NUR 109 EXAM 3 ACTUAL STUDY QUESTIONS WITH ACCURATELY SOLVED -GRADED A+
A nurse is assessing an older adult brought to the emergency department following a fall
and wrist fracture. She notes that the patient is very thin and unkempt, has a stage 3
pressure ulcer to her coccyx, and has old bruising to the extremities in addition to her new
bruises from the fall. She defers all of the questions to her caregiver son who accompanied
her to the hospital. The nurse’s next step is to:
Ask the son to step out of the room so she can complete her assessment.
The assessment leads you to suspect elder mistreatment, but the nurse needs more
information directly from the patient before calling social services or the adult protective
services. She will best get this information by asking the son to leave so she can ask the
patient direct questions privately. If the son refuses to leave, this will be another indication
that elder mistreatment may be occurring. Cognitive testing will be important but is not the
priority.
A patient’s family member is considering having her mother placed in a nursing center. The
nurse has talked with the family before and knows that this is a difficult decision. Which of
the following criteria does the nurse recommend in choosing a nursing center?
*Adequate staffing is available on all shifts.
*Social activities are available for all residents.
*Staff encourage family involvement in care planning and assisting with physical care.
Adequate staffing, provision of social activities, and active family involvement are
essential. Meals should be high quality with options for what to eat and when it is served. A
nursing center should be clean, but it should look like a person's home rather than a
hospital.
,A nurse conducted an assessment of a new patient who came to the medical clinic. The
patient is 82 years old and has had osteoarthritis for 10 years and diabetes mellitus for 20
years. He is alert but becomes easily distracted during the assessment. He recently moved
to a new apartment, and his pet beagle died just 2 months ago. He is most likely
experiencing:
Depression.
Factors that often lead to depression include presence of a chronic disease or a recent
change or life event (such as loss). Patients are alert but easily distracted in conversation.
The nurse is working with an older adult after an acute hospitalization. The goal is to help
this person be more in touch with time, place, and person. Which intervention will likely be
most effective?
Reality orientation
Reality orientation is a communication technique that can help restore a sense of reality,
improve level of awareness, promote socialization, elevate independent functioning, and
minimize confusion.
As a nurse, you are assigned to four patients. Which patient do you need to see first?
A. The patient who had abdominal surgery 2 days ago who is requesting pain medication.
,B. A patient admitted yesterday with atrial fibrillation with decreased level of
consciousness.
C. A patient with a wound drain who needs teaching before discharge in the early
afternoon.
D. A patient going to surgery for a mastectomy in 3 hours who has a question about the
surgery.
B. A patient admitted yesterday with atrial fibrillation with decreased level of
consciousness
This patient is of high priority. The patient is experiencing the physiological problem of
decreased level of consciousness, which is an immediate threat to his or her survival and
safety. The nurse must intervene promptly and notify the health care provider of the life-
threatening problem.
While administering medications, a nurse realizes that a prescribed dose of a medication
was not given. The nurse acts by completing an incident report and notifying the patient’s
health care provider. The nurse is exercising:
Accountability.
Accountability is nurses being answerable for their actions. It means that nurses accept
the commitment to provide excellent patient care and the responsibility for the outcomes
of the actions in providing it. Following institutional policy for reporting medication errors
demonstrates the nurse’s commitment to safe patient care.
, Which example demonstrates a nurse performing the skill of evaluation?
A. The nurse explains the side effects of the new blood pressure medication ordered for the
patient.
B. The nurse asks a patient to rate pain on a scale of 0 to 10 before administering the pain
medication.
C. After completing the teaching, the nurse observes a patient draw up and administer an
insulin injection.
D. The nurse changes a patient’s leg ulcer dressing using aseptic technique
C. After completing the teaching, the nurse observes a patient draw up and administer an
insulin injection.
Evaluation is one of the most important aspects of clinical care coordination, involving the
determination of patient outcomes. Observing a patient do a return demonstration of
teaching is evaluation to ensure that patient has understood teaching. Asking a patient to
rate their pain on a scale is not evaluation but rather an assessment of the patient’s pain
because it occurs before administering a pain medication. The other options are
interventions.
