Nurs 226 Final Questions and Answers

Nurs 226 Final Questions and Answers The nurse has determined that the goal for a particular nursing diagnosis on the client's plan of care has not been met. It will be most important for the nurse to a) report this finding to the provider b) note this finding in the client's record c) revise the plan of care d) remove the nursing diagnosis from the plan c You are a nurse working in the college student health center. You receive a call that an athlete has just fallen and has been injured. You know that according to the general adaptation syndrome, the athlete will be exhibiting: a) an increased appetite b) an increased heart rate c) a decrease in perspiration d) a decrease in respiratory rate b The nurse is caring for a patient with bacterial pneumonia. The effectiveness of the patient's oxygen therapy can be best determined by which indicator of oxygenation? a) absence of cyanosis b) patient's resp rate c) arterial blood gas values d) patient's level of consciousness c A nurse is teaching a patient how to administer medications through a jejunostomy tube. Which of the following instructions should the nurse include in the teaching? a) "Flush the tube before and after each medication" b) "Administer your medications with your enteral feeding" c) "Administer tablets through teh tube slowly" d) "Mix all the crushed medication prior to dissolving in water a What should the nurse do to prevent catheter-associated urinary tract infection? Select all that apply. a) change the catheter daily b) provide perineal care at least once a day c) maintain a closed drainage system d) encourage the patient to drink 3000 mL fluids daily e) recommend health care provider prescribe antibiotics b,c,d A nurse prepares an injection of morphine (Duramorph) to administer to a patient who reports pain. Prior to administering the medication, the nurse is called to another room to assist another patient onto a bedpan. She asks the second nurse to give the injection. Which of the following actions should the second nurse take? a) Offer to assist the patient needing the bedpan. b) Administer the injection prepared by the other nurse. c) Prepare another syringe and administer the injection. d) Tell the patient needing the bedpan she will have to wait for her nurse. a A nurse is preparing to administer a medication to a patient. The medication was scheduled for administration at 0900. Which of the following are acceptable administration times for this medication? (Select all that apply) a) 0905 b) 0825 c) 1000 d) 0840 e) 0935 a,d The nurse is called to the patient's room by another nurse. When the second nurse arrives at the room, she discovers that a fire has occurred in the patient's waste basket. The first nurse has removed the patient from the room. What is the second's nurse next action? a) evacuate the unit b) extinguish the fire c) confine the fire d) activate the fire alarm d Which mental status change may occur when a patient with pneumonia is first experiencing hypoxia? a) coma b) apathy c) irritability d) depression c A patient admitted with pneumonia and dementia has attempted several times to pull out the IV and Foley catheter. After trying other options, the nurse obtains a prescription for bilateral soft restraints. Which nursing action is most appropriate? a) Perform circulation checks to bilateral upper extremities each shift b) Attach the ties of the restraints to the bed frame c) Reevaluate the needs for restraints and document weekly d) Ensure the restraint prescription has been signed by the health care provider (HCP) within 72 hours b TPN is prescribed for a patient with Chron's disease. What indicates to the nurse that the TPN has been effective? a) has met nutritional needs b) is not in metabolic acidosis c) is hydrated d) is in negative nitrogen balance a A nurse is working with a newly hired nurse who is administering medications to patients. Which of the following actions by the newly hired nurse indicates an understanding of medication error prevention? a) Taking all medications out of the unit-dose wrappers before entering the patient's room. b)Checking with the provider when a single dose requires administration of multiple tablets. c)Administering a medication, then looking up the usual dosage range. d)Relying on another nurse to clarify a medication prescription. b The nurse is teaching the patient how to care for an ileostomy. The patient asks the nurse how long to wear the pouch before changing it. What should the nurse tell the patient? a)"The pouch is changed only when it leaks" b)"You can wear the pouch for about 4 to 7 days" c)"You should change the pouch every evening before bedtime." d)"It depends on your activity level and your diet." b The nurse is assessing a hospitalized older patient for the presence of pressure ulcers. The nurse notes that the patient has a 1" by 1" (3cm by 3cm) area on the sacrum in which there is skin breakdown as far as the dermis. What should the nurse note on the medical record? a)Stage I pressure ulcer b)Stage 2 pressure ulcer c)Stage 3 pressure ulcer d)Stage 4 pressure ulcer b When coping becomes dysfunctional