NURS 221 Final Exam: Questions With In-Depth
Solutions
Which of the following nursing interventions is considered the most
effective form of universal precautions in regards to sharps?
a. Discard all uncapped needles and syringes in a puncture-resistant
protective container
b. Report a needle stick to an instructor if there is an onset of
abnormal symptoms
c. Follow the hospital's enteric precautions
d. Recap the dirty needle after giving the injection and then place it
in the sharps container Right Answer - A
Which religion attempts to remove illness by means of stories,
rituals, prayers, symbols and sand painting?
A. Hinduism
B. Judaism
C. Navajos
D. Islam Right Answer - C
When restraining a patient you must remember that
A) You must have a good reason
B) You need a physicians order
C) You can restrain an arm on a combative patient needing an IV
D) Once a patient is restrained, they stay restrained until discharge
Right Answer - B
Which of the following changes occur during the alarm stage of GAS?
a. decrease in blood volume
b. increase in blood glucose
c. increase in digestion
d. decrease in oxygen intake Right Answer - B
,A nurse goes in to assess a patient's wound. She finds that the
wound has been intentionally left open as ordered by the physician.
This patient's wound is ________.
A. Secondary intention
B. Quaternary intention
C. Primary intention
D. Tertiary intention Right Answer - D
During the assessment of the preoperative surgical phase, the nurse
would assess for all of the following except:
a. support sources
b. preoperative pain assessment
c. review of emotional health
d. skin integrity and condition of wound Right Answer - D
Which of the following actions requested of the NAP is
inappropriate by the nurse?
A. Take the pt's vital signs and tell me if his pneumonia is worsening
B. Help me assist this patient in moving from the bed to the chair
C. Document the pt's input and ouput
D. Answer the pt's call light while I'm busy Right Answer - A
Your patient has just received a terminal cancer diagnosis and is
expected to live for less than six months. He is visibly upset, so you
provide a nursing presence for comfort. He states, "I will go to
church every time the doors open, tithe my whole paycheck,
anything, if God will just take this cancer away." According to Kubler
Ross' stages of dying theory, what stage is this patient in?
A. depression
B. denial
C. bargaining
D. anger Right Answer - C
,The nurse can delegate with the unlicensed assistive personnel
(UAP) about:
a. performing glucose monitoring every 6 hours on a patient.
b. hanging a bag of enteral feeding
c. inserting the nasogastric tube
d. assessing a patient's risk for aspiration Right Answer - A
In the event of an ischemic stroke on the left side of the brain, these
problems occur. Select all that apply.
a. Altered balance
b. Problems with speech
c. Visual-spatial problems
d. Altered coordination
e. Loss of sensation and coordination in extremities on the left side
of the body Right Answer - A,B,D
What actions help create a nonthreatening physical environment
during an interview? Select all that apply.
A. Placing chairs at a 90-degree angle or side by side
B. Talk loudly with a stern voice
C. Arrange the interview environment so that you can maintain or
avoid eye contact comfortably
D. Let the patient talk and do not say anything Right Answer -
A,C
A woman was driving in her car when out of nowhere she was hit
from behind. Up until this point in her life, the woman had never
experienced chronic stress. After the accident, she has been
struggling with flashbacks and getting into another car. What is the
woman suffering from?
a. Dissociation
b. Situational factors
c. Post-traumatic stress disorder
d. Regression Right Answer - C
, Which of the following can be delegated to the UAP? Select all that
apply.
a. Oropharyngeal suctioning
b. Tracheostomy suctioning
c. Oral suctioning
d. Nasopharyngeal suctioning
e. Nasotracheal suctioning Right Answer - A,C
How can the nurse best communicate with a patient with a hearing
impairment? SATA:
A) Gestures
B) Sign Language
C) Exaggerate mouth movements
D) Face patient directly
E) Shout Right Answer - A,B,D
A patient is admitted through the emergency department following
a motorcycle crash with multiple orthopedic injuries. He goes to
surgery for repair of fractures. He is postoperative day 3 from an
open-reduction internal fixation of bilateral femur fractures and
external to his unstable pelvic fracture. Interventions that are
necessary for the prevention of venous thromboembolism in this
patient include: SELECT ALL THAT APPLY
1. Intermittent pneumatic compression stockings
2. Vitamin K therapy
3. Passive range of motion exercises every 4 hours
4. Subcutaneous heparin or enoxaparin (Lovenox)
5. Continuous heparin drip with a goal of an international
normalized ratio (INR) 5 times higher than baseline Right
Answer - 1,4
The nurse is treating a 38-year-old male patient with recurrent
insomnia and headaches. The patient tells the nurse, "I lost my job
Solutions
Which of the following nursing interventions is considered the most
effective form of universal precautions in regards to sharps?
a. Discard all uncapped needles and syringes in a puncture-resistant
protective container
b. Report a needle stick to an instructor if there is an onset of
abnormal symptoms
c. Follow the hospital's enteric precautions
d. Recap the dirty needle after giving the injection and then place it
in the sharps container Right Answer - A
Which religion attempts to remove illness by means of stories,
rituals, prayers, symbols and sand painting?
