NUR 265 Exam 4 – Galen College Actual
Questions and Answers (PDF)
A nurse in the emergency department (ED) has attended an in-service on
maintaining client safety in the ED. Which of the following statements by the nurse
indicates a correct understanding of the in-service?
- It is necessary to anticipate hostile or violent behavior by clients, family members,
or visitors
- I should ask a client's family member to leave if the client appears confused."
- When searching through the belongings of a client who is confused, someone from
the security department should perform the search."
- Protection from skin injuries or breakdowns is not necessary in the ED since clients
are only here for a short period of time. - ------------ANS: It is necessary to anticipate
hostile or violent behavior by clients, family members, or visitors
Laboratory Test
Hematocrit Hct) 30%
Hemoglobin (Hgb) 9 g/dL
White blood cell (WBC) 4,000 mm
Platelets30,000 mm
Which of the following client assessment findings is a priority for follow- up?
- Petechiae on the anterior abdomen.
- Ulcers on the mucous membrane.
- Reports of activity intolerance and fatigue.
- Reports of increased nausea and vomiting. - ------------ANS: Petechiae on the
anterior abdomen.
The charge nurse is observing a newly hired nurse care for a client who has
laryngeal cancer and had a total laryngectomy 12 hours ago. Which of the following
interventions by the newly hired nurse requires follow-up by the charge nurse?
- Providing preprinted flashcards for communication
- Keeping the head of bed (HOB) elevated to enhance comfort.
- Applying humidified oxygen to the client's tracheostomy.
- Monitoring tissue flap integrity via Doppler every 2 hours. - ------------ANS:
Monitoring tissue flap integrity via Doppler every 2 hours.
The charge nurse is observing a newly hired nurse tag clients during a mass
casualty event using the disaster triage tag system. It requires the charge nurse to
intervene if the newly hired nurse is observed tagging
- a client who has a forehead laceration as nonurgent ( Green)
- a client who has a GCS of 3 as expectant (black)
- A client who has extensive full-thickness burns to the entire body as urgent (yellow)
, - a client who has an open fracture of the femur as urgent ( yellow) - ------------ANS:
A client who has extensive full-thickness burns to the entire body as urgent (yellow)
The charge nurse is observing nursing personnel provide client care during an
external disaster in the community. Which of the following actions by a nurse
requires the charge nurse to intervene?
- Leaving a penetrating object in a client in place
- Placing an IV line in the hand of a client who suspected of closed radial fracture
- Inserting an oropharyngeal airway in an unconscious client
- Performing a jaw-thrust maneuver on a client who has a suspected cervical spine
injury. - ------------ANS: Placing an IV line in the hand of a client who suspected of
closed radial fracture
The emergency department (ED) team has been performing lifesaving measures on
a client who was a victim of spousal abuse. Life-saving measures were
unsuccessful. Which of the following actions should the nurse take initially?
- Prepare the body for release to the morgue. Report the case to the local police
department.
- Placing an IV line in the hand of a client who is suspected of closed radial fracture.
- Notify the hospital's crisis team about the situation.
- Leave all IV lines and tubes in place. - ------------ANS: Leave all IV lines and tubes
in place.
The newly hired nurse has attended a continuing education conference regarding
anaphylaxis with allergen exposure. Which of the following statements by the newly
hired nurse indicates a need for further education?
-"The client may present with widespread hives and hypoxia."
-"The client may present with swollen lips and tongue".
-"The client may report new-onset abdominal cramping with hyperreflexia."
-"The client may have audible wheezes and cyanosis." - ------------ANS: "The client
may report new-onset abdominal cramping with hyperreflexia."
The newly hired nurse is developing a plan of care for a client who has acquired
AIDS and was just diagnosed with PJP. Which of the following interventions should
the nurse preceptor question?
- Offering the client foods high in calories and protein
- Instructing the client to drink at least 2-3L of fluid throughout the day
- Wearing a surgical mask when standing within 3 ft of the client
- Auscultating the client's breath sounds for crackles at least once per shift -
------------ANS: Wearing a surgical mask when standing within 3 ft of the client.
The nurse attended a conference about kidney transplantations. Which of the
following clients who had end-stage renal disease (ESRD) does the nurse recognize
as being a transplant candidate?