enough to require the client to be admitted to the hospital, the nurse expects that the client would be exhibiting what behaviors? a)Objective and rational problem solving b)Tension reduction activities and then problem solving c)Anger management strategies with no problem solving d)Minimal functioning with new problems developing d A nurse is providing teaching to an older adult patient to promote adherence with medication administration. Which of the following instructions should the nurse include? (Select all that apply) a)Adjust the dose according to daily weight. b)Place pills in daily pill holders. c)Provide liquid forms if the patient has difficulty swallowing pills. d)Ask a relative/friend to assist periodically e)Request child-guard caps on medication containers. b,c,d Total parenteral nutrition (TPN) is prescribed for the patient who has recently had a small and large bowel resection and who is currently not taking anything by mouth. What should the nurse do to safely administer the TPN? a) Administer TPN through a nasogastric or gastrostomy tube b) Handle TPN using strict aseptic technique c)Auscultate for the presence of bowel sounds prior to administration of TPN d)Designate a peripheral IV site for TPN administration b A provider is discharging a patient with a prescription for home oxygen therapy via nasal cannula. Which of the following should be included in the instructions? a)Apply petroleum jelly around the nares b)Assure the patient and their family that the patient can still smoke c)Check the position of the nasal cannula frequently d)Remove the nasal cannula during meal time c A patient suffers from sleep pattern disturbance. To promote adequate sleep, the most important nursing intervention is: a)Administering a sleep aid b)Synchronizing the medication, treatment, and vital signs schedule c)Encouraging the patient to exercise immediately before sleep d)Discussing with the patient the benefits of beginning a long-term nighttime medication regimen b When teaching the patient with a urinary tract infection about taking a prescribed antibiotic for 7 days, the nurse should tell the patient to report which symptoms to the health care provider (HCP)? Select all that apply. a)Cloudy urine for the first few days b)Blood in the urine c)Rash d)Mild nausea e)Fever above 100 degrees F (37.8 degrees C) f)Urinating every 3 to 4 hours b,c,e A patient is using biofeedback to manage pain. The nurse can explain to the client that biofeedback will enable the patient to exert control over physiologic processes by which mechanism? a)Regulating the body processes through electrical control b)Shocking the patient when an undesirable response is elicited c)Monitoring the body processes for the therapist to interpret d)Translating the signals of body processes into observable forms d A patient using patient-controlled analgesia (PCA) to manage postoperative pain. What should the nurse do when assisting the client with the PCA? a)Reassure the patient the pain will be relieved b)Document the patient's response to pain medication c)Instruct the patient to continue pressing the system's button whenever pain occurs d)Titrate pain medication until the patient is free from pain b A nurse in a provider's office is caring for a patient who states that, for the past week, she has felt tired during the day and cannot sleep at night. Which of the following questions should the nurse ask when collecting data about the patient's difficulty sleeping. (Select all that apply) a)Does your lack of sleep interfere with your ability to function during the day? b)Do you feel confused in the late afternoon? c)Do you drink coffee tea or other caffeinated drinks? If so how many cups per day? d)Has anyone ever told you that you seem to stop breathing for a few seconds while you are asleep? e)Tell me about your personal stress you are experiencing a,c,d,e The nurse is going to lunch and is conducting a "hand-off of care" to the charge nurse. Which information should the nurse communicate to the charge nurse during the "hand-off of care" communication? a)Tell the charge nurse that the nurse is going to lunch b)Verify that the charge nurse has assigned someone to take care of the patient c)Give the charge nurse information about what care should be given while the nurse is at lunch d)Remind the charge nurse about the patient's history and current medicaitons c The nurse should perform passive range-of-motion (ROM) exercises on which patients? Select all that apply a)Has septic joints b)Has temporary loss of consciousness c)Is unconscious d)Has plantar flexion of the foot e)Has supination of the hand b,c Which factor puts an older adult at the greatest risk for impaired wound healing after abdominal surger? a)Age over 75 years b)Poorly controlled diabetes c)History of one myocardial infarction d)Chronic peripheral vascular disease b The nurse is assessing a client with dark skin for the presence of a stage 1 pressure ulcer (injury). Which is the best approach to making this assessment? a)Use a fluorescent light source to assess the skin b)Inspect the skin only when the Braden score is above 12 c)Look for skin color