NR 226 FINAL EXAM NEWEST ACTUAL EXAM
A client is having a tonic-clonic seizure. Which is a priority nursing action?
1
Elevating the head of the bed
2
Restraining the client's arms and legs
3
Placing a tongue blade in the client's mouth
4
Taking measures to prevent injury - ANSWER 4
Protecting the client from injury is the immediate priority during a seizure. Elevating
the head of the bed would have no effect on the client's condition or safety.
Restraining the client's arms and legs could cause injury. Placing a tongue blade or
other object in the client's mouth could damage the teeth.
The nurse assesses an elderly client with a diagnosis of dehydration and recognizes
which finding as an early sign of dehydration?
1
Sunken eyes
2
Dry, flaky skin
3
Change in mental status
4
Decreased bowel sounds - ANSWER 3
Older adults are sensitive to changes in fluid and electrolyte levels, especially
sodium, potassium, and chloride. These changes will manifest as a change in mental
status and confusion. It is difficult to assess dehydration in older adults based on
sunken eyes, dry skin, and decreased bowel sounds because these can be
prominent as general normal findings in the elderly client.
A nurse uses the Braden Scale to predict a client's risk for developing pressure
ulcers. Which data should the nurse use to determine a client's score on this scale?
Select all that apply.
1
Age
2
Anorexia
3
Hemiplegia
4
History of diabetes
5
Urinary incontinence - ANSWER 2,3,4,5
Anorexia causes nutritional problems; nutrition is a category on the Braden Scale.
Hemiplegia causes mobility problems; this affects the categories of mobility, activity,
and friction on the Braden Scale. Clients with a history of diabetes can also have
,peripheral neuropathy, causing numbness or loss of sensation in the hands in feet;
sensory perception is a category on the Braden Scale. Urinary incontinence causes
moisture, a category on the Braden Scale. Age is not used in the Braden Scale.
A hospice nurse is caring for a dying client and his wife. What factor will be a major
determinant in the mourning outcome for the wife?
1
Duration of the relationship shared by the couple
2
Age of the wife at the time of the husband's death
3
Health of the surviving spouse at the time of the death
4
Importance of the deceased person as a source of support - ANSWER 4
The more dependent the client was on the deceased for support, the more difficult
the grieving process will be. Emotional and financial considerations are major
factors. The duration of the couple's relationship and the age of the wife at the time
of the man's death are not major influences on the mourning outcome. The health of
the surviving spouse at the time of the death may or may not be a major factor in the
mourning outcome; the spouse may be healthy and still be dependent on the
partner.
A client is experiencing stomatitis as a result of chemotherapy. Which action should
the nurse take when caring for this client?
1
Provide frequent saline mouthwashes
2
Use karaya powder to decrease irritation
3
Increase fluid intake to compensate for accompanying diarrhea
4
Offer meticulous skin care of the abdomen with a gentle antiseptic - ANSWER 1
Saline mouthwashes are soothing to the oral mucosa and help clean the mouth,
minimizing infection. Stomatitis refers to the oral cavity; karaya is used to protect the
skin around a stoma created on the abdomen. Stomatitis does not cause diarrhea or
fluid loss. The abdomen is not involved; stomatitis is an inflammation of the oral
mucosa.
The primary health care provider has prescribed a stat chest x-ray exam and
electrocardiogram for a client with a history of heart failure. The pulse oximeter has
changed from 90% to 86% oxygen saturation. Which immediate actions will the
nurse take? Select all that apply.
1
Tell a staff member to get the electrocardiogram machine.
2
Notify the x-ray department that a chest x-ray exam must be done stat.
3
Have a staff member notify the nursing supervisor of the change in client status.
4
, Notify the healthcare provider of the change in the oxygen saturation to ask what to
do.
5
Tell the certified nursing assistant to get a prescription from the healthcare provider
to increase the oxygen.
6
Increase the supplemental oxygen without a prescription from 2 L nasal cannula to 4
L nasal cannula and notify the healthcare provider. - ANSWER This question makes
no sense to me......
1,2,3,6
A staff member can get the electrocardiogram machine and start the procedure.
Ancillary personnel are trained to do electrocardiograms even if they are not able to
interpret the results. Anyone can notify the x-ray department that the chest x-ray
exam must be done. It is important to delegate the tasks to a specific person.
Increasing the oxygen without a prescription is appropriate in the short term, but the
nurse must obtain a prescription when notifying the healthcare provider. Notifying the
healthcare provider of the change in oxygen saturation is appropriate, but it would be
expected that nursing judgment had taken place and the oxygen already was
increased from 2 L/min. Telling the certified nursing assistant (CNA) to get a
prescription is an inappropriate action as a CNA is not allowed to take medical
prescriptions. Taking a medical prescription is a nursing role.
A nurse uses the Braden Scale to predict a client's risk for developing pressure
ulcers. Which data should the nurse use to determine a client's score on this scale?
Select all that apply.
1
Age
2
Anorexia
3
Hemiplegia
4
History of diabetes
5
Urinary incontinence - ANSWER 2,3,4,5
Anorexia causes nutritional problems; nutrition is a category on the Braden Scale.
Hemiplegia causes mobility problems; this affects the categories of mobility, activity,
and friction on the Braden Scale. Clients with a history of diabetes can also have
peripheral neuropathy, causing numbness or loss of sensation in the hands in feet;
sensory perception is a category on the Braden Scale. Urinary incontinence causes
moisture, a category on the Braden Scale. Age is not used in the Braden Scale.
When donning sterile gloves, how should the second glove be handled?
1
Grasp by cuff and place on remaining hand.
