NR 224 Exam 1: The Real Test Results Questions and Answers | 100% Verified PAPER

NR 224 Exam 1: The Real Test Results Questions and Answers 1. Which is the five-step process that professional nurses use when caring for clients? The nursing process 2. The nurse palpates a client’s radial pulse as 52 beats per minute. The client spear alert and oriented and in no distress. Which action by the nurse best demonstrates effective use of the nursing process? Use the stethoscope to listen for the radial pulse 3. The nurse is assessing the client after being admitted from the emergency room. Which findings are objective data? (select all that apply) Age, height, weight 4. An elderly client with pneumonia has an elevated respiratory rate, decreased oxygen saturation, and a fever. The client also states that there is no family member that live in town. Which nursing diagnosis is the priority? Ineffective airway clearance 5. Which is the best method for nurses to use to reduce the spread of healthcare associated infection (HAIs)? Proper use of PPE 6. Which intervention breaks the chain of infection at the portal of entrance? Cleaning your hands frequently 7. The student nurse is reviewing the chain of infection. Which are considered portals of exit? (select all that apply) Skin, respiratory, urogenital, GI tracts 8. Which statement about standard/universal precaution is correct? All human blood and certain human body fluids are treated as infectious. 9. Which events occur during the convalescence stage of an infection? Marked by complete resolution of clinical signs of the illness (3 months) 10. When assessing a surgical incision, which sign and symptoms of surgical infection? (select all that apply) Redness, drainage, inflammation, edema 11. The client has been immobilized for a prolonged period of time after experiencing a cerebral vascular accident (CIA). Which sign and symptoms of immobility would the nurse be assessing for in this client/ (select all that apply) 12. Which nursing measures are implemented to prevent effects of immobility while hospitalized? (select all that apply) Turn patient, ambulate 13. Which precaution is necessary when caring for a client with clostridium difficile (cdiff)? Hand hygiene, gloves, wash hands with soap and water 14. Which is a violation of the health insurance portability and accountability act (HIPPA)? “Required the creation of national standards to protect sensitive patient health information from being disclosed without the patietns consent of knowledge” 15. The nurse is providing discharge teaching to an elderly patient with a chronic lung disease. Which recommended by the nurse would be most beneficial to reduce host susceptibility? 16. Which client would place in a private room with negative flow air pressure? TB patients 17. A client has a medical order for non-weight bearing to the injured left leg. What instructions are provided to the client about proper crutch use? (select all that apply) The client would move the right crutch followed by the left foot. 18. A client arrives to the emergency room with an oral temperature of 104.3 degrees Fahrenheit. He has been working outside in the yard most of the day. On assessment his skin is hot and dry. Which condition does the nurse suspect? Heat stroke 19. Which nursing diagnosis is the priority for a client with orthostatic hypotension? Fall risks 20. A nurse is caring for clients on a medical surgical unit. The unlicensed assistive personnel (UAP) reports vital signs to the nurse. Which client should the nurse assess first? 21. A client who has been stable throughout the shift, suddenly calls to then nurse and states that she “feels funny”. What should the nurse do first? Check vital signs and ask to describe how they are feeling 22. The nurse is assessing the blood pressure manually on the upper arm of an adult client using a stethoscope and sphygmomanometer. When the nursing student asks, “what are you auscultating for?” which is the best response by the nurse? Heart sounds systolic and diastolic 23. Which factors can affect blood pressure? (select all that apply) Smoking, pain, fast heart rate, legs crossed, talking, moving around 24. The nurse is caring for a female client who is 55 years old. The client denies any medical history. Which set of vital signs are normal? 25. The nurse is caring for a client who ... an injury to the hypothalamus. Which condition does the nurse suspect may occur from this injury? Temperature regulation, sleep cycles, water balance, weight 26. The client’s radial pulse is 58 beats per minute and irregular. Which action does the nurse take next? Use stethoscope to check 27. An average sized adult client appears pale. The nurse assessed the client’s vital signs as: …. which action does the nurse take next? 28. In order to take a manual blood pressure on the client’s thigh or upper leg. Where would the nurse place the stethoscope over? Popliteal pulse or dorsalis pulse 29. The nurse decides to check the carotid pulse based on which assessment finding? 30. Body temperature may be…by which factors (select all that apply) 31. The nurse assesses a client’s oral temperature at m. as 36 C. yesterday at p, it was 37 C orally. Which action will the nurse take next? 32. Which blood pressure value is … pre-hypertensive based on 2017 American heart association? 33. The RN is instructing a group of nursing students on properly measuring a client’s body temperature. Which statements made by the RN are correct? (select all that apply) 34. Healthcare provider orders Tylenol 650 mg for a temperature greater than 101 degrees F. The clients a temperature greater than 1010 degrees F. The client’s temperature is 27.8 degrees. Which action will the nurse take next? 35. The nurse is caring for a client and is unable to accurately obtain am oxygen saturation reading? Which factor is most likely the cause of this? 36. When observing nursing students performing hand hygiene, which student of concern to the instructor? 37. Which personal protective equipment must the nurse wear when caring for client on droplet precautions? 38. Which is the nurse’s priority intervention for a client experiencing tachypnea and shortness of breath? 39. Which statements regarding blood pressure are accurate? 40. Diastolic blood pressure occurs during which phase of the cardiac cycle? 41. Which client is at greatest risk to develop tachycardia? 42. The nurse is instructing a group of nursing students about standard/universal precautions. Which procedure mandates the use of gloves? 43. Which client is a greatest risk for developing bradypnea? 44. If the nursing assistant reports to the nurse that a client’s blood pressure abnormally low, what would the nurse do next? 45. When assessing a client’s radial pulse, the nurse notes that the pulse is weak and thread. What will the nurse document this finding as? 46. When demonstrating the proper use of a cane, which side is the cane held on? 47. Which are the body’s compensatory mechanisms in response to hypoxemia? 48. Which statement best defines blood pressure? 49. Which conditions are likely to cause tachypnea? (select all that apply) 50. When transferring a client from bed to chair, which technique is the best use of proper body mechanics? Show Less