A. Hinduism
B. Judaism
C. Navajos
D. Islam Right Answer - C
When restraining a patient you must remember that
A) You must have a good reason
B) You need a physicians order
C) You can restrain an arm on a combative patient needing an IV
D) Once a patient is restrained, they stay restrained until discharge
Right Answer - B
Which of the following changes occur during the alarm stage of GAS?
a. decrease in blood volume
b. increase in blood glucose
c. increase in digestion
d. decrease in oxygen intake Right Answer - B
,A nurse goes in to assess a patient's wound. She finds that the
wound has been intentionally left open as ordered by the physician.
This patient's wound is ________.
A. Secondary intention
B. Quaternary intention
C. Primary intention
D. Tertiary intention Right Answer - D
During the assessment of the preoperative surgical phase, the nurse
would assess for all of the following except:
a. support sources
b. preoperative pain assessment
c. review of emotional health
d. skin integrity and condition of wound Right Answer - D
Which of the following actions requested of the NAP is
inappropriate by the nurse?
A. Take the pt's vital signs and tell me if his pneumonia is worsening
B. Help me assist this patient in moving from the bed to the chair
C. Document the pt's input and ouput
D. Answer the pt's call light while I'm busy Right Answer - A
Your patient has just received a terminal cancer diagnosis and is
expected to live for less than six months. He is visibly upset, so you
provide a nursing presence for comfort. He states, "I will go to
church every time the doors open, tithe my whole paycheck,
anything, if God will just take this cancer away." According to Kubler
Ross' stages of dying theory, what stage is this patient in?
A. depression
B. denial
C. bargaining
D. anger Right Answer - C
,The nurse can delegate with the unlicensed assistive personnel
(UAP) about:
a. performing glucose monitoring every 6 hours on a patient.
b. hanging a bag of enteral feeding
c. inserting the nasogastric tube
d. assessing a patient's risk for aspiration Right Answer - A
In the event of an ischemic stroke on the left side of the brain, these
problems occur. Select all that apply.
a. Altered balance
b. Problems with speech
c. Visual-spatial problems
d. Altered coordination
e. Loss of sensation and coordination in extremities on the left side
of the body Right Answer - A,B,D
What actions help create a nonthreatening physical environment
during an interview? Select all that apply.
A. Placing chairs at a 90-degree angle or side by side
B. Talk loudly with a stern voice
C. Arrange the interview environment so that you can maintain or
avoid eye contact comfortably
D. Let the patient talk and do not say anything Right Answer -
A,C
A woman was driving in her car when out of nowhere she was hit
from behind. Up until this point in her life, the woman had never
experienced chronic stress. After the accident, she has been
struggling with flashbacks and getting into another car. What is the
woman suffering from?
a. Dissociation
b. Situational factors
c. Post-traumatic stress disorder
d. Regression Right Answer - C
, Which of the following can be delegated to the UAP? Select all that
apply.
a. Oropharyngeal suctioning
b. Tracheostomy suctioning
c. Oral suctioning
d. Nasopharyngeal suctioning
e. Nasotracheal suctioning Right Answer - A,C
How can the nurse best communicate with a patient with a hearing
impairment? SATA:
A) Gestures
B) Sign Language
C) Exaggerate mouth movements
D) Face patient directly
E) Shout Right Answer - A,B,D
A patient is admitted through the emergency department following
a motorcycle crash with multiple orthopedic injuries. He goes to
surgery for repair of fractures. He is postoperative day 3 from an
open-reduction internal fixation of bilateral femur fractures and
external to his unstable pelvic fracture. Interventions that are
necessary for the prevention of venous thromboembolism in this
patient include: SELECT ALL THAT APPLY
1. Intermittent pneumatic compression stockings
2. Vitamin K therapy
3. Passive range of motion exercises every 4 hours
4. Subcutaneous heparin or enoxaparin (Lovenox)
5. Continuous heparin drip with a goal of an international
normalized ratio (INR) 5 times higher than baseline Right
Answer - 1,4
The nurse is treating a 38-year-old male patient with recurrent
insomnia and headaches. The patient tells the nurse, "I lost my job
