NUR 101 : Exam 1
____________________ is total separation of the layers of a wound with internal viscera protruding through the incision. -
ANS -ANS:
Evisceration
\. A patient admitted with an acute exacerbation of chronic obstructive pulmonary disease has a nursing diagnosis of
Activity Intolerance. Which type of bath is preferred for this patient?
1) Tub bath
2) Complete bed bath
3) Towel bath
4) Bed bath - ANS -ANS:
3) Towel bath
A towel bath is a modification of the bed bath, in which a large towel and a bath blanket are placed in a plastic bag and
saturated with a commercially prepared mixture of moisturizer, nonrinse cleaning agent, and water. The bag and its
contents are then placed in the microwave, and they are used to bathe the patient. This bathing method is preferred for
patients who have Activity Intolerance. A tub bath, complete bed bath, and conventional bed bath may deplete this
patients energy.
\A 73-year-old patient admitted after a stroke has expressive aphasia. Which pain intensity scale(s) would be appropriate
to use with this patient? Choose all that apply.
1) Visual analog
2) Numerical rating
3) Wong-Baker face rating
4) Simple descriptor - ANS -ANS:
,1) Visual analog
3) Wong-Baker face rating
The Wong-Baker face-rating scale uses simple illustrations of faces to depict various levels of pain. The scale was
developed for children but has proved effective for adults with communication and cognitive impairments. The visual
analog requires patients to point to a location on a line that reflects their pain level. Some patients have difficulty with the
abstract nature of this scale. When using the numerical rating scale, the patient must choose a number from 0 to 10 to
denote his pain level. This scale is sometimes difficult for clients with cognitive impairments, such as expressive aphasia;
however, it would be appropriate to try it if the face-rating scale is not available. Patients commonly find the simple
descriptor scale difficult to understand. This scale uses a list of adjectives that describe pain intensity.
\A 78-year-old patient is being seen in the emergency department. The nurse observes his gait and balance appear to be
slightly unsteady. What assessment should the nurse perform next?
1) Perform the Get Up and Go Test.
2) Ask the patient if he has fallen in the past year.
3) Refer the patient for a comprehensive fall evaluation.
4) Administer the Timed Up and Go Test. - ANS -ANS: 2
2) Ask the patient if he has fallen in the past year.
If a patients gait or balance is unsteady, the nurse should question the patient for a history of falls. If the patient reports a
single fall, the nurse should do the Get Up and Go Test. If the patient has difficulty with that test, or is unsteady with it, the
nurse should perform a follow-up assessment of gait and balance by having the person close the eyes for a few seconds
wile standing in place; stand with eyes closed while the nurse pushes gently on the sternum; walk, stop, turn around,
return to the chair, and sit in the chair without using his arms for support. Physicians and advanced practitioners perform
the Timed Up and Go Test; it is recommended annually for patients 65 years or older.
\A child is brought to the emergency department after swallowing liquid cleanser. He is awake and alert and able to
swallow. Which action should the nurse take first?
1) Administer a dose of syrup of ipecac.
,2) Administer activated charcoal immediately.
3) Give water to the child immediately.
4) Call the nearest poison control center. - ANS -ANS: 3
3) Give water to the child immediately.
If the child is awake and able to swallow, and the child has swallowed a household chemical, give one-half glassful of
water immediately. After giving the water, call the poison control center. The American Academy of Pediatrics does not
advise giving syrup of ipecac. Emergency departments have stopped using ipecac in favor of activated charcoal, which
binds to poison in the stomach and prevents it from entering the bloodstream. Continued vomiting caused by syrup of
ipecac may later result in the child being unable to tolerate activated charcoal or other poison treatments. No one can tell
how much a child vomits, and therefore, no one would know if all the poison was eliminated from the stomach. There is
also potential for misuse by bulimics. The poison control center may recommend activated charcoal, depending upon the
agent ingested.
\A client developed a stage IV pressure ulcer to his sacrum 6 weeks ago, and now the ulcer appears to be a shallow
crater involving only partial skin loss. What would the nurse now classify the pressure ulcer as?
1) Stage I pressure ulcer, healing
2) Stage II pressure ulcer, healing
3) Stage III pressure ulcer, healing
4) Stage IV pressure ulcer, healing - ANS -ANS:
4) Stage IV pressure ulcer, healing
Reverse staging is not done because as the ulcer heals with granulation tissue and becomes shallower, the lost muscle,
subcutaneous fat, and dermis are not replaced. Pressure ulcers maintain their original staging classification throughout
the healing process but are accompanied by the modifier healing.
