NURS 101 Final Exam Questions With 100% Correct Answers
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Course
NURS 101
Institution
NURS 101
NURS 101 Final Exam Questions With 100% Correct Answers
A client has an advance health care directive on file at a hospital that identifies a friend as the legal healthcare agent. A nurse is to obtain informed consent for the client to have an exploratory laparotomy. Because of sedation, the cli...
A client has an advance health care directive on file at a hospital that identifies a friend
as the legal healthcare agent. A nurse is to obtain informed consent for the client to
have an exploratory laparotomy. Because of sedation, the client is unable to sign the
form or give verbal consent. Who should provide consent for this client?
1. The client's spouse
2. The client's oldest adult child
3. Since the client is unable to give consent, the surgery cannot be performed.
4. The clients'durable power of attorney for healthcare. - Answer-Correct answer # 4 -
since the client has a durable power of attorney for health care that person is
designated to make healthcare decisions when the client is unable to do so.
1 & 2 - incorrect - The client's spouse & oldest adult child would not be able to give
consent.
3 - incorrect - Even though the client is unable to provide consent, the surgery may be
performed by following the legal process for obtaining consent.
/.A client informs a nurse that a physician is recommending a kidney biopsy. The client
fears the result will be cancer and would not want treatment. The client feels it would be
better just "not to know." which action should be taken by the nurse to determine if the
client understands his/her client rights?
1. Explain to the client that the physician is doing what is best for the client.
2. Inform the client of his/her right to make decisions based on personal values & beliefs
3. Encourage the client to talk with family & let the family decide
4. Talk with the physician about the client's fear of having the biopsy - Answer-Correct
answer # 2 - clients have the right to make decisions based on personal values &
beliefs.
1& 3 - incorrect - Physicians cannot make treatment decisions without the consent of
the client, nor may the family.
4 - incorrect - It is important to notify the physician about the client's fear of the biopsy,
however, it does not address the client's understanding of client's rights.
/.A client is admitted to a surgical unit. The client has multiple rings, a watch, and $65 in
cash. What is the safest action for a nurse to take regarding the valuables?
1. Allowing the client to keep the items so they will be safeguarded by the client
2. Collecting the items and placing them in the client's room closet
3. Giving the money to the client's spouse and allowing the client to keep the jewelry
4. Collecting the items according to hospital policy for safekeeping - Answer-Correct
answer # 4 - hospital policy will determine if the items were handled appropriately in the
case of loss
,1, 2 & 3 - incorrect - Although the hospital policy may allow the items to stay with the
client, to be in the room, or to be sent home with the spouse the safest action is to
follow hospital policy
/.A client is admitted with vancomycinresistant enterococci (VRE) in a leg wound. The
wound is draining although dressings are covering the wound. To prevent the spread of
VRE which is a nurse's best plan of action?
1. Assign the client to a private room
2. Assign only one caregiver to the pt
3. Do not allow pregnant staff to enter the room
4. Place the client in a negative air flow room - Answer-Correct answer # 1 - single client
rooms are preferred when there is a concern about transmission of an infectious agent.
2 - incorrect - It is not practical to assign only one caregiver as the client will likely
require multiple caregivers throughout the hospitalization
3 - incorrect - VRE is not spread to pregnant staff at higher rates than non pregnant staff
4 - incorrect - a negative air flow room is required for airborne diseases. VRE is not an
airborne disease.
/.A client who is on nothing by mouth status is constantly asking for a drink. Which of
the following is the most appropriate nursing intervention?
1. Re-explain to the client why she cannot drink.
2. Offer ice chips every hour to decrease thirst.
3. Offer the client frequent oral hygiene care.
4.Divert the client's attention by turning on the television. - Answer-Correct answer - 3 -
the most appropriate intervention is to offer the client frequent mouth care to moisten
the dry oral mucosa.
1 - incorrect - re-explaining why the client cannot drink may be helpful but will not relieve
her thirst.
2 - incorrect - Ice chips cannot be given to a client who is on NPO status.
4 - incorrect - Diverting the client's attention does not treat her complaint.
/.A hospitalized client diagnosed with end stage cancer has suddenly decided to
discontinue treatment. The client requests no additional treatment, such as antibiotics,
tube feedings, & mechanical ventilation. When acting as the client's advocate, which
action should a nurse take?
1. Respect the client's wishes & indicate those wishes on the plan of care
2. Encourage the client to share the decision with the family & the client's physician
3. Clarify other treatments that the client wishes to withhold.
4. Wait until additional treatment is required & then decide what to do based on the
client's condition - Answer-Correct answer # 2 - in advocating for the client the nurse
should encourage the client to share the decision with family & the physician. To
advocate for someone means to speak for that person when the person is unable to
, speak for their self. The client is still able to make his or her own decisions, which will be
better supported when the client shares with the family & physician.
1 - incorrect - although the wishes should be indicated on the plan of care this nurse
action does not demonstrate advocating for the client
3 - incorrect - A physician order is required to limit treatment
4 - incorrect - Although additional treatments should be discussed, the priority at this
time is the discussion with the family & physician.
/.A nurse admits a client who is experiencing nausea and vomiting to the ER. The client
is alone. The nurse completes an assessment & prepares to leave the room. Which is
the safest instructions for the client?
1. If you need to vomit, here is a basin for you. I don't want you to get up on your own.
2. I will be in the room next door. I'll check back in about 10 minutes
3. I will go update the doctor about you. Do you need anything before I go?
4. Here is the nurse call light. Press this button if you need me. - Answer-Correct
answer # 4 - a newly admitted client should be oriented to the new environment. One of
the most important features of safety is teaching the client how to use the call light; a
mechanism to signal staff members at all times is essential to client safety.
Making sure there is a basin available
/.A nurse assist a physician with the placement of a central venous catheter. The nurse
notices the physician brush his sterile glove against the client's bedspread. Which action
by the nurse demonstrates professional conduct?
1. Inform the Dr of the break in sterile procedure & provide new sterile gloves
2. Inform the Dr of the break in sterile procedure after the procedure is completed &
observe the CVC for infection
3. Notify the supervisor of break in sterile procedure
4. Report the event to the Infection Control Nurse to educate the Dr on proper sterile
procedure - Answer-Correct answer # 1 - the drshould be notified immediately of the
break in sterile procedure to reduce risk of infection to the client
2, 3 & 4 - incorrect - to wait until after the procedure is completed to talk with the dror to
report the event to someone else will not prevent this client from a hospital acquired
infection
/.A nurse calls a physician regarding a change in a client's condition. The physician
gives orders over the telephone for arterial blood gases (ABGs) to be drawn stat. which
is the most important safety consideration when obtaining the order?
1. Writing the order down & reading it back to the physician.
2. Calling the respiratory therapist stat to draw the ABGs
3. Giving the order stat to the health unit coordinator to place in the computer
4. Writing down the order for the ABGs immediately - Answer-Correct answer # 1 - The
Joint Commission National Patient Safety Goals requires telephone orders to be written
down & read back. This action will validate the accuracy of the order received.
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