that is darker than the surrounding tissue d)Avoid touching the skin during inspection c A nurse is preparing to feed a patient via NG tube. Which of the following is the nurse's highest priority before initiating the feeding? a)Check the feeding container for expiration b)Confirm the patient does not have diarrhea c)Make sure the client is alert and oriented d)Verify placement of the NG tube d During meal time the nurse notices the patient's hands are holding the throat. Which patient situation requires immediate action by the nurse? a)The patient has a high-pitched inspiratory stridor b)The patient is talking and gagging c)The patient is coughing d)The patient is not making any sounds d A patient comes into the emergency department complaining of chest pain. When discussing possible reasons why the chest pain has occurred, the nurse learns that the patient is depressed because of the loss of a job. This type of crisis can be classified as: a) maturational b) situational c) sociocultural d) posttraumatic b During rounds on the night shift, you note that a patient stops breathing for 1 to 2 minutes several times during the shift. This condition is known as: a) cataplexy b) insomnia c) narcolepsy d) sleep apnea d While assessing a new wound, the nurse notes red, watery drainage. How should the nurse describe this type of drainage when documenting? a) sanguineous b) serosanguineous c) serous d) purosanguineous b Which patient has an naturally acquired active immunity? a)The adult who received immunizations b)The infant whose immunity was transferred from the mother to the infant. c)The child is recovering from a childhood disease that conferred immunity. d)The adult who received gamma globulin after exposure to Hepatitis. c A 4-year-old pediatric patient resists going to sleep. To assist this patient, the best action to take would be: a) adding a daytime nap b) allowing the child to sleep longer in the morning c) maintaining the child's home sleep routine d) offering the child a bedtime snack c Which of the following is an example of an active listening behavior? a) taking frequent notes b) asking for more details c) leaning toward the patient d) sitting comfortably with legs crossed c The nurse is reviewing hand hygiene with UAPs. Which statement by the UAP requires further instructions? a)"I will wash my hands before and after care and I wear gloves with each patient." b)"I wash my hands when they are visible soiled." c)"I will not wear artificial nails when providing care." d)"It is OK to use the alcohol based products outside of the patient's room when entering and leaving the area." b Which of the following describes the difference between dehiscence and evisceration? a)With dehiscence, there is a separation of one or more layers of wound tissue; evisceration involves the protrusion of internal viscera from the incision site. b)Dehiscence is an urgent complication that requires surgery as soon as possible; evisceration is not as urgent c)Dehiscence involves the protrusion of internal viscera from the incision site; with evisceration, there is a separation of one or more layers of wound tissue. d)Dehiscence involves rupture of subcutaneous tissue; evisceration involves damage to dermal tissue. a The client was found lying on the floor next to the bed. Once urgent care is provided, the nurse completes an incident report. Which statements (in chart) would be inappropriate to include in the report. Select all that apply. 1. The client fell out of bed 2. No bruises or injuries are noted on the client 3. The client apparently climbed over the side rails when the nurse was out of the room 4. The physician was notified that the client was found lying on the floor next to the bed 5. The client is alert and oriented and stated that he needed to go to the bathroom and didn't want to bother the nurse 6. Vital signs are temperature 98.6, pulse 78 regular, respiration 16, BP 118/78 a)1 b)2 c)3 d)4 e)5 f)6 a,c Which are complications of bed rest? Select all that apply. a) extremity contractures b) decreased dependency c) diarrhea d) pneumonia e) pressure ulcers f) thrombi g) urinary calculi a,d,e,f,g The nurse is planning the care of a frail, immobile, elderly patient. Which of the following is the best treatment or prevention to protect the patient's skin? a)Administer fluid boluses as directed by the healthcare provider b)Assisting the patient to sit in a chair three times a day c)Offering the patient six small meals a day d)Turning the patient at least every 2 hours d What is the correct method for turning an adult patient brought to the ER with a suspected spinal cord injury? a)Ask the patient to assist with the turn by holding the siderails of the bed b)Place a draw sheet under the patient to assist with turning c)Request help from another nurse to perform logrolling technique d)Use a mechanical lift for safe turning and protecting the nurse's back c A nurse is assess the pain level of a client who has come to the emergency department reporting severe abdominal pain. The nurse asks the client whether he has nausea and has been vomiting. The nurse is assessing which of the following? a) presence