NURS 325: Exam 1-Fundamentals. Questions and Answers with Complete Solution. Latest 2021

NURS 325: Exam 1-Fundamentals. Questions and Answers with Complete Solution. Latest 2021. Question 1 A nurse needs to begin discharge planning for a patient admitted with pneumonia and a congested cough. When is the best time the nurse should start discharge planning for this patient? Selected Answer: d. Upon admission Answers: a. When the primary care provider writes the order b. After the congestion is treated c. Right before discharge d. Upon admission Response Feedback: Ideally, discharge planning begins at admission. Right before discharge is too late for discharge planning. After the congestion is treated is also too late for discharge planning. Usually the primary care provider writes the order too close to discharge, and nurses do not need an order to begin the teaching that will be needed for discharge. By identifying discharge needs early, nursing and other health care professionals begin planning for discharge to the appropriate level of care, which sometimes includes support services such as home care and equipment needs.  Question 2 The nurse is assessing skin turgor. Which technique will the nurse use? Selected Answer: d. Grasp a fold of skin on the sternal area. Answers: a. Grasp a fold of skin on the back of the hand. b. Press lightly on the fingertips. c. Press lightly on the forearm. d. Grasp a fold of skin on the sternal area. Response Feedback: To assess skin turgor, grasp a fold of skin on the back of the forearm or sternal area with the fingertips and release. Since the skin on the back of the hand is normally loose and thin, turgor is not reliably assessed at that site. Pressing lightly on the forearm can be used to assess for pitting edema or pain or sense of touch. Pressing lightly on the fingertips and observing nail color is assessing capillary refill.  Question 3 During a routine pediatric history and physical, the parents report that their child was a very small, premature infant that had to stay in the neonatal intensive care unit longer than usual. They state that the infant was yellow when born and developed an infection that required “every antibiotic under the sun” to reach a cure. Which exam is a priority for the nurse to conduct on the child? Selected Answer: c. Hearing acuity Answers: a. Cardiac b. Respiratory c. Hearing acuity d. Ophthalmic Response Feedback: Hearing is the priority. Risk factors for hearing problems include low birth weight, nonbacterial intrauterine infection, and excessively high bilirubin levels. Hearing loss due to ototoxicity (injury to auditory nerves) can result from high maintenance doses of antibiotics. Cardiac, respiratory, and eye examinations are important assessments but are not relevant to this child’s condition.  Question 4 The nurse is caring for a group of patients. Which patient will the nurse see first? Selected Answer: a. A patient with Clostridium difficile in droplet precautions Answers: a. A patient with Clostridium difficile in droplet precautions b. A patient with a lung transplant in protective environment precautions c. A patient with tuberculosis in airborne precautions d. A patient with MRSA infection in contact precautions Response Feedback: A patient with Clostridium difficile should be on contact precautions, not droplet; therefore, the nurse will see this patient first to correct the precautions. All the rest are on correct precautions. Patients with tuberculosis belong in airborne precautions; patients with MRSA infection belong in contact precautions; and patients with lung transplants belong in protective environment precautions.  Question 5 Which action by the nurse will be the most important for preventing skin impairment in a mobile patient with local nerve damage? Selected Answer: a. Assess for pain during a bath. Answers: a. Assess for