NR 545 EXAM 2 STUDY GUIDE REVIEW
QUESTIONS AND ANSWERS
The nurse reviews care needs for a group of clients. Which task is inappropriate to
assign to unlicensed assistive personnel (UAP)?
1) Make sure a client takes their pills after a meal
2) Ambulate a post-surgical client to the bathroom
3) Bathe a client who is listed as a fall risk
4) Feed a client with severe visual impairment - Answer-Make sure the client takes their
pills after a meal
In meeting the safety needs of the adolescent client, which area would be most
important for the nurse to focus their teaching?
1) Smoking cessation
2) Sports injuries
3) Alcohol abuse
4) Driver's education - Answer-Driver's education
When implementing the use of restraints on a hospitalized client, what is the most
appropriate action by the nurse?
1) Restrain all confused clients so that they do not sustain a fall injury
2) Tie the restraint to the bottom of the side rail so the client cannot reach it
3) Ensure that the primary care provider renews the order for restraints once every 21
hours
4) Release the restraints and provide skin care at least once every shift - Answer-
Ensure the primary care provider renews the order for restraints once every 21 hours.
Release restraints every 2 hours to ensure circulation and prevent skin breakdown.
Don't apply restraints to side rails. don't restrain all confused clients
Which statement by the nurse indicates understanding of maintaining proper posture?
1) It's important to sleep on the softest mattress possible
2) It's important to avoid arching my shoulders forward when sitting
3) It's important to keep my knees locked when standing upright
4) It's important to keep my stomach muscles relaxed to prevent back spasms - Answer-
It's important to avoid arching my shoulders forward when sitting.
Locking knees can cause you to pass out. Keep stomach muscles tight to ensure a
good core
, The nurse is caring for a client who is immobile. Which intervention should be priority for
the nurse?
1) Encourage a diet high in fiber and extra fluids
2) Administer the prn (as needed) medication for sleep
3) Having the client use the incentive spirometer q 2 hours
4) Massaging the client's legs every hour - Answer-Having the client use the incentive
spirometer q 2 hours
A nursing instructor discusses devices used when assisting clients to ambulate. Which
statement made by a student nurse indicated understanding?
1) The client should stand a foot back from the back legs of a walker
2) A cane should be used by the client to support the weakest side of the body
3) A transfer belt should be placed around the client's chest for maximum lift
4) Each crutch-walking gait begins with the client in the tripod position - Answer-Each-
crutch walking gait begins with the client in the tripod position.
Of the following factors, which would put a client at greatest risk for impaired skin
integrity?
1) Medication, digoxin
2) Moisture
3) Decreased sensation
4) Dehydration - Answer-Decreased sensation.
The client calls the nurse to the room and stats, "Look, my incision is popping open
where they did my hip surgery!" The nurse notes that the wound edges have separated
1 cm at the center and there is straw-colored fluid leaking from one end. What is the
nurse's best action at this time?
1) Notify a surgeon STAT
2) Place a clean, sterile 4x4 over the incision and monitor the drainage
3) Wrap an ace bandage firmly around the area and have the client maintain bedrest
4) Immediately cover the wound with sterile towels soaked in normal saline and call the
surgeon - Answer-Immediately cover the wound with sterile towels soaked in normal
saline and call the surgeon
Why is important to possess the knowledge and skills needed for patient teaching?
1) Allows them to complete the documentation forms related to client teaching
accurately
2) Helps the hospital to meet The Joint Commission standards requiring client teaching
3) Enables them to promote the health, safety, and rights of clients through education
QUESTIONS AND ANSWERS
The nurse reviews care needs for a group of clients. Which task is inappropriate to
assign to unlicensed assistive personnel (UAP)?
1) Make sure a client takes their pills after a meal
2) Ambulate a post-surgical client to the bathroom
3) Bathe a client who is listed as a fall risk
4) Feed a client with severe visual impairment - Answer-Make sure the client takes their
pills after a meal
In meeting the safety needs of the adolescent client, which area would be most
important for the nurse to focus their teaching?
1) Smoking cessation
2) Sports injuries
3) Alcohol abuse
4) Driver's education - Answer-Driver's education
When implementing the use of restraints on a hospitalized client, what is the most
appropriate action by the nurse?
1) Restrain all confused clients so that they do not sustain a fall injury
2) Tie the restraint to the bottom of the side rail so the client cannot reach it
3) Ensure that the primary care provider renews the order for restraints once every 21
hours
4) Release the restraints and provide skin care at least once every shift - Answer-
Ensure the primary care provider renews the order for restraints once every 21 hours.
Release restraints every 2 hours to ensure circulation and prevent skin breakdown.
Don't apply restraints to side rails. don't restrain all confused clients
Which statement by the nurse indicates understanding of maintaining proper posture?
1) It's important to sleep on the softest mattress possible
2) It's important to avoid arching my shoulders forward when sitting
3) It's important to keep my knees locked when standing upright
4) It's important to keep my stomach muscles relaxed to prevent back spasms - Answer-
It's important to avoid arching my shoulders forward when sitting.
Locking knees can cause you to pass out. Keep stomach muscles tight to ensure a
good core
, The nurse is caring for a client who is immobile. Which intervention should be priority for
the nurse?
1) Encourage a diet high in fiber and extra fluids
2) Administer the prn (as needed) medication for sleep
3) Having the client use the incentive spirometer q 2 hours
4) Massaging the client's legs every hour - Answer-Having the client use the incentive
spirometer q 2 hours
A nursing instructor discusses devices used when assisting clients to ambulate. Which
statement made by a student nurse indicated understanding?
1) The client should stand a foot back from the back legs of a walker
2) A cane should be used by the client to support the weakest side of the body
3) A transfer belt should be placed around the client's chest for maximum lift
4) Each crutch-walking gait begins with the client in the tripod position - Answer-Each-
crutch walking gait begins with the client in the tripod position.
Of the following factors, which would put a client at greatest risk for impaired skin
integrity?
1) Medication, digoxin
2) Moisture
3) Decreased sensation
4) Dehydration - Answer-Decreased sensation.
The client calls the nurse to the room and stats, "Look, my incision is popping open
where they did my hip surgery!" The nurse notes that the wound edges have separated
1 cm at the center and there is straw-colored fluid leaking from one end. What is the
nurse's best action at this time?
1) Notify a surgeon STAT
2) Place a clean, sterile 4x4 over the incision and monitor the drainage
3) Wrap an ace bandage firmly around the area and have the client maintain bedrest
4) Immediately cover the wound with sterile towels soaked in normal saline and call the
surgeon - Answer-Immediately cover the wound with sterile towels soaked in normal
saline and call the surgeon
Why is important to possess the knowledge and skills needed for patient teaching?
1) Allows them to complete the documentation forms related to client teaching
accurately
2) Helps the hospital to meet The Joint Commission standards requiring client teaching
3) Enables them to promote the health, safety, and rights of clients through education
