Nur - 120 Exam 1 LATEST SOLUTION 2024/25 GUARANTEED GRADE A+

Order for Donning PPE 1. gown 2. mask 3. goggles 4. gloves Order for Doffing PPE gloves, goggles, gown, mask Incubation Stage of Infection interval between the pathogen entering the body and the presentation of the first symptom(s) Prodromal Stage of Infection person is most infectious, vague and nonspecific signs of disease Illness Stage of Infection Interval of most severe symptoms - if not treated this can result in death Convalescence Stage of Infection characterized by tissue repair and a return to health as the remaining number of microorganisms approaches zero. Can last for days, weeks, or even months. Principles of Body Mechanics 1. Proper Body Alignment 2. Coordination 3. Joint Mobility 4. Balance Airborne Precautions PPE Standard PLUS N95 Mask, Isolated Room, Negative Pressure with Minimum 6 exchanges per hour Droplet Precautions PPE Standard PLUS surgical mask, goggles, and gloves Contact Precautions PPE Standard PLUS gloves and gown A nurse manager is reviewing with nurses on the unit in the care of a client who has had a seizure. Which of the following statements by a nurse requires further instruction? A. "I will place the client on their right side" B. "I will go to the nurses' station for assistance" C. "I will note the time the seizure begins" D. "I will prepare to insert an airway" B. "I will go to the nurses' station for assistance" - You would never do this. You must stay with the and use the call bell to request additional help. A nurse observes smoke coming from under the door of the staff lounge area, which of the following actions is the nurse's priority? A. Extinguish the fire B. Activate the fire alarm C. Move the clients who are nearby D. Close all open doors on the unit C. Move the clients who are nearby The greatest risk to the client is injury from the fire. Therefore priority intervention would be to move those clients. A nurse is caring for a client with a history of falls, which of the following actions is the nurse's priority? A. Complete a fall risk assessment B. Educate the client and family about fall risks C. Eliminate safety hazards from the client's room D. Make sure client uses assistive aids in their possession A. Complete a fall risk assessment Assessment is always the first action to take in the nursing process. This will work as a guide in implementing appropriate safety measures. A nurse is caring for a client who is receiving enteral tube feedings due to dysphagia. Which of the following bed positions should the nurse use for safe care fo this client? A. Supine B. Semi-Fowler's C. Semi-Prone D. Trendelenburg B. Semi Fowler's - This position helps prevent regurgitation and aspiration by clients who have difficulty swallowing. A nurse is caring for a client who is sitting in a chair and asks to return to bed. Which of the following actions is the nurse's priority at this time? A. Obtain a walker for the client to use to get back to bed. B. Call for additional staff to help with the transfer C. Use a transfer belt and assist the client back to bed D. Determine the client's ability to help with the transfer D. Determine the client's ability to help with the transfer This is because assessment is the first step of the nursing process. This will help you in deciding the best measures to proceed in getting them back to be safely. A nurse is caring for a client who has had a cough for three weeks and begins to cough up blood. The client has manifestations of which condition? A. Allergic Reaction B. Ringworm C. Systemic Lupus Erythematous D. Tuberculosis D. Tuberculosis A nurse is caring for a client who reports a severe sore throat, pain when swallowing, and swollen lymph nodes. The client is experiencing which of the following stages of infection? A. Prodromal B. Incubation C. Convalescence D. Illness D. Illness This is because they are experiencing severe symptoms which occurs only in the illness stage. A nurse is caring for a client who decides not to have surgery despite significant blockages of the coronary arteries. The nurse understands that this client's choice is an example of: A. Fidelity B. Autonomy C. Justice D. Nonmaleficence B. Autonomy The right for a patient to make decisions over their own body. A nurse offers pain medicine to a client who is postoperative prior to ambulation. The nurse understands that this is aspect of care delivery is an example of: A. Fidelity B. Autonomy C. Justice D. Beneficence D. Beneficence This is the action that promotes good for others. By giving before ambulation (a potentially panful experience postoperative), the nurse is taking a specific and positive action to help the client. A nurse is instructing a group of new nurses about how to know and what to expect when ethical dilemmas arise. Which of the following situations should the new nurse identify as an ethical dilemma? A.A nurse on a med-surg unit demonstrating signs of chemical impairment B. A nurse overhears another nurse telling a client that if they do not stay in bed they will have to sue restraints on them C. A family has conflicting feelings about the initiation of enteral tube feedings for their father, who is terminally ill. D. A client who is terminally ill hesitates to name their significant other as their power of attorney. C. A family has conflicting feelings about the initiation of enteral tube feedings on their father who