Summary NURS 320 Quiz 1 (fall 2023) all correct answers.

NURS 320 Quiz 1 (fall 2022) all correct answers. A 16-year old patient with cystic fibrosis is admitted with increased shortness of breath and possible pneumonia. Which nursing activity is most important to include in the patient's care? A Perform postural drainage and chest physiotherapy every 4 hours B Allow the patient to decide whether she needs aerosolized medications C Place the patient in a private room to decrease the risk of further infection D Plan activities to allow at least 8 hours of uninterrupted sleep A boy was riding his bike to school when he hit the curb. He fell and hurt his leg. The school nurse was called and found him alert and conscious, but in severe pain with a possible fracture of the right femur. Which of the following is the FIRST action that the nurse should take? 1. Immobilize the affected limb with a splint and ask him not to move. 2. Make a thorough assessment of the circumstances surrounding the accident. 3. Put him in semi-Fowler's position for comfort. 4. Check the pedal pulse and blanching sign in both legs. A child undergoes a tonsillectomy for treatment of chronic tonsillitis unresponsive to antibiotic therapy. After surgery, the child is brought to the recovery room. Which of the following actions should the nurse include in the child's plan of care? 1. Institute measures to minimize crying. 2. Perform postural drainage every 2 hours. 3. Cough and deep-breathe every hour. 4. Give ice cream as tolerated. A client admitted for a myocardial infarction is now stable. Appropriate activities to assign to unlicensed personnel would include all the following EXCEPT: A. Teaching about what foods are high in sodium B. Recording intake and output (I/O) C. Assisting with ambulation to the restroom D. Reporting to the nurse that the patient complained of chest pain A client admitted to the hospital with a diagnosis of cirrhosis has massive ascites and difficulty breathing. The nurse performs which intervention as a priority measure to assist the client with breathing? a) repositions side to side every 2 hours b) elevates the head of the bed 60 degrees c) auscultates the lung field every 4 hours d) encourages deep breathing exercises every 2 hours A client arrives at the emergency department with upper gastrointestinal (GI) bleeding and is in moderate distress. The priority nursing action is to: a) obtain vital signs b) ask the client about the precipitating events c) complete an abdominal physical assessment d) insert a nasogastric (NG) tube and Hematest the emesis A client has had a tracheostomy for 2 weeks after a motor vehicle accident. Which task could the RN safely delegate to unlicensed assistive personnel (UAP)? Discuss o A. Teach the client how to cough up secretions o B. Changes the tracheostomy trach ties o C. Monitor if client has shortness of breath o D. Perform routine tracheostomy dressing care A client in a long-term care facility has had a series of gastrointestinal (GI) diagnostic tests, including an upper GI series and endoscopies. Upon return to the long-term care facility, the priority nursing assessment should focus on: a) the comfort level b) activity tolerance c) the level of consciousness d) the hydration and nutrition status A client is 3 hours postoperative following a right upper lobectomy. The collection chamber of the closed pleural drainage system contains 400 ml of bloody drainage. The client's vital signs are blood pressure 100/50 mmHg, heart rate of 100 beats per minute, and respiratory rate 26 breaths per minute. There is intermittent bubbling in the water seal chamber. One hour following the initial assessment, the nurse notes that the bubbling in the water seal chamber is now constant and the client appears dyspneic. The nurse should first check: a) lung sounds b) vital signs c) the chest tube connections d) the amount of drainage A client is brought to the emergency department by the police after having lacerated both wrists in a suicide attempt. The nurse should take which initial action? a) examine and treat the wound sites b) obtain and record a detailed history c) encourage and assist the client to ventilate feelings d) administer an anti-anxiety agent A client is scheduled for an arteriogram using a radiopaque dye. The nurse assesses which most critical item before the procedure? a) vital signs b) intake and output c) height and weight d) allergy to iodine or shellfish A client is scheduled for surgery in the morning. Preoperative orders have been written. What is the most important to do before surgery? A. Remove all jewelries or tape wedding ring B. Verify that all laboratory work is complete C. Inform family or next of kin D. Have all consent forms signed A client with a history of suicide attempts is admitted to the mental health unit with the diagnosis of depression. Upon the client's arrival, the client's therapist reports to the nurse that the clients telephoned the