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NUR 2530 EXAM 2 practice questions with correct answers

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NUR 2530 EXAM 2 practice questions with correct answers The nurse prepares to give a bath and change the bed linens of a client with cutaneous Kaposi's sarcoma lesions. The lesions are open and draining a scant amount of serous fluid. Which would the nurse incorporate into the plan during the b...

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  • November 13, 2024
  • 16
  • 2024/2025
  • Exam (elaborations)
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NUR 2530 EXAM 2 practice questions
with correct answers

The nurse prepares to give a bath and change the bed linens of a client with cutaneous

Kaposi's sarcoma lesions. The lesions are open and draining a scant amount of serous

fluid. Which would the nurse incorporate into the plan during the bathing of this client?


A. wearing gloves


B. wearing a gown and gloves


C. wearing a gown, gloves, and a mask


D. wearing a gown and gloves to change the bed linens, and gloves only for the bath -

ANSWER✔✔-B. wearing a gown and gloves


Rationale: Gowns and gloves are required if the nurse anticipates contact with soiled

items such as those with wound drainage or is caring for a client who is incontinent

with diarrhea or a client who has an ileostomy or colostomy. Regardless of the amount

of wound drainage, a gown and gloves must be worn.


The nurse provides home care instructions to a client with systemic lupus

erthyematosus and tells the client about methods to manage fatigue. Which statement

by the client indicates a need for further instruction?

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,A. "I should take hot baths because they are relaxing."


B. "I should sit whenever possible to conserve my energy."


C. "I should avoid long periods of rest because it causes joint stiffness."


D. "I should do some exercises, such as walking, when I am not fatigued." -

ANSWER✔✔-A. "I should take hot baths because they are relaxing"


Rationale: To help reduce fatigue in the client with lupus, the nurse should instruct the

client to sit whenever possible, avoid hot baths (they exacerbate fatigue), schedule low-

impact exercises when not fatigued, and maintain a balanced diet.


A client develops an anaphylactic reaction after receiving morphine. The nurse should

plan to institute which actions? Select all that apply.


A. Administer oxygen


B. Quickly assess the clients respiratory status.


C. Document the event, interventions, and client's response.


D. Leave the client briefly to contact a primary health care provider (HCP).


E. Keep the client supine regardless of the blood pressure readings.


F. Start an intravenous (IV) infusion of D5W and administer a 500ml bolus. -

ANSWER✔✔-A, B, C. - administer oxygen, assess respiratory status, and

documentation.


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, Rationale: An anaphylactic reaction requires immediate action starting with quickly

assessing the clients respiratory status. Although the PHCP and RRT team must be

notified immediately, the nurse must stay with the client. Oxygen is administered and

an IV of normal saline is started and infused per PHCP prescription. Documentation of

the event, actions taken, and client outcomes needs to be performed. The HOB should

be elevated if the client's blood pressure is normal.


The nurse is conducting a teaching session with a client on their diagnosis of

pemphigus. Which statement by the client indicates that the client understands the

diagnosis?


A. "My skin will have tiny red vessels"


B. "The presence of the skin vesicles is caused by a virus."


C. "I have an autoimmune disease that causes blistering in the skin."


D. "Red, raised papule and large plaques covered by silvery scales will be present on

my skin." - ANSWER✔✔-C - "I have an autoimmune disease that causes blistering in

the skin."


Rationale: Pemphigus is an autoimmune disease that causes blistering in the epidermis.

The client has large flaccid blisters (bullae). Because the blisters are in the epidermis,

they have a thin covering of the skin and break easily, leaving denuded areas of skin.

On initial examination, clients may have crusting areas instead of intact blisters.



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