A nurse is assessing an older adult brought to the emergency department following a fall
and wrist fracture. She notes that the patient is very thin and unkempt, has a stage 3
pressure ulcer to her coccyx, and has old bruising to the extremities in addition to her new
bruises from the fall. She defers all of the questions to her caregiver son who accompanied
her to the hospital. The nurse’s next step is to:
Ask the son to step out of the room so she can complete her assessment.
The assessment leads you to suspect elder mistreatment, but the nurse needs more
information directly from the patient before calling social services or the adult protective
services. She will best get this information by asking the son to leave so she can ask the
patient direct questions privately. If the son refuses to leave, this will be another indication
that elder mistreatment may be occurring. Cognitive testing will be important but is not the
priority.
A patient’s family member is considering having her mother placed in a nursing center. The
nurse has talked with the family before and knows that this is a difficult decision. Which of
the following criteria does the nurse recommend in choosing a nursing center?
*Adequate staffing is available on all shifts.
*Social activities are available for all residents.
*Staff encourage family involvement in care planning and assisting with physical care.
Adequate staffing, provision of social activities, and active family involvement are
essential. Meals should be high quality with options for what to eat and when it is served. A
nursing center should be clean, but it should look like a person's home rather than a
hospital.
,A nurse conducted an assessment of a new patient who came to the medical clinic. The
patient is 82 years old and has had osteoarthritis for 10 years and diabetes mellitus for 20
years. He is alert but becomes easily distracted during the assessment. He recently moved
to a new apartment, and his pet beagle died just 2 months ago. He is most likely
experiencing:
Depression.
Factors that often lead to depression include presence of a chronic disease or a recent
change or life event (such as loss). Patients are alert but easily distracted in conversation.
The nurse is working with an older adult after an acute hospitalization. The goal is to help
this person be more in touch with time, place, and person. Which intervention will likely be
most effective?
Reality orientation
Reality orientation is a communication technique that can help restore a sense of reality,
improve level of awareness, promote socialization, elevate independent functioning, and
minimize confusion.
As a nurse, you are assigned to four patients. Which patient do you need to see first?
A. The patient who had abdominal surgery 2 days ago who is requesting pain medication.
,B. A patient admitted yesterday with atrial fibrillation with decreased level of
consciousness.
C. A patient with a wound drain who needs teaching before discharge in the early
afternoon.
D. A patient going to surgery for a mastectomy in 3 hours who has a question about the
surgery.
B. A patient admitted yesterday with atrial fibrillation with decreased level of
consciousness
This patient is of high priority. The patient is experiencing the physiological problem of
decreased level of consciousness, which is an immediate threat to his or her survival and
safety. The nurse must intervene promptly and notify the health care provider of the life-
threatening problem.
While administering medications, a nurse realizes that a prescribed dose of a medication
was not given. The nurse acts by completing an incident report and notifying the patient’s
health care provider. The nurse is exercising:
Accountability.
Accountability is nurses being answerable for their actions. It means that nurses accept
the commitment to provide excellent patient care and the responsibility for the outcomes
of the actions in providing it. Following institutional policy for reporting medication errors
demonstrates the nurse’s commitment to safe patient care.
, Which example demonstrates a nurse performing the skill of evaluation?
A. The nurse explains the side effects of the new blood pressure medication ordered for the
patient.
B. The nurse asks a patient to rate pain on a scale of 0 to 10 before administering the pain
medication.
C. After completing the teaching, the nurse observes a patient draw up and administer an
insulin injection.
D. The nurse changes a patient’s leg ulcer dressing using aseptic technique
C. After completing the teaching, the nurse observes a patient draw up and administer an
insulin injection.
Evaluation is one of the most important aspects of clinical care coordination, involving the
determination of patient outcomes. Observing a patient do a return demonstration of
teaching is evaluation to ensure that patient has understood teaching. Asking a patient to
rate their pain on a scale is not evaluation but rather an assessment of the patient’s pain
because it occurs before administering a pain medication. The other options are
interventions.
