcompromisedlbloodlflow,lbothloflwhichlrequ
irelimmediatelattention.
BlChangelinlthelqualityloflthelperipherallpulses.l-
lChangeslinlperipherallpulseslcanlindicatelcompromisedlcirculation,lwhichlislalmedicallemerge
ncy.lThislcouldlleadltoltissuelnecrosisliflnotladdressedlpromptly.
ClComplaintloflincreasedlpainlandlpressure.l-
lIncreasedlpainlandlpressurelcouldlindicatelcompartmentlsyndrome,lalseriouslconditionlthatlcan
lleadltolmusclelandlnerveldamageliflnotltreatedlimmediately.
QUESTION
Whichlnursinglresponsibilitylislrelatedltolhealthlpromotionlandlteachinglforlthelclientlwithlrheu
matoidlarthritis?
AlImmobilizationloflaffectedljoints.
BlAvoidanceloflfoodslcontaininglpurine.lClApplicationloflheatlandlcoldltherapy.
DlPreventionlthroughlnutritionlandlexercise.
Answer:
lDlPreventionlthroughlnutritionlandlexerciselislthelmostlcomprehensivelapproachlthatlalignslwit
hlhealthlpromotion
andlteachinglforlclientslwithlrheumatoidlarthritis.lItlincludesleducatinglclientslonlalbalancedldie
tlandlphysicallactivityltolmanagelsymptomslandlimproveloveralllhealth.
l
Incorrect:
AlApplicationloflheatlandlcoldltherapylcanlhelplmanagelsymptomslbutldoeslnotlencompasslthel
broaderlaspectsloflhealthlpromotionlandlteaching.
BlAvoidanceloflfoodslcontaininglpurinelislmorelspecificltolconditionsllikelgoutlratherlthanlrheu
matoidlarthritis,landlwhileldietlislimportant,litldoeslnotlfullylrepresentlhealthlpromotionlandltea
ching.
ClImmobilizationloflaffectedljointslislnotlalhealthlpromotionlstrategylandlcanlactuallylworsenls
ymptomsloverltime.lActivelandlpassivelrange-of-motionlexerciseslarelrecommendedlinstead.
QUESTION
Afterlreceivinglshiftlreport,lthelnurselworkinglonlalpostpartumlunitlshouldlassesslwhichlclientlf
irst?
AlCesareanlbirthlofltwinsltodaylwholislnowlcomplainingloflpain.lBlPost-
cesareanlbirthltodaylwithlfunduslatlthelumbilicus.
ClVaginallbirthltodaylwhoselinfantlislrefusingltolbreastfeed.
DlMultiparalvaginallbirthlyesterdaylwholislsaturatingltwolpads/hour.
Answer:
