Latest Comprehensive Exam 2 Questions And Answers

1. Which type of management style is a case management model for nursing care delivery? a. Patient focused and primary nursing. b. Clinically oriented and business oriented. c. Centralized and decentralized systems models. d. Clinical pathways and patient classifications - ANS A 2. The nurse is assessing a client with multiple trauma from a motorcycle crash who is being ventilated due to multiple organ dysfunction syndrome (MODS). Which system assessment should the nurse monitor as an indicator of MODS progression? a. Cardiac function. b. Renal function. c. Hepatic function. d. Coagulation system. - ANS B 3. A staff member tells the charge nurse that a float nurse assigned to work on the unit has made several medication errors in the past, but is currently working with the education department to improve this skill. What action is best for the charge nurse to take? a. Dismiss the staff nurse's report about the float nurse because it may be just gossip. b. Call the nursing supervisor and request a different employee be sent to the unit. c. Assign the float nurse to function as an unlicensed assistive personnel (UAP) for the day. d. Arrange for someone to be available to assess and assist the float nurse. - ANS D 4. Parents of a toddler tell the nurse that their child eats little at mealtime, sits at the table with the family only briefly, and wants snacks "all the time." What recommendation should the nurse provide? a. Give the toddler nutritious snacks. b. Offer rewards for eating at mealtimes. c. Avoid snacks so the child is hungry at mealtimes. d. Explain to the child in a firm manner what is expected. - ANS A 5. Which action should the nurse implement when implementing a physical assessment of an older client? a. Avoid unnecessary touching while interacting with the client. b. Apply additional pressure to palpate the hepatic edge. c. Arrange the exam sequence to minimizes position changes. d. Speak loudly and slowly when telling the client how to assist. - ANS C 6. When culturing a wound, the nurse should obtain the sample from which part of the wound? a. The outer edges of the wound. b. All necrotic sections of the wound. c. Areas containing purulent or pooled exudates. d. Any particularly painful area of the wound. - ANS C 7. An adult male with a history of heart failure tells the nurse that his lower extremities and feet swell when he sits at his computer all day. Which response is best for the nurse to provide? a. Limit the amount of table salt that you add to your meals. b. Take a daily vitamin with minerals to correct imbalances. c. Get up and walk around frequently during the day. d. Elevate your feet every night to reduce swelling. - ANS C 8. A client is transferred to the postoperative unit after 2 hours in the postanesthesia care unit (PACU). What is the priority nursing action? a. Determine the client's pain. b. Take the client's vital signs. c. Calculate the IV infusion rate. d. Check the postop prescriptions. - ANS B 9. The nurse is teaching a client how to self-administer a subcutaneous injection. To help ensure sterility of the procedure, which subject is most important for the nurse to include in the teaching plan? a. Hand washing prior to preparation of the injection. b. Method used to aspirate medication from a vial. c. Selection and rotation of injection sites. d. Proper disposal of injection equipment. - ANS B 10. The nurse observes an empty secondary infusion of diltiazem (Cardizem) is attached to the client's IV pump, but realizes that this client has no prescription for Cardizem. In what sequence, from first to last, should the following interventions be implemented? (Place the first action on top and last action on the bottom.) a. Review medications client is taking. b. Measure the client's vital signs. c. Complete an incident report. d. Notify the healthcare provider. - ANS B, A, D, C 11. A client with terminal pancreatic cancer is receiving hospice care at home and reports increasing shortness of breath and associated anxiety. Which prescription should the nurse implement first? a. Prednisone (Deltasone) 10 mg PO. b. Albuterol (Proventil) 0.5% solution per nebulizer. c. Morphine sulfate (Roxanol) 5 to 10 mg SL as needed. d. Oxygen 2 to 6 liters per minute using a nasal cannula. - ANS C 12. A healthcare provider (HCP) asks the nurse to give a medication to a client, and the nurse tells the HCP that the client is allergic to the medication. The HCP says, "Give the medication or I will report this to your supervisor." What response should the nurse provide? a. Walk away and ignore the threatening statement. b. Give the prescribed medication and document the situation. c. Tell the HCP that both of you should talk to the supervisor now. d. Respond that this client is not assigned to the nurse. - ANS C