therapist earlier in the evening and reported having a overwhelming suicidal thoughts. Keeping this information in mind, the priority of the nurse is to assess for: a) interaction with peers b) the presence of suicidal thoughts c) the amount of food intake for the past 24 hours d) information regarding the past medication regimen A client with mania will be placed in seclusion after overturning two tables and throwing a chair against the wall. Before placing the client in seclusion, the nurse would first: a) inspect the client for injuries resulting from the incident and initiate appropriate treatment b) document the behavior leading to seclusion c) document the time and the client is placed in seclusion d) make sure that there is a written order by the physician allowing for the seclusion A client's total parenteral nutrition (TPN) infusion rate was too slow, and is now 3 hours behind schedule. The nurse should: A. Contact the health care provider B. Increase the rate to catch up to schedule C. Run the next bag of infusion at a slightly higher rate to make up the volume deficit D. Double the infusion rate until desired amount has infused A community health nurse is working with older residents who were involved in a recent flood. Many of the residents are emotionally despondent, and they refused to leave their homes for days. When planning forth rescue and relocation of these older residents, what is the first item that the nurse needs to consider? a) contacting the older resident's families b) attending to the emotional needs of the older residents c) arranging for ambulance transportation for the oldest residents d) attending to the nutritional status and basic needs of the older residents A group of health nurse is caring for a group of homeless people. When planning for the potential needs of this group, what is the most immediate concern? a) peer support through structured groups b) finding affordable housing for the group c) setting up a 24-hour crisis center and hotline d) meeting the basic needs to ensure that adequate food, shelter, and clothing are available A labor room nurse is caring for a client in labor with a known history of sickle cell anemia. Which priority action would the nurse implement to assist in preventing a sickle cell crisis from occurring during labor? a) continually reassure and coach the client b) administer the prescribed oxygen throughout labor c) maintain strict asepsis throughout the labor process d) increase the intravenous (IV) fluids if the client complains of feeling thirsty A major hospital has received notification of a mass casualty event in the area. Which of the following actions should a charge nurse of an inpatient neurovascular floor do FIRST? A. Expedite discharge of appropriate clients B. Reallocate staff according to mass casualty plan of action C. Initiate paper charting methods for consistency D. Reduce vital sign frequency to every 8 hours for patients currently on the unit A nurse from medical-surgical unit is asked to work on the orthopedic unit. The medical-surgical nurse has no orthopedic nursing experience. Which client should be assigned to the medical-surgical nurse? Discuss o A. A client with a cast for a fractured femur and who has numbness and discoloration of the toes o B. A client with balanced skeletal traction and who needs assistance with morning care o C. a client who had an above-the-knee amputation yesterday and has a temperature of 101.4F o D. a client who had a total hip replacement 2 days ago and needs blood glucose monitoring A nurse has just administered a dose of hydralazine hydrochloride (Apresoline) intravenously to a client. Based on the action of this medication, the nurse would initially assess the client's: a) cardiac rhythm b) oxygen saturation c) blood pressure d) respiratory rate A nurse in a postanesthesia care unit (PACU) receives a client transferred from the operating room. The PACU nurse assesses the client for which of the following first? a) active bowel sounds b) adequate urine output c) orientation to the surroundings d) a patent airway A nurse is assessing a 39 year old Caucasian female client. The client has a blood pressure (BP) of 152/92 mm Hg at rest, a total cholesterol of level of 190 mg/dL, and a fasting blood glucose level of 110 mg/dL. The nurse would place priority on which risk factor for coronary heart disease (CHD) in this client? a) age b) hypertension c) hyperlipidemia d) glucose intolerance A nurse is assigned to provide care to a client in labor and will care for the client throughout labor and into the postpartum period. The nurse assists in developing a plan of care and determines that the priority assessment in the fourth stage of labor is which of the following? a) assessing the uterine fundus and lochia b) checking the mother's temperature c) encouraging food and fluid intake d) providing privacy for the parents and their newborn infant A nurse is caring for a client who has wrist