Questions and Answers (PDF)
A nurse in the emergency department (ED) has attended an in-service on
maintaining client safety in the ED. Which of the following statements by the nurse
indicates a correct understanding of the in-service?
- It is necessary to anticipate hostile or violent behavior by clients, family members,
or visitors
- I should ask a client's family member to leave if the client appears confused."
- When searching through the belongings of a client who is confused, someone from
the security department should perform the search."
- Protection from skin injuries or breakdowns is not necessary in the ED since clients
are only here for a short period of time. - ------------ANS: It is necessary to anticipate
hostile or violent behavior by clients, family members, or visitors
Laboratory Test
Hematocrit Hct) 30%
Hemoglobin (Hgb) 9 g/dL
White blood cell (WBC) 4,000 mm
Platelets30,000 mm
Which of the following client assessment findings is a priority for follow- up?
- Petechiae on the anterior abdomen.
- Ulcers on the mucous membrane.
- Reports of activity intolerance and fatigue.
- Reports of increased nausea and vomiting. - ------------ANS: Petechiae on the
anterior abdomen.
The charge nurse is observing a newly hired nurse care for a client who has
laryngeal cancer and had a total laryngectomy 12 hours ago. Which of the following
interventions by the newly hired nurse requires follow-up by the charge nurse?
- Providing preprinted flashcards for communication
- Keeping the head of bed (HOB) elevated to enhance comfort.
- Applying humidified oxygen to the client's tracheostomy.
- Monitoring tissue flap integrity via Doppler every 2 hours. - ------------ANS:
Monitoring tissue flap integrity via Doppler every 2 hours.
The charge nurse is observing a newly hired nurse tag clients during a mass
casualty event using the disaster triage tag system. It requires the charge nurse to
intervene if the newly hired nurse is observed tagging
- a client who has a forehead laceration as nonurgent ( Green)
- a client who has a GCS of 3 as expectant (black)
- A client who has extensive full-thickness burns to the entire body as urgent (yellow)
, - a client who has an open fracture of the femur as urgent ( yellow) - ------------ANS:
A client who has extensive full-thickness burns to the entire body as urgent (yellow)
The charge nurse is observing nursing personnel provide client care during an
external disaster in the community. Which of the following actions by a nurse
requires the charge nurse to intervene?
- Leaving a penetrating object in a client in place
- Placing an IV line in the hand of a client who suspected of closed radial fracture
- Inserting an oropharyngeal airway in an unconscious client
- Performing a jaw-thrust maneuver on a client who has a suspected cervical spine
injury. - ------------ANS: Placing an IV line in the hand of a client who suspected of
closed radial fracture
The emergency department (ED) team has been performing lifesaving measures on
a client who was a victim of spousal abuse. Life-saving measures were
unsuccessful. Which of the following actions should the nurse take initially?
- Prepare the body for release to the morgue. Report the case to the local police
department.
- Placing an IV line in the hand of a client who is suspected of closed radial fracture.
- Notify the hospital's crisis team about the situation.
- Leave all IV lines and tubes in place. - ------------ANS: Leave all IV lines and tubes
in place.
The newly hired nurse has attended a continuing education conference regarding
anaphylaxis with allergen exposure. Which of the following statements by the newly
hired nurse indicates a need for further education?
-"The client may present with widespread hives and hypoxia."
-"The client may present with swollen lips and tongue".
-"The client may report new-onset abdominal cramping with hyperreflexia."
-"The client may have audible wheezes and cyanosis." - ------------ANS: "The client
may report new-onset abdominal cramping with hyperreflexia."
The newly hired nurse is developing a plan of care for a client who has acquired
AIDS and was just diagnosed with PJP. Which of the following interventions should
the nurse preceptor question?
- Offering the client foods high in calories and protein
- Instructing the client to drink at least 2-3L of fluid throughout the day
- Wearing a surgical mask when standing within 3 ft of the client
- Auscultating the client's breath sounds for crackles at least once per shift -
------------ANS: Wearing a surgical mask when standing within 3 ft of the client.
The nurse attended a conference about kidney transplantations. Which of the
following clients who had end-stage renal disease (ESRD) does the nurse recognize
as being a transplant candidate?
