NUR 215 Exam 2 Questions & Correct Detailed Answers
| Comprehensive Nursing Study Guide |100% Verified
|Graded A+ and Updated|Rationalized
It is most important for the nurse to understand the various ways in which pain is
classified so that he or she can
A. Document the client’s pain using accurate terms.
B. Be clear in communication with the physician.
C. Develop an effective pain management plan.
D. Educate the client thoroughly.
ANS C: Develop an effective pain management plan
Rationale:
Different modalities are used in the treatment/ management of pain and are
often based on how the pain is classified (e.g., acute versus chronic).
The nurse is assessing the confused client. In trying to determine the client’s
level of pain, the nurse should
A. Be aware that confused clients do not feel as much pain due to their
confusion.
B. Observe the client carefully for changes in behavior or vital signs.
C. Ask the client’s family how much pain the client normally has.
D. Use only pain scales that feature numbers or “faces” the client can point to.
ANS B. Observe the client carefully for changes in behavior or vital signs.
Rationale:
The nurse should observe the confused client for nonverbal cues to pain.
,Mr. Zenobia’s chronic cancer pain has recently increased, and he asks the
home health nurse what can be done. In relation to his long-acting opioid, which
is an appropriate response by the nurse?
A. “If you take more opioid, it will not change your pain relief.“
B. “I’ll call the primary care provider and ask for an increased dose.”
C. “The amount you are taking now is all I can give you.”
D. “I’m worried if we increase your dose that you will stop breathing.”
ANS B. "I'll call the primary care provider and ask for an increased dose."
Rationale:
There is no ceiling on the analgesic effect of opioid narcotics. Patients develop a
tolerance to the effects, which often necessitates an increase in the dose.
To maintain proper posture, it is important to
A. Sleep on the softest mattress possible.
B. Avoid arching shoulders forward when sitting.
C. Keep your knees locked when standing upright.
D. Keep your stomach muscles relaxed to prevent back spasms.
ANS B. Avoid arching shoulders forward when sitting.
Rationale:
Arching shoulders forward when sitting alters the curvature of the spine and
contributes to poor body alignment.
Of the following interventions for the client who is immobile, the nurse will give
priority to
A. Encouraging a diet high in fiber and extra fluids
B. Administering the medication for sleep as needed
C. Having the client use the incentive spirometer q 2 hrs
D. Massaging the client’s legs every hour
ANS C. Having the client use the incentive spirometer q 2 hrs
Rationale:
, Use of the incentive spirometer helps to prevent atelectasis, which improves
oxygenation—a priority need.
Identify the true statement about devices used when assisting clients to
ambulate.
A. The client should stand a foot back from the back legs of a walker.
B. A cane should be used by the client to support the weakest side of the body.
C. A transfer belt should be placed around the client’s chest for maximum lift.
D. Each crutch-walking gait begins with the client in the tripod position.
ANS D. Each crutch-walking gait begins with the client in the tripod position.
Rationale:
The tripod position is the basic crutch standing position from which the client
then moves forward.
A name-brand ice cream contains the following nutrition information for each
serving: 30 g carbohydrates, 19 g fat, 5 g protein. The total number of calories in
a serving would be
A. 366
B. 311
C. 435
D. 176
ANS B. 311
Rationale:
CHO = 4 cal per gram = 120 cal
Fat = 9 cal per gram = 171 cal
Protein = 4 cal per gram = 20 cal
Total: 311 cal
Identify the client with the greatest risk for developing protein-calorie
malnutrition.
| Comprehensive Nursing Study Guide |100% Verified
|Graded A+ and Updated|Rationalized
It is most important for the nurse to understand the various ways in which pain is
classified so that he or she can
A. Document the client’s pain using accurate terms.
B. Be clear in communication with the physician.
C. Develop an effective pain management plan.
D. Educate the client thoroughly.
ANS C: Develop an effective pain management plan
Rationale:
Different modalities are used in the treatment/ management of pain and are
often based on how the pain is classified (e.g., acute versus chronic).
The nurse is assessing the confused client. In trying to determine the client’s
level of pain, the nurse should
A. Be aware that confused clients do not feel as much pain due to their
confusion.
B. Observe the client carefully for changes in behavior or vital signs.
C. Ask the client’s family how much pain the client normally has.
D. Use only pain scales that feature numbers or “faces” the client can point to.
ANS B. Observe the client carefully for changes in behavior or vital signs.
Rationale:
The nurse should observe the confused client for nonverbal cues to pain.
,Mr. Zenobia’s chronic cancer pain has recently increased, and he asks the
home health nurse what can be done. In relation to his long-acting opioid, which
is an appropriate response by the nurse?
A. “If you take more opioid, it will not change your pain relief.“
B. “I’ll call the primary care provider and ask for an increased dose.”
C. “The amount you are taking now is all I can give you.”
D. “I’m worried if we increase your dose that you will stop breathing.”
ANS B. "I'll call the primary care provider and ask for an increased dose."
Rationale:
There is no ceiling on the analgesic effect of opioid narcotics. Patients develop a
tolerance to the effects, which often necessitates an increase in the dose.
To maintain proper posture, it is important to
A. Sleep on the softest mattress possible.
B. Avoid arching shoulders forward when sitting.
C. Keep your knees locked when standing upright.
D. Keep your stomach muscles relaxed to prevent back spasms.
ANS B. Avoid arching shoulders forward when sitting.
Rationale:
Arching shoulders forward when sitting alters the curvature of the spine and
contributes to poor body alignment.
Of the following interventions for the client who is immobile, the nurse will give
priority to
A. Encouraging a diet high in fiber and extra fluids
B. Administering the medication for sleep as needed
C. Having the client use the incentive spirometer q 2 hrs
D. Massaging the client’s legs every hour
ANS C. Having the client use the incentive spirometer q 2 hrs
Rationale:
, Use of the incentive spirometer helps to prevent atelectasis, which improves
oxygenation—a priority need.
Identify the true statement about devices used when assisting clients to
ambulate.
A. The client should stand a foot back from the back legs of a walker.
B. A cane should be used by the client to support the weakest side of the body.
C. A transfer belt should be placed around the client’s chest for maximum lift.
D. Each crutch-walking gait begins with the client in the tripod position.
ANS D. Each crutch-walking gait begins with the client in the tripod position.
Rationale:
The tripod position is the basic crutch standing position from which the client
then moves forward.
A name-brand ice cream contains the following nutrition information for each
serving: 30 g carbohydrates, 19 g fat, 5 g protein. The total number of calories in
a serving would be
A. 366
B. 311
C. 435
D. 176
ANS B. 311
Rationale:
CHO = 4 cal per gram = 120 cal
Fat = 9 cal per gram = 171 cal
Protein = 4 cal per gram = 20 cal
Total: 311 cal
Identify the client with the greatest risk for developing protein-calorie
malnutrition.