is terminally ill. A review of scientific data cannot resolve the issue and it is not easy to resolve. The result will have a profound effect on the situation and on the client. A & B are both legal issues and D is a legal decision that the client has a right to make. A nurse observes assistive personnel reprimanding a client for not using the urinal properly. The AP tells the client that diapers will be used next time the urinal is used improperly. Which of the following torts is the AP committing? A. Assault B. Battery C. False imprisonment D. Invasion of Privacy A. Assault By threatening the client, they are committing assault. A nurse in a surgeon's office is providing preoperative teaching for a client who is scheduled for surgery the following week. The client tells the nurse "I plan to prepare my advance directives before I come to the hospital". Which of the following statements made by the client should indicate to the nurse an understanding of advance directives? A. "I'd rather have my brother make decisions for me, but I know it has to be my wife" B. "I know they wont go ahead with the surgery unless I prepare these forms" C. "I plan to write that I don't want them to keep me on a breathing machine" D. I will get my regular doctor approve my plan before I hand it in at the hospital" C. " I plan to write that I don't want them to keep me on a breathing machine" The client has a right to decide and specify which medical procedures he wants when a life-threatening situation arises. By the second postoperative day, a client has not achieved satisfactory pain relief. Based on this evaluation, which of the following actions should the nurse take, according to the nursing process? A. Reassess the client to determine the reasons for inadequate pain relief B. Wait to see whether the pain lessens during the next 24 hours C. Change the plan of care to provide different pain relief interventions D. Teach the client about the plan of care for managing the pain A. Reassess the client t determine the reasons for inadequate pain relief Collect further data from the client determine why they have not achieved satisfactory pain relief, because various factors might be interfering with their comfort. The nursing process repeats in an ongoing manner across the span of client care. A charge nurse is observing a newly licensed nurse care for a client who reports pain. The nurse checked the client's MAR and noted the last does of pain meds. was 6 hrs. ago. The prescription reads every 4 hrs. PRN for pain. The nurse administered the medication and checked with the client 4o minutes later, when the client reported improvement. The newly licensed nurse left out which step of the nursing process? A. Assessment B. Planning C. Intervention D. Evaluation A. Assessment The newly licensed nurse should have used the assessment step by asking the client to evaluate the pain severity on a scale of 0-10. The nurse should have then asked about the characteristics of the pain and assessed for any changes that might have contributed to the worsening of the pain. A charge nurse is reviewing the steps of the nursing process with a group of nurses. Which of the following data should the charge nurse identify as objective data? Select all that apply. A. Respiratory rate of 22/min with even, unlabored respirations B. The client's partner states "they said they hurt after walking about ten minutes" C. The client's pain rating is a 3 on a scale of 0-10 D. The client's skin is pink, warm, and dry E. The assistive personnel reports that the client walked with a limp A., D., & E. Objective data includes items the nurse measures and observes. Also includes information from the observation of staff and family A charge nurse is talking with a newly licensed nurse and is reviewing nursing interventions that do not require a provider's prescription. Which of the following interventions should the charge nurse include? Select all that apply. A. Writing a prescription for morphine sulphate as needed for pain. B. Inserting a NG tube to relieve gastric distention C. Showing a client how to use progressive muscle relaxation D. Performing a daily bath after the evening meal E. Repositioning a client every two hours to reduce pressure injury risk C., D., & E. These are all appropriate nurse initiated interventions. Options A & B require a prescription from the provider. A nurse is discussing the nursing process with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates understanding of the planning step of the nursing process? A. "I will determine the most important client problems that we should address" B. "i will review the past medical history on the client's record to get more information" C. " I will carry out the new prescriptions from the provider" D. " I will ask the client if their nausea has resolved" A. "I will determine the most important client problems that we should address" Prioritize the client's problems during the planning step of the nursing process. A nurse is caring for a client who is post operative. Which of the following interventions should the nurse take to reduce risk of thrombus development? Select all that Apply A. Instruct client not to perform the Valsalva maneuver B. Apply elastic stockings C. Review laboratory values for total protein levels D. Place pillow's under the client's knees and lower extremities E. Assist the client to reposition often B. & E.