of associated symptoms b) location of the pain c) pain quality d) aggravating and relieving factors a Which of the following is an example of a problem that nurses can treat independently? a) hemorrhage b) nausea c) fracture d) infection b The nurse must transfer a dependent patient from a bed to a gurney. Which action by the nurse will be safest for the patient and nurse? a) adjust bed height b) avoid movements that twist spine c) keet pt close to nurse's body when lifting d) obtain an appropriate mechanical life device d What is wrong with the following diagnostic statement? "Impaired Physical Mobility related to laziness and not having appropriate shoes." The statement is: a) judgemental b) too complex c) legally questionable d) without supportive data a A client is admitted to the hospital with an acute respiratory problem resulting from lung disease. The nurse makes a diagnosis of Ineffective Breathing Pattern related to inability to maintain adequate rate and depth of respirations. Which nursing intervention should be listed first on the care plan? a) determine airway adequacy hourly as needed b) administer oxygen as needed c) monitor arterial blood gas values d) place the client in high fowler's position a A nurse is caring for a client with dysphagia and has a new dietary prescription. Which of the following should the nurse include in the plan of care? (Select all that apply) a)Have suction equipment available for use b)Use thickened liquids c)Place food on the client's unaffected side of her mouth d)Assign an assistive personnel to feed the client slowly e)Teach the client to swallow with her neck flexed a,b,c,e A nurse is completing an assessment of a client who is a first generation immigrant to the U.S. Which of the following questions should the nurse consider asking to understand the client's culture-based nutrition habits? a)"What type of afternoon snacks do you consume?" b)"What type of meal do you prepare for a holiday?" c)"What time of day do you eat breakfast?" d)"What cooking utensils are used in food preparation?" b A nurse is assessing a client who is in respiratory distress. The nurse should recognize that which of the following can cause a low pulse oximetry reading? (select all that apply) a) nail polish b) inadequate peripheral circulation c) hypothermia d) increased hgb level e) edema a,b,e Which statement related to prioritizing patient problems is most accurate? a)Nurses must resolve one problem before addressing another problem. b)Nurses prioritize problems in order of urgency. c)Actual problem always take priority over risk problems. d)Nurses give the highest priority to problems that the patient thinks are most important. B Post-op, the patient is receiving morphine via the patient controlled analgesia pump (PCA). The nurse finds the patient drowsy, with Temp 97.2 F, pulse 52, RR 11, BP 101/58 and pulse ox 93% on 2L of oxygen. Which action should the nurse take first? a) attempt to arouse pt b) contact hcp c) check PCA pump setting an history d) document findings a A patient has a colostomy in the descending (sigmoid) colon and wants to control bowel evacuation and possibly stop wearing an ostomy pouch. To help achieve this goal, the nurse should teach the patient to: a)Avoid returning to the use of an ostomy appliance if he becomes ill. b)Call the primary care provider if the stoma becomes pale, dusky, or black. c)Irrigate the stoma to produce a bowel movement on a schedule. d)Limit the intake of gas-forming foods such as cabbage, onions, and fish c Which of the following is the best example of an outcome statement? The patient will: a)Use the incentive spirometer when awake b)Walk two times during day and evening shift c)Maintain oxygen saturation above 92% while performing ADLs each morning d)Tolerate 10 sets of range-of-motion exercises with physical therapy c A nurse is instructing a client on the use of an incentive spirometer. Which of the following statements made by the client indicates an understanding of the teaching? a)"I will place the adapter on my finger to read my blood oxygen saturation level." b)"I will lie on my back with my knees bent." c)" I will rest my hand over my abdomen to create resistance." d)" I will take in a deep breath and hold it before exhaling." d A nurse is caring for an 80-year-old patient of Chinese heritage. When planning outcomes for this patient, which actions by the nurse would meet the American Nurses Association standards for outcomes identification? Select all that apply. a)Developing culturally appropriate outcomes b)Using the standardized outcomes on the clinical pathway c)Choosing the best outcome for the patient regardless of the cost d)Involving the patient and family in formulating the outcomes a,d A nurse is assessing a client who is postoperative following a colon resection. Which of the following findings indicates that the client is ready to transition from NPO to oral intake? a) client report of hunger b) urinary output exceeding 30mL/hr c) decrease in incisional pain d) passage of flatus d A nurse is caring for several clients in an extended care facility. Which of the following clients is the