NURS 5434 PREVENTION CASE FINAL TEST
2026 QUESTIONS WITH CORRECT
ANSWERS GRADED A+
◍ The 2 units of packed RBCs are transfused without complication. The
drainage begins to decrease, and Ms. Jackson's hemoglobin and hematocrit
remain stable.The nurse is assisting Ms. Jackson to the bedside commode on
the second postoperative day. Ms. Jackson states, "I have never had to
depend on anyone before. I like to take care of myself. I feel so helpless."In
response to these remarks, the nurse plans care for Ms. Jackson based on the
identification of which nursing diagnosis?A) Disturbed body image.B)
Situational low self-esteem.C) Anticipatory grieving.D) Impaired physical
mobility..
Answer: B) Situational low self-esteem.The client's remarks regarding
feelings of helplessness relate to her sense of how she perceives herself and
her present ability to care for herself.
◍ ** A case manager is reviewing notations made in clients' records. Which
note indicates an unexpected outcome and the need for immediate
follow-up?A client with a spinal cord injury transfers himself from a bed to
a wheelchair.A client who exhibits signs/symptoms of increased intracranial
pressure after a craniotomy.A client who has sustained a stroke dresses
herself.Normal neurological findings are noted in a client with a cerebral
aneurysm..
Answer: A client exhibits signs of increased intracranial pressure after a
craniotomy.
◍ During the postoperative assessment, the nurse observes Ms. Jackson's
surgical site. The left hip dressing has a moderate amount of sanguineous
drainage. What action should the nurse implement? (select all that apply)A)
, Apply pressure to the site.B) Elevate the leg on a pillow.C) Observe the
linens under the hip.D) Use sterile technique to replace the dressing.E) Mark
the amount of drainage on the dressing..
Answer: C) Observe the linens under the hip.Gravity pulls drainage down,
so the nurse should inspect the area below the surgical site for additional
drainage. The nurse may also mark the amount of drainage on the dressing
for later comparison.E) Mark the amount of drainage on the
dressing.Marking the amount of drainage on the dressing will allow for later
comparison.
◍ **A registered nurse (RN) is planning assignments for five clients on the
nursing unit. The team includes a licensed practical nurse (LPN) and a
nursing assistant. Which clients should the nurse assign to the LPN? Select
all that apply.A client who must be accompanied to physical therapy twice
during the shiftA client with a colostomy who requires reinforcement
regarding the procedure for irrigationA client requiring a bed bath and
frequent ambulation with a caneA client with diabetes mellitus who requires
the administration of regular insulin in accordance with a sliding dosage
scale every 4 hoursA client who is confused and requires assistance with a
shower.
Answer: A client with a colostomy who requires reinforcement regarding
the procedure for irrigationA client with diabetes mellitus who requires the
administration of regular insulin in accordance with a sliding dosage scale
every 4 hours
◍ A nurse manager discusses staff empowerment with the nursing team. The
nurse manager explains that staff empowerment:Fosters the growth of others
so that they are less dependent on the leaderMeans that the staff has the
power to reprimand and punish any individual who is not meeting the
standards of care deliveryIndicates that the nurse leader will make decisions
regarding the nursing unit and expects that the staff will comply with the
changesAllows the staff to make every decision regarding employee
scheduling.
Answer: Fosters the growth of others so that they are less dependent on the
, leader
◍ Once the OR team has assembled in the room, the circulating nurse calls for
a time out.What action should the nurse take during the time out?A) Ensure
that sufficient surgical supplies are available.B) Check that all surgical
personnel are properly attired.C) Review the scheduled procedure, site, and
client.D) Confirm that informed consent has been obtained..
Answer: C) Review the scheduled procedure, site, and client.A time out, the
designated method for final verification before surgery begins, is a
component of the JCAHO universal protocol to prevent wrong site, wrong
procedure, wrong person surgery.
◍ The nurse begins the preoperative assessment by taking Ms. Jackson's vital
signs. 1. Which vital sign requires follow-up by the nurse?A) BP of
160/88.B) Pulse of 68.C) Respirations of 14.D) Temperature of 97.2°
F. .
Answer: A) BP of 160/88.This blood pressure is elevated and requires
further action by the nurse.
◍ When the nurse begins teaching about the benefits of early mobilization
following surgery, Ms. Jackson states, "Oh, I know if I stay in bed very long
I will get bedsores."How should the nurse respond?A) "Getting a bedsore is
very serious. Sometimes people die from infected bedsores."B) "The nurses
will make sure you do not stay in bed long enough to get bedsores."C)
"Bedsores are one of many problems that can occur from prolonged
bedrest."D) "Those are now called pressure ulcers because they are caused
by pressure.".