\A client reports taking acetaminophen (Tylenol) to control osteoarthritis. Which instruction should the nurse give the
patient requiring long-term acetaminophen use?
1) Caution the patient against combining acetaminophen with alcohol.
, 2) Explain that acetaminophen increases the risk for bleeding.
3) Advise taking acetaminophen with meals to prevent gastric irritation.
4) Explain that physical dependence may occur with long-term oral use. - ANS -ANS:
1) Caution the patient against combining acetaminophen with alcohol.
Even in recommended doses, acetaminophen can cause hepatotoxicity in those who consume alcohol. Therefore, the
nurse should caution the patient against combining acetaminophen with alcohol. Aspirin, not acetaminophen, increases
the risk for bleeding because it inhibits platelet aggregation. Nonsteroidal anti-inflammatory drugs (NSAIDs), not
acetaminophen, cause gastric irritation and should be taken with meals. Opioid analgesics, not acetaminophen, can
cause physical dependence.
\A client who has been hospitalized for an infection states, The nursing assistant told me my vital signs are all within
normal limits; that means Im cured. The nurses best response would be which of the following?
1) Your vital signs confirm that your infection is resolved; how do you feel?
2) Ill let your healthcare provider know so you can be discharged.
3) Your vital signs are stable, but there are other things to assess.
4) We still need to keep monitoring your temperature for a while. - ANS -ANS: 3) Your vital signs are stable, but there are
other things to assess.
Vital signs are one indicator of a clients physiological status, but they are not an absolute indicator of well-being from
every aspect. It may be inaccurate to state that the vital signs indicate the infection is resolved; vital signs could stabilize
even if the infection remains active. The healthcare providers decision regarding the clients readiness for discharge is not
based exclusively on the vital signs but rather is based on a compilation of other sources of information, primarily the
clients clinical status, but also cultures, complete blood counts, and various other laboratory and possibly radiologic
evidence. Although the nurse will need to continue monitoring the temperature, other clinical signs must also be
monitored; therefore, the statement We still need to keep monitoring your temperature . . . is incomplete and less useful
than the statement that begins Your vital signs are stable, but . . .
\A clients average normal temperature is 98F. Which of the following temperatures would be expected during the night in
this healthy young adult client who does not have a fever, inflammatory process, or underlying health problems?
____________________ is total separation of the layers of a wound with internal viscera protruding through the incision. -
ANS -ANS:
Evisceration
\. A patient admitted with an acute exacerbation of chronic obstructive pulmonary disease has a nursing diagnosis of
Activity Intolerance. Which type of bath is preferred for this patient?
1) Tub bath
2) Complete bed bath
3) Towel bath
4) Bed bath - ANS -ANS:
3) Towel bath
A towel bath is a modification of the bed bath, in which a large towel and a bath blanket are placed in a plastic bag and
saturated with a commercially prepared mixture of moisturizer, nonrinse cleaning agent, and water. The bag and its
contents are then placed in the microwave, and they are used to bathe the patient. This bathing method is preferred for
patients who have Activity Intolerance. A tub bath, complete bed bath, and conventional bed bath may deplete this
patients energy.
\A 73-year-old patient admitted after a stroke has expressive aphasia. Which pain intensity scale(s) would be appropriate
to use with this patient? Choose all that apply.
1) Visual analog
2) Numerical rating
3) Wong-Baker face rating
4) Simple descriptor - ANS -ANS:
,1) Visual analog
3) Wong-Baker face rating
The Wong-Baker face-rating scale uses simple illustrations of faces to depict various levels of pain. The scale was
developed for children but has proved effective for adults with communication and cognitive impairments. The visual
analog requires patients to point to a location on a line that reflects their pain level. Some patients have difficulty with the
abstract nature of this scale. When using the numerical rating scale, the patient must choose a number from 0 to 10 to
denote his pain level. This scale is sometimes difficult for clients with cognitive impairments, such as expressive aphasia;
however, it would be appropriate to try it if the face-rating scale is not available. Patients commonly find the simple
descriptor scale difficult to understand. This scale uses a list of adjectives that describe pain intensity.
\A 78-year-old patient is being seen in the emergency department. The nurse observes his gait and balance appear to be
slightly unsteady. What assessment should the nurse perform next?
1) Perform the Get Up and Go Test.
2) Ask the patient if he has fallen in the past year.
3) Refer the patient for a comprehensive fall evaluation.
4) Administer the Timed Up and Go Test. - ANS -ANS: 2
2) Ask the patient if he has fallen in the past year.
