Nr302 Exam Final Review Questions And Answers Exam New Version Latest Update With Accurate Answers Guaranteed Pass Best Studying Material

During an admission assessment on a 79-year-old client, the nurse learns the client has been taking four different medications, all for the same health condition. What should the nurse do with this information? A.Document it in the medical record. B.Contact the primary care physician. C.Send an order for the medications to the pharmacy. D.Nothing. This is typical for clients in this age range. - correct answer-B.Contact the primary care physician. Older adults often consume several prescription medications. Overmedication may occur because older adults seek care from multiple health care providers without collaboration regarding treatment. Multiple medications for the same condition may combine to produce dangerous side effects. The nurse would document the medications in the medical record; however, the priority intervention is to call the physician and verify that they are aware of the situation. Sending an order to the pharmacy and doing nothing are not appropriate. The nurse needs more information about the prescribed medications. Prior to measuring a client's height and weight, the client states, "I am 5 feet 10 inches tall and weigh 160 pounds." Upon assessment, the nurse finds the client is shorter and weighs 15 pounds more. What can the nurse surmise from this finding? A.The client might have a self-image disturbance. B.The client is lying. C.The client is embarrassed about his/her weight. D.The client hasn't been weighed or measured in a long time. - correct answer-A.The client might have a self-image disturbance. Discrepancies between the stated height and weight and the actual measurements may provide clues to the client's self-image. Not enough information is provided to determine if the client is lying, is embarrassed about their height and weight, or has not had a height and weight assessment recently. Discrepancies in weight may also indicate the client's lack of awareness of sudden weight change that may be due to illness. A client tells the nurse, "It's okay that I'm 20 pounds overweight. Everyone in my family is much fatter." Which of the following would be the best response for the nurse to make at this time? A."Being overweight contributes to the development of diabetes." B."Do your family members have health problems related to being overweight?" C."Being the lightest in your family must make you feel good." D."How do you feel about being 20 pounds overweight?" - correct answer-D."How do you feel about being 20 pounds overweight?" The client is overweight and is attempting to rationalize it by comparing herself with other family members. The fact is, the client is overweight, and the nurse needs more information on the client's feelings about this fact before educating the client on the risks of being overweight and obtaining family history. A client is brought into the emergency department after being rescued from a major motor vehicle accident. The nurse notes that the client's body temperature is 99.6°F. The nurse realizes that this finding might suggest: A.The temperature elevation is due to a diurnal variation. B.The client is ovulating. C.The client is stressed. D.The client has an underlying illness not yet diagnosed. - correct answer-C.The client is stressed. The most reasonable cause for the temperature elevation is stress. The temperature of a highly stressed client may be elevated as a result of increased production of epinephrine and norepinephrine, which increase metabolic activity and heat production. Core body temperature that is highest in the late evening and lowest in the early morning is an example of diurnal temperature variations. Ovulation can raise body temperature by as much as 0.5°F. This question doesn't identify the gender of the client. There is nothing to suggest that this client had an underlying infection or illness prior to the injury. The nurse is preparing to measure the temperature of a client with an endotracheal tube. Which method of temperature measurement should the nurse use for this client? A.Tympanic B.Rectal C.Axillary D.Oral - correct answer-A.Tympanic The tympanic temperature measures a client's core body temperature quickly and accurately. This method is the most comfortable and least invasive for the client. Rectal temperatures are used in clients who are comatose, confused, or unable to close their mouth. However, in these situations a tympanic temperature could be used and is less invasive. An oral temperature should not be used on this client because of the endotracheal tube and the inability to close the mouth. The axillary temperature is the least accurate of the temperature methods and isn't indicated since a tympanic device is available. A client has just walked the length of the hallway as part of her prescribed physical therapy program. When the nurse immediately assesses this client's apical pulse, the finding will most likely be: A.A reduced heart rate B.An elevated heart rate C.A heart rate that is the same as her resting heart rate D.An irregular heart rate - correct answer-B.An elevated heart rate The pulse rate will normally increase with exercise. This client just walked down the hall as part of the prescribed physical therapy program. A reduced heart rate might be assessed if the client was at rest. The heart