Answer: C) "Bedsores are one of many problems that can occur from
prolonged bedrest."This response acknowledges the client's previous
learning and promotes further learning related to other complications of
immobility such as thrombus formation, constipation, and atelectasis.
◍ While cleansing the incision, the nurse observes that the staples are intact,
but a 2 cm gap has opened at the bottom of the incision.How should the
nurse document this finding?A) Bottom edges of incision approximated.B)
, Small area of dehiscence at bottom of incision.C) Evisceration of incision
noted at bottom edge.D) Wound healing via secondary intention..
Answer: B) Small area of dehiscence at bottom of incision.An unintentional
opening in a surgical wound prior to healing is referred to as dehiscence.
◍ After completing the admission interview, the nurse reviews Ms. Jackson's
medical record and notes that the surgical consent form is filled out but is
not signed by the client.What action should the nurse take?A) Ask Ms.
Jackson if she has received sufficient information to sign the consent
form.B) Call the operating room and notify the staff that the surgery needs
to be cancelled.C) Notify the surgeon of the need to come to the client's
room so the consent can be signed.D) Inform a family member of the need
to serve as a witness to the client's signature..
Answer: A) Ask Ms. Jackson if she has received sufficient information to
sign the consent form.The nurse may witness the client's signature if the
nurse is able to determine that the client has been sufficiently informed of
the necessary information.
◍ The nurse talks with Ms. Jackson about what to expect the day of surgery
and during the immediate postoperative period. The nurse provides
instructions regarding cough and deep breathing exercises. Ms. Jackson
performs a return demonstration by breathing in through her mouth deeply
and exhaling through pursed lips forcefully and rapidly.4. What action
should the nurse implement?A) Advise the client to avoid pursing her lips
when exhaling.B) Remind the client to cough after taking two to three
breaths.C) Demonstrate the deep breathing and coughing technique again.D)
Document successful completion of the return demonstration..
Answer: C) Demonstrate the deep breathing and coughing technique
again.Ms. Jackson has demonstrated incorrect technique. When performing
deep breathing exercises, the client should inhale through the nose and
exhale slowly through the mouth without pursing the lips. The nurse should
demonstrate the entire procedure again for best learning by the client.
◍ The nurse observes that the word, "Yes" has been marked on Ms. Jackson's
2026 QUESTIONS WITH CORRECT
ANSWERS GRADED A+
◍ The 2 units of packed RBCs are transfused without complication. The
drainage begins to decrease, and Ms. Jackson's hemoglobin and hematocrit
remain stable.The nurse is assisting Ms. Jackson to the bedside commode on
the second postoperative day. Ms. Jackson states, "I have never had to
depend on anyone before. I like to take care of myself. I feel so helpless."In
response to these remarks, the nurse plans care for Ms. Jackson based on the
identification of which nursing diagnosis?A) Disturbed body image.B)
Situational low self-esteem.C) Anticipatory grieving.D) Impaired physical
mobility..
Answer: B) Situational low self-esteem.The client's remarks regarding
feelings of helplessness relate to her sense of how she perceives herself and
her present ability to care for herself.
◍ ** A case manager is reviewing notations made in clients' records. Which
note indicates an unexpected outcome and the need for immediate
follow-up?A client with a spinal cord injury transfers himself from a bed to
a wheelchair.A client who exhibits signs/symptoms of increased intracranial
pressure after a craniotomy.A client who has sustained a stroke dresses
herself.Normal neurological findings are noted in a client with a cerebral
aneurysm..
Answer: A client exhibits signs of increased intracranial pressure after a
craniotomy.
◍ During the postoperative assessment, the nurse observes Ms. Jackson's
surgical site. The left hip dressing has a moderate amount of sanguineous
drainage. What action should the nurse implement? (select all that apply)A)
, Apply pressure to the site.B) Elevate the leg on a pillow.C) Observe the
linens under the hip.D) Use sterile technique to replace the dressing.E) Mark
the amount of drainage on the dressing..
Answer: C) Observe the linens under the hip.Gravity pulls drainage down,
so the nurse should inspect the area below the surgical site for additional
drainage. The nurse may also mark the amount of drainage on the dressing
for later comparison.E) Mark the amount of drainage on the
dressing.Marking the amount of drainage on the dressing will allow for later
comparison.