restraints applied. Which nursing intervention would receive highest priority regarding the wrist restraints? a) providing range-of-motion exercises to the wrists b) removing the restraints periodically per agency guidelines c) applying lotion to the skin under the restraints d) assessing color, sensation, and pulses distal to the restraint A nurse is caring for a client with preeclampsia who suddenly progresses to an eclamptic state. The initial nursing action would be to: a) check the fetal heart rate b) check the maternal blood pressure c) maintain an open airway d) administer oxygen to the mother by face mask A nurse is developing a care plan for a patient who is at risk for developing pneumonia after surgery. Which of the following is not an appropriate nursing intervention?* A. Encourage patient intake of 3000 ml/day of fluids if not contraindicated B. Encourage patient to use the incentive spirometer device 10 times every 1-2 hours while awake C. Encourage early ambulation and patient to eat meals in beside chair D. Repositioning every 3-4 hours A nurse is formulating a plan of care for a client receiving enteral feedings. The nurse identifies which nursing diagnosis as the highest priority for this client? a) diarrhea b) risk for aspiration c) risk for deficient flid volume d) imbalanced nutrition, less than body requirements A nurse is scheduling a client for diagnostic studies of gastrointestinal (GI) system. Which of the following studies, if ordered, should the nurse schedule last? a) ultrasound b) colonoscopy c) barium enema d) computed tomography A nurse manager is planning the client assignments for the day. Which of the following clients would the nurse assign to the nursing assistant? a) a 2-day postoperative client who had a below-the-knee amputation b) a client on a 24-hour urine collection who is on strict bedrest c) a cleint scheduled to be discharged after coronary artery bypass surgery d) a client scheduled for a cardiac catheterization A nurse manager of a medical-surgical unit returns to work after being on vacation for a week. It is the beginning of the shift, and the nurse manager is faced with several activities that need attention. Which activity will the nurse manager attend to first? a) a crash cart needs checking b) client assignments for the day c) a phone message that indicates that the charge nurse of the next shift is ill and will not be reporting to work d) a stack of mail from the education department and administrative services A nurse preceptor is working with a new nurse and notes that the new nurse is reluctant to delegate tasks to members of the care team. The nurse preceptor recognizes that this reluctance most likely is due to Discuss o A. Role modeling behaviors of the preceptor o B. The philosophy of the new nurse's school of nursing o C. The orientation provided to the new nurse o D. Lack of trust in the team members A nurse responds to an external disaster that occurred in a large city when a building collapsed. Numerous victims require treatment. Which victim will the nurse attend to first? a) an alert victim who has numerous bruises on the arms and legs b) a victim with a partial amputation of a leg who is bleeding profusely c) a hysterical victim who received a head injury d) a victim who sustained multiple serious injuries and is deceased A patient arrives at the emergency department complaining of mid-sternal chest pain. Which of the following nursing actions should take priority? a. A complete history with emphasis on preceding events b. An electrocardiogram (EKG) c. Careful assessment of vital signs d. Chest exam with auscultation A patient is 6 days post-opt from abdominal surgery. The patient is to be discharged later today. The patient uses the call light and asks you to come to his room and look at his surgical site. On arrival, you see that approximately 2 inches of internal organs are protruding through the incision. What intervention would you NOT do?* A. Put the patient in prone position with knees extended to put pressure on the site B. Cover the wound with sterile normal saline dressing C. Monitor for signs of shock D. Notify the MD and administer as prescribed antiemetic to prevent vomiting A patient is now in the recovery room after having vaginal surgery. Due to the positioning of the procedure, you would want to assess for what while the patient is in recovery? A. Bowel Sounds B. Dysrhythmia C. Homan's Sign D. Hemoglobin Level A patient is recovering from surgery. The patient is very restless, heart rate is 120 bpm and blood pressure is 70/53, skin is cool/clammy. As the nurse you would?* A. Continue to monitor the patient B. Notify the MD C. Obtain an EKG D. Check the patient's blood glucose A patient is taking Aspirin 325 mg PO by mouth daily. The patient is scheduled for surgery in a week. What education do you provide the patient with before surgery?