NR 2241 Exam 1 Review Questions With Verified Answers

A wound is full thickness with visible bone and serous drainage. What stage is this wound? - Answer Stage IV A wound has eschar, is dry, hardened, and closed. What stage is this wound? - Answer Unstageable A wound is closed with non-blanchable redness plus and intact blister. What stage is this wound? - Answer Stage I A wound is shallow with serous drainage and no visible fat. What stage is this wound? - Answer Stage II A wound has visible fat with partial thickness tissue loss. What stage is this wound? - Answer Stage III A client's telemetry monitor displays ventricular tachycardia. Upon reaching the client's bedside, which action should the nurse take first? - Answer Check the client's pulse The nurse teaches a client with hypertension to recognize the signs/symptoms that may occur during periods of elevated blood pressure. The nurse determines that the client needs additional teaching if the client states that which sign/symptom is associated with this condition? - Answer Nausea A client has implemented dietary and other lifestyle changes to manage hypertension. The nurse determines that the client has been most successful when the client has which follow-up blood pressure reading? - Answer 125/85 The nurse notes that an older client's current apical pulse is 82 beats per minute, strong but irregular. The nurse notes that prior baseline data indicated that the client's apical pulse ranged from 60 to 90 beats per minute and was strong and regular. On further assessment, the client reports "feeling tired lately." Based on this data, what intervention should the nurse implement? - Answer Call the client's healthcare provider A clinic nurse is performing an assessment on a client diagnosed with primary hypertension. Which should the nurse do to best assess the client's blood pressure accurately? - Answer Seat the client with the arm bared, supported and at heart level