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ASSESSMENT 1 PRE PROCTORIO FUNDAMENTALS (NURS 100) EXAM Q’S AND A’S
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ASSESSMENT 1 PRE PROCTORIO FUNDAMENTALS (NURS 100) EXAM Q’S AND A’S
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ASSESSMENT 1 PRE PROCTORIO FUNDAMENTALS(NURS 100) EXAM Q’S AND A’S
A nurse is preparing to apply a dressing for a client who has a stage 2
pressure injury. Which of the following types of dressing should the nurse
use? - -Hydrocolloid
(Hydrocolloid dressings promote healing in stage 2 pressure injuries by
creating a moist wound bed.)
- A nurse is caring for a client who has a terminal illness and is at the end of
life. The nurse should recognize that which of the following statements by
the client's partner indicates effective coping? - -"I am relying on support
from our family during this time."
(This statement indicates effective coping because the partner is relying on
others in the family for support during a time of crisis.)
- A nurse is assessing an older adult client's risk for falls. Which of the
following assessments should the nurse use to identify the client's safety
needs? (Select all that apply.) - -Pupil clarity
Visual fields
Visual acuity
-Pupil clarity is correct. Cloudy pupils mean that the client has cataracts. This
makes vision cloudy and creates halos around lights, which can increase the
risk for falls because clients cannot see items in their path clearly.
-Visual fields is correct. The nurse should use a finger to test the client's
peripheral vision by moving the finger out of range and then back into the
visual field to determine when the client sees the finger. Clients who have a
visual field impairment are at an increased risk for falls because they might
not see objects outside of their central vision and trip over them or bump
into them and fall.
-Visual acuity is correct. The nurse should use a Snellen chart to assess
distance vision and a handheld card to assess near vision. Clients who wear
eyeglasses should wear them during the assessments. Clients who have
impaired visual acuity are at an increased risk for falls because they might
not see objects in their path and trip over them or bump into them and fall.
- A nurse is evaluating a client's use of a cane. Which of the following
actions should the nurse identify as an indication of correct use? - -The
client holds the cane on the stronger side of her body.
(The client should hold the cane on the stronger side of her body to increase
support and maintain alignment.)
- A nurse is initiating a protective environment for a client who has had an
allogeneic stem cell transplant. Which of the following precautions should the
,nurse plan for this client? - -Make sure the client wears a mask when outside
her room if there is construction in the area.
(An allogeneic stem cell transplant compromises the client's immune system,
greatly increasing the risk for infection. The client will need protection from
breathing in any pathogens in the environment.)
- A nurse is providing discharge instructions to a client who will be using a
walker. Which of the following client statements indicates an understanding
of the teaching? - -"I will hire someone to trim the tree that hangs low over
the stairs of my front porch."
(Clearing stairs of any object that could cause the client to trip or require
them to bend over while walking will decrease the risk for falls.)
- A nurse is preparing to administer enoxaparin subcutaneously to a client.
Which of the following actions should the nurse take? - -Administer the
medication with the needle at a 45° angle.
(The nurse should insert the needle at a 45° to 90° angle for a subcutaneous
injection.)
- A nurse manager is preparing to review medication documentation with a
group of newly licensed nurses. Which of the following statements should the
nurse manager plan to include in the teaching? - -"Use the complete name
of the medication magnesium sulfate."
(The Institute for Safe Medication Practices designates that nurses and
providers write the complete medication name for magnesium sulfate when
documenting medications to avoid any misinterpretation of MgSO4 as MSO4,
which means morphine sulfate.)
- A nurse is talking with the partner of a client who has dementia. The
client's partner expresses frustration about finding time to manage
household responsibilities while caring for their partner. The nurse should
identify that the partner is experiencing which of the following types of role-
performance stress? - -Role overload
(The partner's expression of frustration is an example of role overload, which
refers to having more responsibilities within a role than one person can
manage.)
- A nurse is preparing an education program for staff about advocacy. Which
of the following information should the nurse include? - -Advocacy ensures
clients' safety, health, and rights.
(Advocacy is a key component of professional nurses' code of ethics. As a
client advocate, the nurse ensures clients' safety, health, and rights,
including the right to privacy, confidentiality, and refusal of care.)
- A nurse is caring for a client who has a new diagnosis of seizure disorder.
-Exhibit 1
, Nurses' Notes
0800:Client awake, alert, oriented to person, place, and time. Preparing for
discharge today. No seizure activity recorded during the night. Discharge
teaching provided to client and partner regarding a new prescription for
carbamazepine. Taught importance of taking medication twice daily as
prescribed, not to miss a dose, and not to double a dose if one is missed.
Advised client to avoid grapefruit and grapefruit juice while taking
carbamazepine. Reminded client that follow-up laboratory tests and eye
examinations will be necessary while on this medication. Client and partner
verbalized understanding of all medication teaching.
0900:On entry into client's room with discharge papers, client was found on
the floor seizing. Call button pressed to ask for additional help.
-Exhibit 2
Medication Administration Record
Carba - -The nurse should first address the client's *Physical safety* followed
by the client's *Positioning*
-Physical safety is correct. The greatest risk to the client is injury from the
seizure. Therefore, the first action the nurse should take is to ensure the
client's physical safety by protecting the client's head. The nurse should
cradle the client's head in their lap or place a pad underneath the head.
-Positioning is correct. The nurse should attempt to turn the client on their
side with their head tilted slightly forward. This position will protect the
client's airway from the aspiration of any secretions that may occur.
Therefore, this is the second action the nurse should take.
- A nurse is caring for a client who requires an NG tube for stomach
decompression. Which of the following actions should the nurse take when
inserting the NG tube? - -Have the client take sips of water to promote
insertion of the NG tube into the esophagus.
(Taking sips of water as the NG tube passes through the oropharynx will
close the epiglottis over the trachea and prevent the tube from passing into
the trachea.)
- A nurse is admitting a new client. Which of the following actions should the
nurse take while performing medication reconciliation? - -Compare the
client's home medications with the provider's prescriptions.
(The nurse should compare the client's home medications with the provider's
prescriptions when performing medication reconciliation.)
- A nurse is providing discharge teaching to a client about self-administering
heparin. Which of the following instructions should the nurse include in the
teaching? - -Administer the medication into the abdomen.
(The nurse should instruct the client to administer the medication into the
abdomen at least 5.08 cm (2 in) from the umbilicus. The client should pinch
or spread the skin at the injection site to administer the medication into the
subcutaneous tissue.)
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