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NURS 3005 Concepts - Exam 1 Review Questions and Answers
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NURS 3005 Concepts - Exam 1 Review2020 Hospital Patient Safety Goals - ✅✅ -purpose: improve patient safety; goals focus on
problems in healthcare safety and how to solve them
> identify patients correctly
> improve staff communication
> use medicines safely
> use alarms safely
> prevent infection
> identify patient safety risks
> prevent mistakes in surgery
A child is playing soccer and is involved in a head-to-head collision with another player.
Which assessment findings should the nurse be alert to that may indicate a concussion?
Select all that apply.
a. Drowsiness
b. Fever
c. Headache
✅✅
d. Increased thirst
e. Vomiting - -a. Drowsiness
c. Headache
e. Vomiting
Concussions are a frequently seen sports injury in school-age children. Nurses should be
aware of symptoms that may indicate that a concussion or more serious head injury is
present. Symptoms of a concussion include headache, vomiting, problems with balance,
fatigue, dazed or stunned appearance, difficulty concentrating and remembering, confusion,
forgetfulness, irritability, nervousness, very emotional behavior, drowsiness, difficulty falling
asleep, and sleeping more or less than usual. Fever and increased thirst are not symptoms
usually seen with a concussion.
A client asks what trochanter rolls are used for when providing client care. What is the
appropriate nursing response?
a. "To preserve your functional ability to grasp and pick up objects."
b. "To prevent foot drop."
✅✅
c. "To avoid contractures."
d. "To prevent your legs from rotating outward." - -d. "To prevent your legs from rotating
outward."
Trochanter rolls prevent the client's legs from rotating outward. The other statements do not
describe trochanter rolls. Hand rolls preserve the client's functional ability to grasp and pick
up objects and help the client avoid contractures. Foot boards prevent foot drop.
, ✅✅
A client expresses concern that there is an increase in urine output after exercising. How
would the nurse address the client's concern? - -> Explain that urination after exercise
is a result of increased circulation to the kidneys and is a normal function
> Assess cardiovascular function and blood pressure
> Ask the client to provide details of the exercise regimen including frequency and type
> Evaluate for diabetes mellitus
Urination after exercise is a result of increased circulation to the kidneys and is a normal
function. Especially in overweight individuals, the elevated heart rate from exercise can
cause temporary high blood pressure and one of the body's first defense mechanisms for
high blood pressure is to decrease blood volume, hence fluid is excreted as urine. Certain
exercises can increase pressure on the bladder causing the sensation that urination is
needed, even if the bladder is not full. While there are several causes that may be benign
reasons for increased urination, it can also be caused by more significant issues, including
diabetes and urinary tract infections that are not caused by or related to exercise. Therefore,
conducting a comprehensive assessment of physical activity, cardiovascular health, and
testing for diabetes is needed to determine if increased urine output is due to exercise.
✅✅
A client had a mild stroke with residual left sided weakness. While teaching the client about
walking with the cane, the nurse will offer which instruction? - -Hold the cane on your
right side
Rationale: cane is being used due to weakness, so it should be placed on the "stronger"
side, which is the right side in this case. Client should stand tall and not lean on the cane
A client has been ordered nasal drops, which the nurse will administer. How should the
nurse best position the client?
a. Lying flat, with the head extended as much as the client can tolerate
b. Seated at a 45-degree angle with the nares flared
✅✅
c. Supine, with the neck in a neutral position
d. Upright, with head tilted back - -d. Upright, with head tilted back
✅✅
A client has undergone foot surgery and will use crutches in the short term. Which teaching
point should the nurse provide to the client? - -"Your elbows will be slightly bent when
you are using your crutches."
rationale: When using crutches, the elbow should be slightly bent at about 30 degrees, and
the hands, not the armpits, should support the client's weight. Supervision of the client
learning to use crutches should not be performed by unlicensed assistive personnel (UAP).
The client should stop ambulating and sit down if fatigued.
A client who has been lying prone reports shortness of breath and a sensation of choking.
Into which position will the nurse place the client?
,a. supine
b. prone
✅✅-d. Fowler's
c. Sims'
d. Fowler's -
Fowler's position, a semi-sitting position, will assist the client with dyspnea because this
position allows the abdominal organs to drop away from the diaphragm. The other position
choices do not promote oxygenation.