If a patients gait or balance is unsteady, the nurse should question the patient for a history of falls. If the patient reports a
single fall, the nurse should do the Get Up and Go Test. If the patient has difficulty with that test, or is unsteady with it, the
nurse should perform a follow-up assessment of gait and balance by having the person close the eyes for a few seconds
wile standing in place; stand with eyes closed while the nurse pushes gently on the sternum; walk, stop, turn around,
return to the chair, and sit in the chair without using his arms for support. Physicians and advanced practitioners perform
the Timed Up and Go Test; it is recommended annually for patients 65 years or older.
\A child is brought to the emergency department after swallowing liquid cleanser. He is awake and alert and able to
swallow. Which action should the nurse take first?
1) Administer a dose of syrup of ipecac.
,2) Administer activated charcoal immediately.
3) Give water to the child immediately.
4) Call the nearest poison control center. - ANS -ANS: 3
3) Give water to the child immediately.
If the child is awake and able to swallow, and the child has swallowed a household chemical, give one-half glassful of
water immediately. After giving the water, call the poison control center. The American Academy of Pediatrics does not
advise giving syrup of ipecac. Emergency departments have stopped using ipecac in favor of activated charcoal, which
binds to poison in the stomach and prevents it from entering the bloodstream. Continued vomiting caused by syrup of
ipecac may later result in the child being unable to tolerate activated charcoal or other poison treatments. No one can tell
how much a child vomits, and therefore, no one would know if all the poison was eliminated from the stomach. There is
also potential for misuse by bulimics. The poison control center may recommend activated charcoal, depending upon the
agent ingested.
\A client developed a stage IV pressure ulcer to his sacrum 6 weeks ago, and now the ulcer appears to be a shallow
crater involving only partial skin loss. What would the nurse now classify the pressure ulcer as?
1) Stage I pressure ulcer, healing
2) Stage II pressure ulcer, healing
3) Stage III pressure ulcer, healing
4) Stage IV pressure ulcer, healing - ANS -ANS:
4) Stage IV pressure ulcer, healing
Reverse staging is not done because as the ulcer heals with granulation tissue and becomes shallower, the lost muscle,
subcutaneous fat, and dermis are not replaced. Pressure ulcers maintain their original staging classification throughout
the healing process but are accompanied by the modifier healing.
\A client reports taking acetaminophen (Tylenol) to control osteoarthritis. Which instruction should the nurse give the
patient requiring long-term acetaminophen use?
1) Caution the patient against combining acetaminophen with alcohol.
, 2) Explain that acetaminophen increases the risk for bleeding.
3) Advise taking acetaminophen with meals to prevent gastric irritation.
4) Explain that physical dependence may occur with long-term oral use. - ANS -ANS:
1) Caution the patient against combining acetaminophen with alcohol.
Even in recommended doses, acetaminophen can cause hepatotoxicity in those who consume alcohol. Therefore, the
nurse should caution the patient against combining acetaminophen with alcohol. Aspirin, not acetaminophen, increases
the risk for bleeding because it inhibits platelet aggregation. Nonsteroidal anti-inflammatory drugs (NSAIDs), not
acetaminophen, cause gastric irritation and should be taken with meals. Opioid analgesics, not acetaminophen, can
cause physical dependence.
\A client who has been hospitalized for an infection states, The nursing assistant told me my vital signs are all within
normal limits; that means Im cured. The nurses best response would be which of the following?
1) Your vital signs confirm that your infection is resolved; how do you feel?
2) Ill let your healthcare provider know so you can be discharged.
3) Your vital signs are stable, but there are other things to assess.
4) We still need to keep monitoring your temperature for a while. - ANS -ANS: 3) Your vital signs are stable, but there are
other things to assess.
Vital signs are one indicator of a clients physiological status, but they are not an absolute indicator of well-being from
every aspect. It may be inaccurate to state that the vital signs indicate the infection is resolved; vital signs could stabilize
even if the infection remains active. The healthcare providers decision regarding the clients readiness for discharge is not
based exclusively on the vital signs but rather is based on a compilation of other sources of information, primarily the
clients clinical status, but also cultures, complete blood counts, and various other laboratory and possibly radiologic
evidence. Although the nurse will need to continue monitoring the temperature, other clinical signs must also be
monitored; therefore, the statement We still need to keep monitoring your temperature . . . is incomplete and less useful
than the statement that begins Your vital signs are stable, but . . .
\A clients average normal temperature is 98F. Which of the following temperatures would be expected during the night in
this healthy young adult client who does not have a fever, inflammatory process, or underlying health problems?