◍ **A registered nurse (RN) is planning assignments for five clients on the
nursing unit. The team includes a licensed practical nurse (LPN) and a
nursing assistant. Which clients should the nurse assign to the LPN? Select
all that apply.A client who must be accompanied to physical therapy twice
during the shiftA client with a colostomy who requires reinforcement
regarding the procedure for irrigationA client requiring a bed bath and
frequent ambulation with a caneA client with diabetes mellitus who requires
the administration of regular insulin in accordance with a sliding dosage
scale every 4 hoursA client who is confused and requires assistance with a
shower.
Answer: A client with a colostomy who requires reinforcement regarding
the procedure for irrigationA client with diabetes mellitus who requires the
administration of regular insulin in accordance with a sliding dosage scale
every 4 hours
◍ A nurse manager discusses staff empowerment with the nursing team. The
nurse manager explains that staff empowerment:Fosters the growth of others
so that they are less dependent on the leaderMeans that the staff has the
power to reprimand and punish any individual who is not meeting the
standards of care deliveryIndicates that the nurse leader will make decisions
regarding the nursing unit and expects that the staff will comply with the
changesAllows the staff to make every decision regarding employee
scheduling.
Answer: Fosters the growth of others so that they are less dependent on the
, leader
◍ Once the OR team has assembled in the room, the circulating nurse calls for
a time out.What action should the nurse take during the time out?A) Ensure
that sufficient surgical supplies are available.B) Check that all surgical
personnel are properly attired.C) Review the scheduled procedure, site, and
client.D) Confirm that informed consent has been obtained..
Answer: C) Review the scheduled procedure, site, and client.A time out, the
designated method for final verification before surgery begins, is a
component of the JCAHO universal protocol to prevent wrong site, wrong
procedure, wrong person surgery.
◍ The nurse begins the preoperative assessment by taking Ms. Jackson's vital
signs. 1. Which vital sign requires follow-up by the nurse?A) BP of
160/88.B) Pulse of 68.C) Respirations of 14.D) Temperature of 97.2°
F. .
Answer: A) BP of 160/88.This blood pressure is elevated and requires
further action by the nurse.
◍ When the nurse begins teaching about the benefits of early mobilization
following surgery, Ms. Jackson states, "Oh, I know if I stay in bed very long
I will get bedsores."How should the nurse respond?A) "Getting a bedsore is
very serious. Sometimes people die from infected bedsores."B) "The nurses
will make sure you do not stay in bed long enough to get bedsores."C)
"Bedsores are one of many problems that can occur from prolonged
bedrest."D) "Those are now called pressure ulcers because they are caused
by pressure.".
Answer: C) "Bedsores are one of many problems that can occur from
prolonged bedrest."This response acknowledges the client's previous
learning and promotes further learning related to other complications of
immobility such as thrombus formation, constipation, and atelectasis.
◍ While cleansing the incision, the nurse observes that the staples are intact,
but a 2 cm gap has opened at the bottom of the incision.How should the
nurse document this finding?A) Bottom edges of incision approximated.B)
, Small area of dehiscence at bottom of incision.C) Evisceration of incision
noted at bottom edge.D) Wound healing via secondary intention..
Answer: B) Small area of dehiscence at bottom of incision.An unintentional
opening in a surgical wound prior to healing is referred to as dehiscence.
◍ After completing the admission interview, the nurse reviews Ms. Jackson's
medical record and notes that the surgical consent form is filled out but is
not signed by the client.What action should the nurse take?A) Ask Ms.
Jackson if she has received sufficient information to sign the consent
form.B) Call the operating room and notify the staff that the surgery needs
to be cancelled.C) Notify the surgeon of the need to come to the client's
room so the consent can be signed.D) Inform a family member of the need
to serve as a witness to the client's signature..
Answer: A) Ask Ms. Jackson if she has received sufficient information to
sign the consent form.The nurse may witness the client's signature if the
nurse is able to determine that the client has been sufficiently informed of
the necessary information.
◍ The nurse talks with Ms. Jackson about what to expect the day of surgery
and during the immediate postoperative period. The nurse provides
instructions regarding cough and deep breathing exercises. Ms. Jackson
performs a return demonstration by breathing in through her mouth deeply
and exhaling through pursed lips forcefully and rapidly.4. What action
should the nurse implement?A) Advise the client to avoid pursing her lips
when exhaling.B) Remind the client to cough after taking two to three
breaths.C) Demonstrate the deep breathing and coughing technique again.D)
Document successful completion of the return demonstration..
Answer: C) Demonstrate the deep breathing and coughing technique
again.Ms. Jackson has demonstrated incorrect technique. When performing
deep breathing exercises, the client should inhale through the nose and
exhale slowly through the mouth without pursing the lips. The nurse should
demonstrate the entire procedure again for best learning by the client.
◍ The nurse observes that the word, "Yes" has been marked on Ms. Jackson's
