NUR 115 Study Guide Questions With
Complete Solutions
A 56-year-old patient comes to the walk-in clinic
reporting scant rectal bleeding and intermittent
diarrhea and constipation for the past several
months. There is a history of polyps and a family
history of colorectal cancer. While the nurse is
trying to teach about colonoscopy, the patient
becomes angry and threatens to leave. What is the
priority nursing concept to consider in responding
to this patient?
1.
Elimination
2.
Patient education
3.
Cellular regulation
4.
Anxiety Correct Answers 4. Anxiety
Rationale:The patient's physical condition is
currently stable, but emotional needs are affecting
his or her ability to receive the information
required to make an informed decision. The other
concepts are relevant, but if the patient leaves the
clinic, the interventions may be delayed or
ignored.Focus: PrioritizationQSEN: Patient-Centered
CareConcept: Anxiety
,A client has severe pain and bladder distention
related to urinary retention and possible
obstruction. An experienced unlicensed assistive
personnel (UAP) states that she received training in
indwelling catheter insertion at a previous job.
What task can be delegated to this UAP?
1.
Assessing the bladder distention and the pain
associated with urinary retention
2.
Inserting the indwelling catheter after verifying her
knowledge of sterile technique
3.
Evaluating the relief of pain and bladder distention
after the catheter is inserted
4.
Measuring the urine output after the catheter is
inserted and obtaining a specimen Correct
Answers 4.
Measuring the urine output after the catheter is
inserted and obtaining a specimen
A client is crying and grimacing but denies pain
and refuses pain medication because "my brother
is a drug addict and has ruined our lives." What is
the priority intervention for this client?
1.
Encourage expression of fears and past
experiences.
2.
,Provide accurate information about the use of pain
medication.
3.
Explain that addiction is unlikely among acute care
clients.
4.
Seek family assistance in resolving this problem.
Correct Answers 1.
Encourage expression of fears and past
experiences.
A client received as needed (PRN) morphine,
lorazepam, and cyclobenzaprine. The unlicensed
assistive personnel (UAP) reports that the client
has a respiratory rate of 10 breaths/min. What is
the priority action?
1.
Call the health care provider to obtain an order for
naloxone.
2.
Assess the client's responsiveness and respiratory
status.
3.
Obtain a bag-valve mask and deliver breaths at 20
breaths/min.
4.
Double-check the prescription to see which drugs
were ordered. Correct Answers 2.
Assess the client's responsiveness and respiratory
status.
, A client with chronic pain reports to the charge
nurse that the other nurses have not been
responding to your request for pain medication.
What is the charge nurses initial action?
1. Check the medication administration records for
the past several days.
2. Ask the nurse educator to provide in-service
training about pain management.
3. Perform a complete pain assessment on the
client and take a pain history.
4. Have a conference with the staff nurses to
assess their care of this client. Correct Answers 4.
Have a conference with the staff nurses to assess
their care of this client.
A client with diabetic neuropathy reports a burning,
electrical-type pain in the lower extremities that is
worse at night and not responding to nonsteroidal
anti-inflammatory drugs. Which medication will the
nurse advocate for first?
1.
Gabapentin
2.
Corticosteroids
3.
Hydromorphone
Complete Solutions
A 56-year-old patient comes to the walk-in clinic
reporting scant rectal bleeding and intermittent
diarrhea and constipation for the past several
months. There is a history of polyps and a family
history of colorectal cancer. While the nurse is
trying to teach about colonoscopy, the patient
becomes angry and threatens to leave. What is the
priority nursing concept to consider in responding
to this patient?
1.
Elimination
2.
Patient education
3.
Cellular regulation
4.
Anxiety Correct Answers 4. Anxiety
Rationale:The patient's physical condition is
currently stable, but emotional needs are affecting
his or her ability to receive the information
required to make an informed decision. The other
concepts are relevant, but if the patient leaves the
clinic, the interventions may be delayed or
ignored.Focus: PrioritizationQSEN: Patient-Centered
CareConcept: Anxiety
,A client has severe pain and bladder distention
related to urinary retention and possible
obstruction. An experienced unlicensed assistive
personnel (UAP) states that she received training in
indwelling catheter insertion at a previous job.
What task can be delegated to this UAP?
1.
Assessing the bladder distention and the pain
associated with urinary retention
2.
Inserting the indwelling catheter after verifying her
knowledge of sterile technique
3.
Evaluating the relief of pain and bladder distention
after the catheter is inserted
4.
Measuring the urine output after the catheter is
inserted and obtaining a specimen Correct
Answers 4.
Measuring the urine output after the catheter is
inserted and obtaining a specimen
A client is crying and grimacing but denies pain
and refuses pain medication because "my brother
is a drug addict and has ruined our lives." What is
the priority intervention for this client?
1.
Encourage expression of fears and past
experiences.
2.
,Provide accurate information about the use of pain
medication.
3.
Explain that addiction is unlikely among acute care
clients.
4.
Seek family assistance in resolving this problem.
Correct Answers 1.
Encourage expression of fears and past
experiences.
A client received as needed (PRN) morphine,
lorazepam, and cyclobenzaprine. The unlicensed
assistive personnel (UAP) reports that the client
has a respiratory rate of 10 breaths/min. What is
the priority action?
1.
Call the health care provider to obtain an order for
naloxone.
2.
Assess the client's responsiveness and respiratory
status.
3.
Obtain a bag-valve mask and deliver breaths at 20
breaths/min.
4.
Double-check the prescription to see which drugs
were ordered. Correct Answers 2.
Assess the client's responsiveness and respiratory
status.
, A client with chronic pain reports to the charge
nurse that the other nurses have not been
responding to your request for pain medication.
What is the charge nurses initial action?
1. Check the medication administration records for
the past several days.
2. Ask the nurse educator to provide in-service
training about pain management.
3. Perform a complete pain assessment on the
client and take a pain history.
4. Have a conference with the staff nurses to
assess their care of this client. Correct Answers 4.
Have a conference with the staff nurses to assess
their care of this client.
A client with diabetic neuropathy reports a burning,
electrical-type pain in the lower extremities that is
worse at night and not responding to nonsteroidal
anti-inflammatory drugs. Which medication will the
nurse advocate for first?
1.
Gabapentin
2.
Corticosteroids
3.
Hydromorphone