2
Place sterile glove under cuff, and slide hand in glove.
3
A client is having a tonic-clonic seizure. Which is a priority nursing action?
1
Elevating the head of the bed
2
Restraining the client's arms and legs
3
Placing a tongue blade in the client's mouth
4
Taking measures to prevent injury - ANSWER 4
Protecting the client from injury is the immediate priority during a seizure. Elevating
the head of the bed would have no effect on the client's condition or safety.
Restraining the client's arms and legs could cause injury. Placing a tongue blade or
other object in the client's mouth could damage the teeth.
The nurse assesses an elderly client with a diagnosis of dehydration and recognizes
which finding as an early sign of dehydration?
1
Sunken eyes
2
Dry, flaky skin
3
Change in mental status
4
Decreased bowel sounds - ANSWER 3
Older adults are sensitive to changes in fluid and electrolyte levels, especially
sodium, potassium, and chloride. These changes will manifest as a change in mental
status and confusion. It is difficult to assess dehydration in older adults based on
sunken eyes, dry skin, and decreased bowel sounds because these can be
prominent as general normal findings in the elderly client.
A nurse uses the Braden Scale to predict a client's risk for developing pressure
ulcers. Which data should the nurse use to determine a client's score on this scale?
Select all that apply.
1
Age
2
Anorexia
3
Hemiplegia
4
History of diabetes
5
Urinary incontinence - ANSWER 2,3,4,5
Anorexia causes nutritional problems; nutrition is a category on the Braden Scale.
Hemiplegia causes mobility problems; this affects the categories of mobility, activity,
and friction on the Braden Scale. Clients with a history of diabetes can also have
,peripheral neuropathy, causing numbness or loss of sensation in the hands in feet;
sensory perception is a category on the Braden Scale. Urinary incontinence causes
moisture, a category on the Braden Scale. Age is not used in the Braden Scale.
A hospice nurse is caring for a dying client and his wife. What factor will be a major
determinant in the mourning outcome for the wife?
1
Duration of the relationship shared by the couple
2
Age of the wife at the time of the husband's death
3
Health of the surviving spouse at the time of the death
4
Importance of the deceased person as a source of support - ANSWER 4
The more dependent the client was on the deceased for support, the more difficult
the grieving process will be. Emotional and financial considerations are major
factors. The duration of the couple's relationship and the age of the wife at the time
of the man's death are not major influences on the mourning outcome. The health of
the surviving spouse at the time of the death may or may not be a major factor in the
mourning outcome; the spouse may be healthy and still be dependent on the
partner.
A client is experiencing stomatitis as a result of chemotherapy. Which action should
the nurse take when caring for this client?
1
Provide frequent saline mouthwashes
2
Use karaya powder to decrease irritation
3
Increase fluid intake to compensate for accompanying diarrhea
4
Offer meticulous skin care of the abdomen with a gentle antiseptic - ANSWER 1
Saline mouthwashes are soothing to the oral mucosa and help clean the mouth,
minimizing infection. Stomatitis refers to the oral cavity; karaya is used to protect the
skin around a stoma created on the abdomen. Stomatitis does not cause diarrhea or
fluid loss. The abdomen is not involved; stomatitis is an inflammation of the oral
mucosa.
The primary health care provider has prescribed a stat chest x-ray exam and
electrocardiogram for a client with a history of heart failure. The pulse oximeter has
changed from 90% to 86% oxygen saturation. Which immediate actions will the
nurse take? Select all that apply.
1
Tell a staff member to get the electrocardiogram machine.
2
Notify the x-ray department that a chest x-ray exam must be done stat.
3
Have a staff member notify the nursing supervisor of the change in client status.
4
, Notify the healthcare provider of the change in the oxygen saturation to ask what to
do.
5
Tell the certified nursing assistant to get a prescription from the healthcare provider
to increase the oxygen.
6
Increase the supplemental oxygen without a prescription from 2 L nasal cannula to 4
L nasal cannula and notify the healthcare provider. - ANSWER This question makes
no sense to me......
1,2,3,6
A staff member can get the electrocardiogram machine and start the procedure.
Ancillary personnel are trained to do electrocardiograms even if they are not able to
interpret the results. Anyone can notify the x-ray department that the chest x-ray
exam must be done. It is important to delegate the tasks to a specific person.
Increasing the oxygen without a prescription is appropriate in the short term, but the
nurse must obtain a prescription when notifying the healthcare provider. Notifying the
healthcare provider of the change in oxygen saturation is appropriate, but it would be
expected that nursing judgment had taken place and the oxygen already was
increased from 2 L/min. Telling the certified nursing assistant (CNA) to get a
prescription is an inappropriate action as a CNA is not allowed to take medical
prescriptions. Taking a medical prescription is a nursing role.
A nurse uses the Braden Scale to predict a client's risk for developing pressure
ulcers. Which data should the nurse use to determine a client's score on this scale?
Select all that apply.
1
Age
2
Anorexia
3
Hemiplegia
4
History of diabetes
5
Urinary incontinence - ANSWER 2,3,4,5
Anorexia causes nutritional problems; nutrition is a category on the Braden Scale.
Hemiplegia causes mobility problems; this affects the categories of mobility, activity,
and friction on the Braden Scale. Clients with a history of diabetes can also have
peripheral neuropathy, causing numbness or loss of sensation in the hands in feet;
sensory perception is a category on the Braden Scale. Urinary incontinence causes
moisture, a category on the Braden Scale. Age is not used in the Braden Scale.
When donning sterile gloves, how should the second glove be handled?
1
Grasp by cuff and place on remaining hand.
2
Place sterile glove under cuff, and slide hand in glove.
3