rate should be higher than the resting heart rate due to exercise. Exercise should not produce irregularities in the rhythm of the pulse. The nurse is assessing the respiratory rate of a 35-year-old male client. Which of the following would indicate a normal finding for this client? A.Respiratory rate of 30 to 80 per minute B.Respiratory rate of 20 to 40 per minute C.Respiratory rate of 15 to 20 per minute D.Respiratory rate of 8 to 10 per minute - correct answer-C.Respiratory rate of 15 to 20 per minute The normal respiratory rate of adults is between 15 and 20 per minute. Respiratory rates of 3080 per minute are the normal range for newborns. Respiratory rates of 20-40 per minute are considered normal for ages up to 1 year. A respiratory rate of 8-10 per minute is abnormally slow respirations for any age group. The nurse finds the blood pressure reading for a 75-year-old female to be 88/60. Which of the following should the nurse do first after measuring this blood pressure? A.Ensure that the correct cuff size was used to measure this blood pressure. B.Place the client in a standing position. C.Call the physician. D.Nothing. Extremely low blood pressures are normal in the elderly. - correct answer-A.Ensure that the correct cuff size was used to measure this blood pressure. The bladder of the blood pressure cuff must fit the length and width of the client's limb. A cuff that is too narrow will produce a false high reading. Conversely, if the cuff is too wide, the reading will be falsely low. If the blood pressure is low, lowering the head of the bed, or placing the client in a supine position is recommended. Standing may further lower the blood pressure. The nurse needs to verify that this blood pressure measurement was correct and gather more assessment data before calling the physician. Low blood pressures are not normal in the elderly. With age, blood pressure tends to rise. The nurse is measuring an adult client's blood pressure and hears Korotkoff sounds. Which sound should the nurse recognize as being the diastolic measurement for this client? A.Phase 1 B.Phase 3 C.Phase 4 D.Phase 5 - correct answer-D.Phase 5 In adults, the diastolic pressure (Phase 5) is the point at which the sounds become inaudible. Phase 1 sounds are the first sounds heard and signify systolic blood pressure. Phase 3 is the period in which the sounds are louder. Phase 2 is the period during which the sounds are softer and longer. Phase 4 is the period during which the sounds become muffled. During a health interview of a client with residual radiculopathic pain after spinal surgery, the nurse learns that the client holds a full-time job, is married, and does at least half of the routine household activities. From this information, the nurse can accurately document: A.The client takes pain medication routinely. B.The pain doesn't interfere with normal activities of daily living. C.The client uses work to cope with the pain. D.The client is stoic. - correct answer-B.The pain doesn't interfere with normal activities of daily living. Assessment of the impact of pain on ADLs enables the nurse to understand the severity of the pain and the impact of the pain on the client's quality of life. There is not enough information to determine whether the client takes pain medication on a "routine" basis. Based on what the client has described as routine ADLs, the nurse can accurately document that the pain doesn't interfere with this client's normal activities. There is no information that implies that the client uses work to cope with the pain or is stoic. An elderly client comes into the pain clinic for follow-up care. The nurse notices that the client grimaces with position changes and continues to have difficulty walking. From this observation, which of the following would be appropriate for the nurse to say to this client? A."Tell me what your pain level is right now." B."I see that you are moving better." C."Did you stop taking your pain medication again?" D."The doctor isn't going to be happy to see how much pain you are in." - correct answer-A."Tell me what your pain level is right now." A variety of behaviors indicate the presence of pain. Many of these behaviors are nonverbal such as grimacing. The nurse would be wise to ask the client about the level of pain instead of making comments that are clearly contrary to observation such as stating that the client is moving better or assuming that the client stopped taking the pain medication. Using the physician as a threat is not using therapeutic communication techniques. A client experiencing pain from an amputated limb tells the nurse that the pain is constant and the pain medication is not effective. Which of the following would be appropriate for the nurse to say or do in this situation? A.Remind the client that the limb is gone and can't be causing pain. B.Call the physician to report the ongoing pain. C.Do nothing. In time the pain will diminish on its own. D.Help the client to a sitting position and offer magazines. - correct answer-B.Call the physician to report the ongoing pain. Pain is whatever the person says it is, existing whenever he or she says it does. It is highly subjective and cannot be shared with others. The best course of action would be for the nurse to contact the physician to report the client's ongoing pain. The other options would not be supportive of the client and the pain experience.