1 | P a g e NUR280/ NUR 280 FINAL EXAM LATEST 2024 COMPREHENSIVE EXAM REVIEW WITH VERIFIED ANSWERS WITH RATIONALES GALEN COLLEGE The community health nurse is caring for the following clients. It would be a priority for the nurse to initiate a multidisciplinary conference for the client who is (a) 12 years old with Autism who is starting a new school and recently had a URI (upper respiratory tract infection) (b) 16 years old, has type 1 Diabetes Mellitus, is unemploye d and had a recent Hemoglobin A1c of 13% (c) 52 years old, with Myasthenia Gravis, recently prescribed Mestinon (pyridostigmine) and employed as a mail carrier (d) 70 years old, has schizophrenia, lives alone and reports hearing non threatening voices. - CORRECT ANSWER >>>3. B. An adolescent with uncontrolled Diabetes Mellitus would require the greatest number of disciplines (multidisciplinary) to manage their care i.e. Medicine, 2 | P a g e Nursing, Social Work, Nutritionist; the other choic es do not require as many providers of care to meet their needs. The nurse from the postpartum unit has been temporarily assigned to the medical surgical unit. It would be most appropriate to assign this nurse to the client who (a) has returned from ri ght total hip replacement surgery four hours ago (b) is being observed for increased intracranial pressure (c) had surgery two hours ago to remove the appendix (d) is two weeks post partum being maintained on a mechanical ventilator for respiratory failure - CORRECT ANSWER >>>4. C. The management of a client following abdominal surgery is standard. The postpartum nurse routinely cares for mothers following caesarean section; therefore it is appropriate to assign this client; The other choices are not approp riate to assign to this nurse. The nurse in a well baby clinic has assessed several children today. It would be a priority for the nurse to suggest follow up for the child who is (a) 2 months old with a positive babinski reflex (b) 5 months old and does not hold their own bottle (c) 10 months old who cries around strangers (d) 18 months old who needs support while ambulating - CORRECT ANSWER >>>5. D. A child experiencing normal growth and development should be ambulating independently by 12 months; the B abinski reflex disappears after 2 years of age; an infant typically holds their own bottle by 6 months; stranger anxiety usually develops at approximately 7 months 3 | P a g e The nurse is caring for a mechanically ventilated client who was declared brain dead. An Advance Directive is not documented on the medical record. It would be most appropriate to obtain consent for organ donation from the (a) client's primary care provider (b) client's nurse manager (c) closest living family member (d) hospital's ethics com mittee - CORRECT ANSWER >>>6. C. Consent for organ donation is given by a client's next of kin in the absence of an Advance Directive The nurse has received report on four clients. The nurse should first assess the client who has: (a) Chronic Obstructiv e Pulmonary Disease (COPD) with a pulse oximetry reading of 90% (b) Parkinson's Disease and is demanding to leave the hospital against medical advice (AMA) (c) been admitted with suspected Guillian Barre Syndrome and has begun plasmapheresis therapy (d) Congestive Heart Failure (CHF) whose pitting edema has increased to 2(+) - CORRECT ANSWER >>>7. C. The client admitted with Guillain -
Barre' Syndrome should be assessed first because of the possibility of rapid progression of this illness and neuromuscu lar respiratory failure; clients with COPD are likely to have pulse oximetry readings of 90% related to chronic hypoxia; this client along with the other two choices are important, but not the priority. It would be appropriate to assign which of these tas ks to the CNA? (a) Feeding a client who is experiencing dysphagia (b) One -on-one client observation for safety (c) Removal of an indwelling catheter 4 | P a g e (d) Performing a simple dressing change - CORRECT ANSWER >>>B. The Certified Nursing Assistant may be assig ned to a client that requires one- to-one observation for safety; the other choices require skilled nursing intervention by a LPN (Licensed Practical Nurse) or RN (Registered Nurse). The nurse should intervene if a staff member is observed: (a) discussin g a client's diagnosis with visiting family members (b) collaborating with another nurse to review a prescription for blood transfusion (c) interrupting other staff members discussing a client in the cafeteria (d) reviewing a clients lab values with the nutritionist - CORRECT ANSWER >>>9. A. To maintain confidentiality the nurse should not discuss the client's diagnosis with family members; it is advisable that two nurses review the prescription for blood transfusion to identify the client, blood type, R h factor, expiration date and the blood numbers; interrupting staff members discussing a client in a public place should be done to maintain client confidentiality; collaborating with the nutritionist is an appropriate nursing intervention. Safe Effective Care Environment; Management of Care The nurse is preparing a staff presentation on legal and ethical issues in nursing. The nurse would be correct to include which of the following examples? (a) Putting a client in a geriatric chair with the lap tray in front of the client in the day room to watch television is false imprisonment (b) Telling a client that you will put in a feeding tube if the client does not eat is an example of battery (c) Telling a client with bipolar disorder who is suicidal that they have a right to refuse to take their medications is an example of malpractice (d) Placing hands on a client who says "do not touch me" is an example of assault - CORRECT ANSWER >>>A. Putting a client in a geriatric chair with the lap tray in front of them restricts movement which constitutes
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