highest priority to observe during meals? a)A client who has decreased vision b)A client who has Parkinson's disease c)A client who has poor dentition d)A client who has anorexia b A nurse is caring for an older adult client in an extended care facility. Which of the following indicates the client has a stool impaction causing a large intestine obstruction? a)The client reports he had a bowel movement yesterday b)The client is having small, frequent liquid stools c)The client is flatulent d)The client indicates he vomited once this morning b A physician orders an indwelling urinary catheter for a client who is mildly confused and has been combative. How should the nurse proceed? a)Ask a colleague for help because the nurse cannot safely perform the procedure alone. b)Gather the equipment and prepare it before informing the client about the procedure. c)Obtain an order to restrain the client before inserting the urinary catheter. d)Inform the primary provider that the nurse cannot perform the procedure because the client is confused a Which of the following is the best example of the implementation phase of the nursing process? a)Patient verbalizes pain is reduced from an 8 to a 3 after receiving pain medication. b)Nurse observes that patient has a small, quarter-sized skin tear over coccyx area. c)Nurse writes in the care plan: Patient requires 2 person assist with ambulation to bathroom. d)Nurse inserts Foley catheter after reporting to physician patient's inability to void. d Which action by the nurse most likely represents a situation of assault? a) In the emergency room, the patient is intoxicated and verbally abusive. The nurse informs the patient restraints will be used if the behavior doesn't cease. b)The patient is in labor and has not received any medications for pain. The patient continues to refuse any pain medications. The nurse administers the pain medication ordered. c)The patient is planning to leave the unit against medical advice. The nurse states it is not in the patient's best interest given the medical condition and will call security if needed d)The patient's church pastor calls the unit regarding the patient's condition. The nurse provides the clergyman with an update on the patient's condition. a Which of the following nursing activities is most reflective of the evaluation phase of the nursing process? a)Administering pain medication prior to changing a complex wound dressing b)Obtaining patient's blood pressure 30 minutes after administering blood pressure medication c)Reporting that there have been three patient falls in the past month on the nursing unit d)Teaching the patient how to perform daily Accu-Cheks for blood sugar readings b A nurse is caring for a patient with a Foley catheter. What should the nurse do to reduce the risk of infection? a) clean perineum with peroxide after each void b) decrease oral fluids c) empty the foley bag every 4-8 hours d) open bag and foley system to check for kinks c When preparing a sterile field, which condition indicates to the nurse the field is at risk for contamination? a)The dressing is laying 3 inches away from the border of the sterile field b)An opened sterile package is placed into the middle of the sterile field c)A sterile item is held above waist level and in eye sight d)Clean gloves are used to pore sterile saline into the sterile cup b A nurse is caring for a patient who is having difficulty breathing. The client is lying in bed and already receiving oxygen via nasal cannula. Which of the following interventions is the nurse's priority? a) increase oxygen b) assist client to fowlers position c) promote removal of pulmonary secretions d)obtain a specimen for ABG b A nurse is discussing foods that are high in Vitamin D with a client who is unable to be out in the sunlight. Which of the following should be included in the teaching? a) tacos and rice b) hamburgers and fried potatoes c) ham and brussels sprouts d) eggs and fortified milk d A nurse is performing a nutritional assessment on a client. Which of the following clinical findings are suggestive of malnutrition? (Select all that apply) a) poor wound healing b) dry hair c) blood pressure in 130/80 d) weak hand grips e( impaired coordination a,b,d,e A nurse is caring for a client who has Alzheimer's Disease and falls frequently. Which of the following actions should the nurse take first to keep the client safe? a)Keep the call light near the client. b)Place client in a room close to the nurses' station c)Encourage client to ask for assistance d)Remind client to walk with someone for support b A school nurse is teaching a group of students how to read food labels. Which of the following should be included in the teaching? (select all that apply) a) total carbohydrates b) total fat c) calories d) magnesium e) dietary fiber a,b,c,e A nurse is obtaining a history from a client who has pain. The nurse's guiding principles throughout this process should be that a)Some clients exaggerate their pain level b)Pain must have an identifiable source to justify the use of opioids c)Objective data are essential in assessing painPain is whatever the client says it is d) d