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NURS 600 HURST READINESS
EXAM 2 QUESTIONS AND
ANSWERS GRADED A+, Exams of
Nursing
A 40 year old client reports a diminished ability to visually focus
on close objects and has also noticed a need for a well lit
environment to enhance vision. To what would the nurse
attribute these changes?
a. normal changes associated with aging
b. a cataract is forming
c. symptoms of a brain tumor
d. precipitated by diabetic retinopathy - ANSWER>>a. normal
changes associated with aging
Rationale: aging results in stiffening of the lens, thus lessening the
ability to focus. The retina is less sensitive to light, making
accurate vision in low-light situations more difficult. Pupillary
response diminishes, affecting the ability to adjust to changing
light levels
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The nurse is assessing pain after surgery in a 3 year old client with
a known developmental delay. Which pain scale should the nurse
use to assess this client's pain level?
a. CRIES scale
b. numeric scale
c. FLACC scale
d. FACES scale - ANSWER>>c. FLACC scale
Rationale: The FLACC scale can be used for pediatric clients from
age 2 months to 7 years and is appropriate when clients cannot
communicate their pain
A client recently diagnosed with diabetes is sent home with a
prescription for subcutaneous insulin. What statement made by
the client indicates that teaching has been effective regarding safe
needle disposal?
a. "I should wrap the needle in a paper towel and place in the
trash."
b. "I should use a hospital issued biohazard container for all
needles."
c. "I may use any hard plastic container with a screw-on cap."
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d. "I should take my needles to the nearest hospital for disposal."
- ANSWER>>c. "I may use any hard plastic container with a screw-
on cap."
Rationale: At home, an FDA approved sharps container is not
needed, however, needles, syringes, and sharps may be disposed
of in a hard plastic container. Clients should follow their
community guidelines for sharps container disposal. This protects
the sanitation engineers from injury by the sharps.
The primary healthcare provider suspects the client has
tuberculosis (TB) and prescribes a Mantoux test. What
precautions should the nurse take when administering the
Mantoux test?
a. don sterile gloves
b. place the client on reverse isolation
c. wear a particulate respirator
d. obtain a consent form
e. initiate airborne precautions - ANSWER>>c. wear a particulate
respirator
e. initiate airborne precautions
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Rationale: A disposable particulate respirator that fits snugly
around the face is needed. The client needs to be on acid-fast
bacilli (AFB) isolation precautions, not reverse isolation. Airborne
precautions include a private room with negative pressure and a
minimum of 6 air exchanges per hour. Ultraviolet lamps and high
efficiency particulate air filters are also needed.
A hysterical college student arrives in the emergency department
in bloody soiled clothing. The nursing assessment reveals facial
bruising and multiple contusions consistent with the client's
report of being raped. Which initial nursing intervention takes
priority at this time?
a. notify police of the alleged rape
b. allow the client privacy to wash self
c. remove clothing and bag for evidence
d. encourage client to express fears and anxiety - ANSWER>>d.
encourage client to express fears and anxiety
Rationale: Although there are specific protocols that must be
followed when dealing with rape clients, it is important to
remember that this client had all control taken away during the
attack. The emotional effects of rape are as traumatizing as the
physical injuries. Allowing the client to first express emotions,
NURS 600 HURST READINESS
EXAM 2 QUESTIONS AND
ANSWERS GRADED A+, Exams of
Nursing
A 40 year old client reports a diminished ability to visually focus
on close objects and has also noticed a need for a well lit
environment to enhance vision. To what would the nurse
attribute these changes?
a. normal changes associated with aging
b. a cataract is forming
c. symptoms of a brain tumor
d. precipitated by diabetic retinopathy - ANSWER>>a. normal
changes associated with aging
Rationale: aging results in stiffening of the lens, thus lessening the
ability to focus. The retina is less sensitive to light, making
accurate vision in low-light situations more difficult. Pupillary
response diminishes, affecting the ability to adjust to changing
light levels
,2|Page
The nurse is assessing pain after surgery in a 3 year old client with
a known developmental delay. Which pain scale should the nurse
use to assess this client's pain level?
a. CRIES scale
b. numeric scale
c. FLACC scale
d. FACES scale - ANSWER>>c. FLACC scale
Rationale: The FLACC scale can be used for pediatric clients from
age 2 months to 7 years and is appropriate when clients cannot
communicate their pain
A client recently diagnosed with diabetes is sent home with a
prescription for subcutaneous insulin. What statement made by
the client indicates that teaching has been effective regarding safe
needle disposal?
a. "I should wrap the needle in a paper towel and place in the
trash."
b. "I should use a hospital issued biohazard container for all
needles."
c. "I may use any hard plastic container with a screw-on cap."
,3|Page
d. "I should take my needles to the nearest hospital for disposal."
- ANSWER>>c. "I may use any hard plastic container with a screw-
on cap."
Rationale: At home, an FDA approved sharps container is not
needed, however, needles, syringes, and sharps may be disposed
of in a hard plastic container. Clients should follow their
community guidelines for sharps container disposal. This protects
the sanitation engineers from injury by the sharps.
The primary healthcare provider suspects the client has
tuberculosis (TB) and prescribes a Mantoux test. What
precautions should the nurse take when administering the
Mantoux test?
a. don sterile gloves
b. place the client on reverse isolation
c. wear a particulate respirator
d. obtain a consent form
e. initiate airborne precautions - ANSWER>>c. wear a particulate
respirator
e. initiate airborne precautions
, 4|Page
Rationale: A disposable particulate respirator that fits snugly
around the face is needed. The client needs to be on acid-fast
bacilli (AFB) isolation precautions, not reverse isolation. Airborne
precautions include a private room with negative pressure and a
minimum of 6 air exchanges per hour. Ultraviolet lamps and high
efficiency particulate air filters are also needed.
A hysterical college student arrives in the emergency department
in bloody soiled clothing. The nursing assessment reveals facial
bruising and multiple contusions consistent with the client's
report of being raped. Which initial nursing intervention takes
priority at this time?
a. notify police of the alleged rape
b. allow the client privacy to wash self
c. remove clothing and bag for evidence
d. encourage client to express fears and anxiety - ANSWER>>d.
encourage client to express fears and anxiety
Rationale: Although there are specific protocols that must be
followed when dealing with rape clients, it is important to
remember that this client had all control taken away during the
attack. The emotional effects of rape are as traumatizing as the
physical injuries. Allowing the client to first express emotions,
