NR 224 Final exam review

NR 224 Final exam review 1). A nurse is discussing the nursing process with a newly hired nurse. Which of the following statements by the newly hired nurse should the nurse identify as appropriate for the planning step of the nursing process? A. ” I will determine the most important client problems that we should address.” B. “I will review the past medical history on the client’s record to get more information.” C. “I will go carry out the new prescriptions from the provider.” D. “I will ask the client if his nausea resolved.” 2). A charge nurse is reviewing the nursing process with a group of nurses. Which of the following data should the nurse identify as objective data? (Select all that apply) A. Respiratory rate of 22/min with even unlabored respirations B. The client’s partner states, “He said he hurts after walking about 10 min” C. Pain rating is 3 on a scale of 10 D. Skin is pink, warm, and dry E. The assistive personnel reports the client walked with a limp 3). By the second postoperative day, a client has not achieved satisfactory pain relief. Based on this evaluation, which of the following actions should the nurse take, according to the nursing process? A. Reassess the client to determine the reasons for inadequate pain relief B. Wait to see whether the pain lessens during the next 24 hr. C. Change the plan of care to provide different pain relief interventions D. Teach the client about the plan of care for managing his pain 4). A nurse is caring for a client who fell at a nursing home. The client is oriented to person, place, and time and can follow directions. Which of the following actions should the nurse take to decrease the risk of another fall? (Select all that apply) A. Place a belt restraint on the client when he is sitting on the bedside commode. B. Keep the bed in its lowest position with all side rails up C. Make sure the client’s call light is within reach D. Provide the client with nonskid foot wear E. Complete a fall risk assessment 5). The nurse is assigned to care for four clients. In planning client rounds, which client should the nurse assess first? A. A client scheduled for a Chest X-ray B. A client requiring daily dressing changes C. A post-operative client preparing for discharge D. A client receiving nasal oxygen who had difficulty breathing during the previous shift 6. The nurse and the UAP are caring for clients on a med-surg unit. Which task should not be assigned to the UAP? A. Instruct the UAP to feed the 69 year old client who is experiencing dysphagia. B. Request the UAP turn and position the 89 year old client with a pressure ulcer C. Tell the UAP to assist the 54 year old client with toilet training activities D. Ask the UAP to obtain vitals on a 72 year old client diagnosed with pneumonia 7). Contact precautions have been initiated for a client with health care associated (nosocomial) infection caused by methicillin –resistant staphylococcus aureus. The nurse prepares to provide colostomy care and should obtain which protective items to perform this procedure? A. Gloves and Gown B. Gloves and Goggles C. Gloves, Gown, and Shoe Protectors D. Gloves, Gown, Goggles, and Face Shield 8). The nurse enters a client’s room and finds the wastebasket on fire. The nurse immediately assists the client out of the room, what is the next nursing action? A. Call for help B. Extinguish the fire C. Activate the Fire alarm D. Confine the Fire by closing the room door 9). A client who has had abdominal surgery complains of feeling as though “ something gave way” in the incisional site. The nurse removes the dressing and notes the presence of a loop of bowel protruding through the incision. Which nursing interventions should the nurse take? Select all that apply A. Contact the surgeon B. Instruct the client to remain quiet C. Prepare the client for wound closure D. Document the findings and actions taken E. Place a sterile saline dressing and ice packs over the wound F. Place the client in supine position without a pillow under the head 10). A nurse is monitoring the status of a post-operative client. The nurse would become most concerned with which sign that could indicate an evolving complication? A. Increasing restlessness B. A pulse of 86 beats per minute C. Blood pressure of 110/70 D. hypoactive bowel sounds in all four quadrants 11). A nurse is planning care for a client who is on bed rest. Which of the following interventions should the nurse plan to implement? A. Encourage the client to perform antiembolic exercises every 2 hours B. Instruct the client to cough and deep breathe every 4 hours C. Restrict the client’s fluid intake D. Reposition the client every 4 hours 12). The UAP tells the nurse that the client has a blood pressure of 78/46 and a pulse of 116 using a vital sign machine. Which intervention should the nurse implement first? A. Notify the health