Which nursing intervention is most likely to prevent respiratory complications such as pneumonia and atelectasis in a postoperative client? use of incentive spirometry
(would not be adequate fluid and nutrition)
The family members of a dying client have asked for the hospital chaplain's help in h...
NSG 321 Study Questions and 100%
Correct Answers
Which nursing intervention is most likely to prevent respiratory complications such as
pneumonia and atelectasis in a postoperative client? ✅use of incentive spirometry
(would not be adequate fluid and nutrition)
The family members of a dying client have asked for the hospital chaplain's help in
having a member of the clergy come to the client's bedside to perform the anointing of
the sick. What religion would this be? ✅Roman Catholic
A nurse observes that a client who underwent knee surgery 2 weeks ago needs
progressively larger doses of analgesics to get relief from pain. The nurse interprets this
as ✅dependence
Perioperative phase refers to what time in relation to surgery? ✅before, during and
after
An appendectomy would be what kind of surgery? ✅emergency surgery
The nurse recognizes common pain syndromes that cause neuropathic pain. Which
clients would the nurse place at risk for this type of pain? ✅a client with postherpetic
neuralgia
a client with phantom limb pain
a client with diabetic neuropathy
a client with complex regional pain syndrome
According to Shelly and Fish, which of the following is a spiritual need underlying all
religious traditions? ✅a need for meaning and purpose
A new nurse observes a priest visiting the clients every Saturday afternoon and praying
with them. This activity supports which of the nursing outcomes? ✅the client uses a
type of spiritual experience that provides her comfort
Allen is an 82-year-old retiree who recently relocated to senior apartments. The
apartments are not affiliated with any religious beliefs. Allen was raised in the Roman
Catholic church and has attended mass every Sunday since childhood. He has not
attended mass for 3 weeks. What best describes Allen's situation? ✅separation from
spiritual ties
What anesthesia is commonly used for a colonoscopy? ✅conscious sedation
,What characteristic is important to know for a bunionectomy (removal of bone tissue
from the base of the great toe)? ✅The patient arrives for the procedure and returns
home the same day
A client comes to the emergency department complaining of a shooting pain in his
chest. When assessing the client's pain, which behavioral response would the nurse
expect to find? ✅guarding of the chest area
Nurses assess clients who have physiologic responses to pain. Which examples of pain
response are physiologic responses? ✅Increased blood pressure
Muscle tension and rigidity
Nausea and vomiting
In which position would the surgical nurse place a patient undergoing minimally invasive
surgery of the lower abdomen or pelvis? ✅Trelendenburg position, in which the pt is
supine and feet are elevated at a 15-30 degree angle
The nurse is preparing to administer prescribed medication to a client who is Native
American/First Nations. The nurse enters the room and observes a shaman performing
a healing ritual for the client. What action would be the most appropriate by the nurse?
✅the nurse leaves the room and comes back when the shaman is finished
A client age 78 years with diabetes needs to have his toenails trimmed. It is important
for the nurse to do what? ✅cut the nails straight across
The charge nurse is reviewing SOAP format documentation with a newly hired nurse.
What information should the charge nurse discuss? ✅Subjective data should be
included when documenting.
Who can make the decision to apply restraints to a client? ✅nurse practitioner or
physician
A nurse is evaluating the effectiveness of health promotion teaching related to hygiene
at a community workshop. Which statements by the one of the participants requires
further teaching to ensure understanding? ✅WRONG STATEMENTS:
"It is important to brush your teeth regularly but flossing is not necessary since it can
damage the gums."
"Hygiene does not contribute to my well-being so I can choose to not perform hygiene."
"Hygiene measures have no affect on skin."
A nurse is at the end of a busy shift on a medical-surgical unit. The nurse enters a room
to empty the client's urinary catheter and the client says, "I feel like you ignored me
today." In response to the statement, the nurse should: ✅sit at the bedside and allow
the patient to explain the statement
, Home health care nurses frequently use the acronym DAME to assess the risk for
falling in older adults at home. What do the letters stand for? ✅D stands for drug and
alcohol use
A stands for age-related physiologic status
M is for medical problems
E represents environment
A nurse caring for the skin of clients of different age groups should consider which
accurately described condition? ✅An adolescent's skin ordinarily has enlarged
sebaceous glands and increased glandular secretions
The nurse receives a verbal order from a physician during an emergency situation.
What actions should be taken by the nurse? ✅1. read back the order
2. mark the date and time of the order
3. include V.O. (verbal order) and the physician name on the order
How can the nurse researcher obtain information from a client record? ✅study the
client records
Which of the following modifications to bathing should be implemented for a client who
is incontinent? ✅use special perineal cleansers and moisture barriers
What is a recommended guideline for caring for dentures? ✅store dentures in cold
water
A client in a long-term care facility has become increasingly unsteady. The nurses are
worried that the client will climb out of bed and fall. Which of the following measures
would be a high priority recommendation for this client? ✅place a client with a bed that
has an alarm
At what time only are verbal orders accepted by the nurse? ✅during emergency
situations
If a doctor is in a rush to get off the unit and says a verbal order for 2mg morphine as
needed q4h, what will the nurse's response be? ✅"Dr. ___, you will need to write an
order for this patient because this is not an emergency situation."
Which of the following are true regarding safety of the older adult while bathing? ✅Use
of a tub/shower seat may be necessary if balance problems are present.
Water temperature should be monitored carefully due to decreased temperature
sensation.
Use a long-handled shower brush or attachment to help with limited mobility.
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