* A. Educate the patient to take the scheduled dose of Aspirin the day of surgery to help prevent blood clots B. To hold his morning dose of Aspirin because the nurse will give it to him before surgery C. None of the above are correct D. The medication should be discontinued for 48 hours prior to the scheduled surgery date A patient reports he hasn't had a bowel movement or passed gas since surgery. On assessment, you note the abdomen is distended and no bowel sounds are noted in the four quadrants. You notify the MD. What non-invasive nursing interventions can you perform without a MD order? A. Insert a nasogastric attached to intermittent suction B. Administer IV fluids C. Encourage ambulation, maintain NPO status, and monitor intake & output D. Encourage at least 3000 ml of fluids per day A patient with a pulmonary embolus is receiving anticoagulation with IV heparin. What instructions would you give the nursing assistant who will help the patient with activities of daily living? Select all that apply. A Use a lift sheet when moving and positioning the patient in bed B Use an electric razor when shaving the patient each day C Use a soft-bristled toothbrush or tooth sponge for oral care D Use a rectal thermometer to obtain a more accurate body temperature E Be sure the patient's footwear has a firm sole when the patient ambulates , B, C, E A patient with acute respiratory distress syndrome (ARDS) is receiving oxygen by a nonrebreather mask, but arterial blood gas measurements still show poor oxygenation. As the nurse responsible for this patient's care, you would anticipate a physician order for what action? A Perform endotracheal intubation and initiate mechanical ventilation B Immediately begin continuous positive airway pressure (CPAP) via the patient's nose and mouth C Administer furosemide (Lasix) 100 mg IV push stat D Call a code for respiratory arrest A patient with chronic obstructive pulmonary disease (COPD). Which intervention for airway management should you delegate to a nursing assistant (PCT)? A Assisting the patient to sit up on the side of the bed B Instructing the patient to cough effectively C Teaching the patient to use incentive spirometry D Auscultation of breath sounds every 4 hours A patient with sleep apnea has a nursing diagnosis of Sleep Deprivation related to disrupted sleep cycle. Which action should you delegate to the nursing assistant (PCT)? A Discuss weight-loss strategies such as diet and exercise with the patient B Teach the patient how to set up the BiPAP machine before sleeping C Remind the patient to sleep on his side instead of his back D Administer modafinil (Provigil) to promote daytime wakefulness A postoperative client receives a dinner tray with gelatin, pudding, and vanilla ice cream. Based on the foods on the client's tray, what would the nurse anticipate the client's current diet order to be: A. Bland diet B. Soft diet C. Full liquid diet D. Regular diet A primigravida is admitted to the labor unit. During the assessment of the client, her membranes rupture spontaneously. The priority nursing action is which of the following? a) monitor the contraction pattern b) assess the fetal heart rate c) note the amount, color, and odor of the amniotic fluid d) check maternal vital signs A registered nurse (RN) has delegated care of a newly postoperative client to a licensed practical nurse (LPN). The LPN notifies the RN that the client's blood pressure and respirations are elevated from the baseline readings and that the client is complaining of pain and dyspnea. The RN takes which action next? a) the RN need not to carry out further assessment because the LPN is very experienced and trustworthy b) the RN requests that the LPN offer the client a opioid analgesic, which has ordered postoperatively c) the RN places a call to the attending surgeon and reports that the client is having pain and dyspneic d) the RN assesses the client, checks the client's surgical notes, and gathers addition data before calling the surgeon A registered nurse (RN) must determine how best to assign coworkers (another RN and one licensed practical nurse LPN) to provide care to a group of clients. Which of the following is the appropriate assignment? a) the RN is assigned to care for an unemployed 26-year old woman, newly diagnosed with acquired immunodeficiency syndrome (AIDS), who has four school-age children b) the LPN is assigned to care for a 41-year old male, postresection of an acoustic neuroma 2 days ago, transferred from the intensive care unit (ICU) this morning c) the LPN is assigned to provide discharge teaching about medications and maintenance of nephrostomy tube to a 35-year old man d) the RN is assigned to care for a 65-year old woman hospitalized because of chest pain, being discharged today to home with no medication A staff nurse complains to the nurse manager that an unlicensed assistive personnel (UAP) consistently leaves the work area untidy and does not restock supplies. The best initial response by the nurse manager is which of these statements? o A.