NUR 337 Study Guide Exam Questions And Actual Answers.
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Course
NUR 337
Institution
NUR 337
During a mental status examination, a hospitalized client states that she cannot remember if she is married or if she has children.
The nurse would document this as an example of what aspect of the mental status examination?
Decreased judgment
Decreased level of knowledge
Poor insight
Poor r...
NUR 337 Study Guide Exam Questions
And Actual Answers.
During a mental status examination, a hospitalized client states that she cannot remember if she is
married or if she has children.
The nurse would document this as an example of what aspect of the mental status examination?
Decreased judgment
Decreased level of knowledge
Poor insight
Poor remote memory - Answer poor remote memory
Which of the following are examples of subjective assessment data? (Select all that apply)
Client states he has "no reason to live."
Client's speech is slow and soft.
Client has jaundiced skin color.
Client can recall three numbers.
Client "meditates for relaxation." - Answer Client states he has "no reason to live"
Client "meditates for relaxation"
While performing a mental status examination on a client, the nurse notices that the client has a
slouched posture.
This information should be documented as part of the client's ______________?
Appearance
Behavior
Thought Process
Judgment - Answer appearance
,Why is it important to label the dressing covering the site of an intravenous access device with the date,
time, and nurse's initials?
Reminds the nurse when to change the infusion tubing.
Informs the nurse and other staff when the next dressing change is due.
Reminds the nurse to document the insertion of the device.
Proves that the access site was assessed. - Answer Informs the nurse and other staff when the next
dressing change is due
The nurse is performing an IV insertion procedure on a client.
Which of the following actions puts the client at risk?
Select All That Apply.
Verify client's name and birthdate.
Place tape for anchoring the IV on the hospital bed railing or tray table so that it is handy
Touch the open hub of the IV catheter after removing the needle
Touch the area that has already been cleansed / prepared for the IV insertion
Perform hand hygiene - Answer Place tape for anchoring the IV on the hospital bed railing or tray table
so that it is handy
Touch the open hub of the IV catheter after removing the needle
Touch the area that has already been cleansed / prepared for the IV insertion
Which action would the nurse take first if an intravenous (IV) insertion site appeared red, warm, and
swollen?
Apply a heat pack.
Elevate the extremity the IV site is on.
Change the dressing.
Discontinue the infusion. - Answer Discontinue the infusion.
, What is the primary - and potentially most serious - danger related to a broken IV catheter tip?
Pain
Phlebitis
Embolus
Infection - Answer Embolus
What would the nurse do to assess a patient's risk for embolus when removing a venous access device?
Ask the patient to rate any pain at the site.
Palpate the site for possible edema.
Visualize the tip of the IV catheter.
Inspect for redness. - Answer Visualize the tip of the catheter
When should the tourniquet be released a second time during the procedure for insertion of a
peripheral intravenous device?
After flushing the newly-placed IV with sterile saline to verify patency.
Immediately after observing a "flashback" of blood in the catheter.
After a "flashback" of blood is observed and the catheter has been advanced off the stylet.
Immediately after the catheter punctures the skin. - Answer After a "flashback" of blood is observed
and the catheter has been advanced off the stylet.
A client states, "The voices keep telling me that my hands are dirty." What is the best response by the
nurse?
"I don't hear anything; you must be imagining it."
"Maybe you should wash your hands."
"I believe you are hearing the voices but I think it is a part of your illness because I cannot hear them."
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