A client who is enrolled in Medicare and who has been recovering in the hospital from a
stroke has developed a pressure injury on the coccyx, an event that the Centers for
Medicare & Medicaid Services (CMS) has identified as a "never event." The nurse should
recognize what implication of this CMS designation?
a. The hospital must bear any costs incurred for treating the client's injury.
b. The hospital will be fined by CMS because the client developed a pressure injury.
✅✅
c. CMS will bear the hospital's costs if the client chooses to sue the hospital.
d. CMS may choose to divert clients to other health care facilities in the future. - -a.
The hospital must bear any costs incurred for treating the client's injury.
If "never events" occur while a client is hospitalized, the cost of the care associated with that
event will not be paid by CMS, but will be borne by the hospital. Fines are not levied against
the hospital, however, and CMS does not actively divert clients to other facilities. CMS does
not pay damages on behalf of hospitals.
A client with a hip fracture is returning to the orthopedic unit, and the orders indicate that the
client should be turned by logrolling. Which statement regarding logrolling is correct?
a. Use a drawsheet or a friction-reducing sheet to facilitate smooth movement.
b. Logrolling can be performed by one experienced nurse.
✅✅-a. Use a
c. Logrolling will maintain straight alignment when the client is sitting in a chair.
d. It is acceptable to twist the client's head, but not the hips, while logrolling. -
drawsheet or a friction-reducing sheet to facilitate smooth movement.
Logrolling requires the assistance of two or three nurses. Logrolling will maintain straight
alignment when the client is being turned. The nurse should use a drawsheet or a
friction-reducing sheet to facilitate smooth movement. The nurse should avoid twisting the
client's head, spine, shoulders, knees, or hips while logrolling. A chair is not used with
logrolling.
A client with limited mobility has an outward rotation of the bony protrusions at the head of
the femur. Which assistive device would the nurse include in the plan of care?
a. trochanter rolls
b. footboards
✅✅-a. trochanter rolls
c. foot splints
d. roller sheets -
, Trochanter rolls prevent the legs from turning outward. The trochanters are the bony
protrusions at the heads of the femurs, near the hip. Placing positioning devices at the
trochanters helps prevent the legs from rotating outward. Other devices are inappropriate for
this client.
A client's EHR states that two medications are due at the same time, both of which are
available in vials and are to be administered by injection. What is the nurse's most
appropriate action?
a. Recognize that it is not safe to mix two medications in one syringe.
b. Page the health care provider to determine whether the drugs can be mixed.
✅✅
c. Determine the compatibility of the two drugs by consulting clinical resources.
d. Collaborate with the pharmacy to have one of the times changed. - -c. Determine the
compatibility of the two drugs by consulting clinical resources.
The nurse must determine the compatibility of the two drugs; some drugs can be safely
combined in a single syringe. However, this is not determined by paging the health care
provider. There is no need to change the times of administration.
A confused client is pulling at the IV line. When considering alternatives to restraints, which
nursing intervention would be used first?
a. Request a sedative from health care provider
b. Conceal IV tubing with gauze wrap
✅✅
c. Ask visiting family members to stay
d. Assure bed alarms are activated - -b. Conceal IV tubing with gauze wrap
Wrapping the IV line provides protection for the site. Medications used to control behavior
can be considered a chemical restraint that is an intervention of last resort. The presence of
a family member may assure client safety and alleviate client anxiety, but would not
necessarily protect the IV site. As well, it is inappropriate to delegate client safety
observation to family members. Bed alarms alert the nurse to the client leaving his or her
bed, but not interference with the IV site.
A father asks the nurse who is caring for his 13-year-old daughter why his daughter could be
performing poorly in school lately, and why she is distancing herself from friends and family.
Which of these possibilities would the nurse consider as the priority risk?
a. She may be the victim of cyber-bullying.
b. She has lost interest in academics because she has a boyfriend c. now.
✅✅-a. She
c. She may be beginning her menses.
d. She may be developing nutritional deficiencies from poor dietary habits. -
may be the victim of cyber-bullying.
Symptoms of cyber-bullying include faltering school achievement, absenteeism, health
concerns, isolating oneself from peers/friends, and increased anxiety and depression
symptoms. Adolescents may neglect academics when involved in personal relationships, but
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