care provider immediately B. Have the UAP check the vital signs manually C. Place the client in reverse Trendelenburg position D. Assess the client’s cardiovascular status 13). A nurse is instructing a client, who has an injury of the left lower extremity about the use of a cane. Which of the following instructions should the nurse include? (Select all that apply). A. Hold the cane on the right side B. Keep two points of support on the floor C. Place the cane 38 cm (15in) in front of the feet before advancing D. After advancing the cane move the weaker leg forward E. Advance the stronger leg so that if aligns evenly with the cane 14). A nurse is contributing to the plan of care of a patient being admitted to the facility with a suspected diagnosis of pertussis. Which of the following interventions should the nurse include in the plan of care (Select all that apply) A. Place the client in a room that has negative air pressure of at least six exchanges per hour B. Wear a mask when providing care within 3 f t of the client C. Place a surgical mask on the client if transportation to another department is unavoidable D. Use sterile gloves when handling soiled linen E. Wear a gown when performing care that might result in contamination from secretions 15). A nurse educator is reviewing the wound healing process with a group of a nurses. The nurse educator should include the information of the following alterations for wound healing by secondary intention? (Select all that apply). A. Stage III pressure ulcer B. Sutured surgical incision C. Casted bone fracture D. Laceration sealed with adhesive E. Open burn area 16). The nurse is preparing to insert a NG tube into a client. The nurse should place the client in which position for insertion? A. Right side B. Low Fowlers C. High Fowlers D. Supine with head of the bed flat 17). A nurse is preparing to administer medications through a NG tube that is connected to suction. To administer the medication the nurse should take which action? A. Position the client supine to assist in medication absorption B. Aspirate the NG tube after medication administration to maintain patency C. Clamp the NG tube for 30-60 minutes following administration of the medication. D. Change the suction setting to Low Intermittent suction for 30 minutes after medication administration 18). A client is being weaned from parenteral nutrition and is expected to begin solid food today. The ongoing solution rate has been 100ml/hr. The nurse anticipates that which prescription regarding the PN solution will accompany the diet prescription? A. Discontinue the PN B. Decrease the PN rate to 50ml/hr C. Start 0.9% NS at 25ml/hr D. Continue the current infusion rate prescribed 19). A post operative client has been placed on a clear liquid diet. The nurse should provide the client with which items that are allowed to be consumed on this diet? (Select all that apply) A. Broth B. Coffee C. Gelatin D. Pudding E. Vegetable juice F. Pureed Vegetables 20). A client has an indwelling catheter reports a need to urinate. Which of the following actions should the nurse take? A. Check to see whether the catheter is patent B. Reassure the client that it is not possible for her to urinate C. Recatheterize the bladder with a larger gauge catheter D. Collect a urine specimen for analysis 21). A nurse is caring for a client who has a tracheostomy. Which of the following actions should the nurse take when providing tracheostomy care? (Select all that apply) A. Apply oxygen source loosely if the SPO2 decreases during the procedure B. Use surgical asepsis to remove and clean the inner cannula C. Clean the outer surface in a circular motion from the stoma site outward D. Replace the tracheostomy ties with new ties E. Cut a slit in the gauze squares to place beneath the tube holder 22). A nurse is working with a newly licensed nurse who is administering medications to clients. Which of the following actions should the nurse identify as an indication that the newly hired nurse understands medication error prevention? A. Taking all the medications out of the unit-dose wrappers before entering the clients room B. Checking with the provider when a single dose requires administration of multiple tablets C. Administering a medication then looking up the usual dosage range D. Relying on another nurse to clarify a medication prescription 23). A primary health-care provider prescribes a medication that must be administered via the intramuscular route. Which site should the nurse eliminate from consideration because it has the highest potential for injury when administering an intramuscular injection:? A. Vastus lateralis B. Rectus femoris C. Ventrogluteal D. Dorsogluteal 24). A nurse is administering an intradermal injection. At which angle should the nurse insert the needle? A. 90-degree angle B. 45-degree angle C. 30-degree angle D. 15-degree angle