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NRSG 2220 NEW EXAM WITH COMPLETE SOLUTIONS
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The client has just returned from surgery. The client asks you fir an extra dose of pain medication. What would be some signs that the clients is in severe pain?
- elevated respiratory rate
- decreased bp
A client is alert but nonverbal after a motor vehicle accident. Which action(s) will the nurse include in the assessment of pain for this client? Select all that apply.
Grimacing and other visible evidence of pain
Utilization of the Wong Baker FACES pain rating scale
Loss of function of the extremities
Writing to the client
Axillary and apical pulse
The nurse is working with a postsurgical client who, along with his family, has varied opinions about the amount of pain that the client is in. What is the most effective way to educate the client and family regarding pain and pain relief?
Discuss with the family that the client is the best person to describe its level
The nurse likes using humor to assist clients manage painWhat guide should a nurse follow in using humour to promote relief of pain?
Humour should take into consideration the personality of the client and the circumstantial events.
A nurse is caring for an older adult client who has experienced an ankle fracture. The client states, "I don't have any pain." What will the nurse do?
Check the client for nonverbal signs of pain
A client is postoperative day 1 and during assessment by the nurse, it is noted that the client is grimacing and guarding Which is the most valid way to assess the client's pain?
Ask the client to rate and describe the intensity of the pain
During a head-to-toe assessment of a client, the nurse carefully palpates the client's nails Which is the best rationale for this technique?
To evaluate capillary refill and oxygenation
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What assessment technique would the nurse use to assess a client's chest for color, shape, or contour?
Inspection
The nurse is going to start a health assessment with a new client. Which nursing consideration will promote a safe and appropriate environment to perform the health assessment?
The room is private, quiet, warm, and free of draft and light.
The nurse is performing a health assessment on a client. Which subjective data would the nurse collect about the client's sleep pattern?
Client states that he only sleeps 2 hours at night
A nurse is preparing a client for a physical assessment The client appears anxious
care-associated infection? Select all that apply
Standard precautions including gloves and hand hygiene
Place client in a private room for safety precautions
Transmission-based precautions including appropriate disinfection of equipment
The nurse is caring for a client in protective isolation due to neutropenia related to chemotherapy. What priority precaution should the nurse institute in this client?
Watch client for depression and loneliness
When would the nurse need to institute the visible PPE intervention?
suctioning a tracheostomy
The nurse is about to enter a client's room who is on airborne precautionsWhich of the following methods would the nurse perform when donning an N-95 mask? Select all that apply
the mask covers the nose and mouth
replace the mask after 20-30 min
tie the upper strings of the mask snugly against back head
What are the general nursing care guidelines that the nurse should follow while caring for the clients in a health care facility?
Avoid wearing of artificial nails
A nurse is performing the changing of the bed linen of a client who has been admitted in the healthcare facility. Which precaution for prevention of infection, the nurse should
perform
standard precaution
When preparing to take a client's blood pressure, the nurse notices that the sphygmomanometer is visibly dirty. What is the appropriate action by the nurse?
Cleanse and disinfect the sphygmomanometer.
The client is worried about " catching the flu" What key Information can the nurse teach the client to best prevent the spread of infection?
Hand hygeine
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The older adult client states, "I do not understand why I have had so many episodes of infection lately." What is the nurse's best response?
"As we age, our immune system does not function as well."
The nurse is about to reposition an older adult client who has vancomycin-resistant enterococci. What precautions will the nurse implement?
Contact
Alice Jones, registered nurse, recording pain assessment after administration of pain medication in the client's medical record. How should the nurse document this -assessment?
Client reports pain at 2 on a scale of 0-10 A. jones, RN
What client information is considered subjective?
Generalized myalgia or muscle ache
While bathing the client, the nurse notices that the client is grimacing. The nurse asks if the client is having pain. The client nods yes and refuses to continue the bath. The nurse removes the wash basin, makes the client comfortable, and documents the event in the client's chart. Which action clearly demonstrates assessing?
Asking whether the client is having pain
Which of the following statements by the nurse would provide data that would be documented as objective data in an assessment?
"The client's right leg is cold to the touch, from the knee to the foot."
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The nurse is providing education to a newly diagnosed hypertensive client regarding the use of taking his or her own BP at home. The client asks why it is so important to do this. What is the best response by the nurse?
"Monitoring your BP at home will assist in controlling your BP, thereby decreasing your risk for heart attack and stroke."
A nurse is teaching client how to monitor the radial pulse after discharge from the hospital Which instruction by the nurse is most appropriate?
Use the fingertips of your second and third fingers.
A hospital unit has a policy that rectal temperatures may not be taken on clients who have had cardiac surgery. What rationale supports this policy?
Thermometer insertion stimulates the vagus nerve.
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When conducting hourly rounds, a client states that he is "different than earlier in the day what time frame will the nurse check the client's vital signs?
immediately
A nurse is completing an incident report about an older adult client who fell while trying to transfer from the bed to a commode. When evaluating the client for future fall risk, the nurse will focus on assessing what?
Lying, sitting and standing bp
A client is admitted to the emergency department with heavy bleeding from a crushing injury at work. Which of the following sets of vital signs does the nurse expect to see in this client?
Blood pressure 80/50 mm Hg, heart rate 120 beats/min, respiratory rate 24 breaths/min
When beta blocker medications are prescribed, the health care provider adds an order to withhold medication when the client is bradycardic. Which statement describes the rationale for this order?
The client's pulse rate is less than 60 beats/min.
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The nurse is checking the pulse of a young adult who is preparing for a triathlon event. The pulse is 48 beats/min. Which is the appropriate education regarding a pulse rate provided by the nurse to the client?
"Your heart rate is within normal limits based on the exercise regimen you are participating in"
- Faint, clear tapping sounds increasing in intensity
- Muffled, swishing sounds that may temporarily disappear
- Distinct loud sounds
- Distinct, abrupt, muffling sounds of a blowing quality
- Sound followed by loss of all sounds
The nurse is performing vital signs for multiple clients. While obtaining body temperature, the nurse must consider which of the following? Choose all that apply
An oral temperature can be obtained if the client has oxygen by nasal cannula.
Tympanic temperature readings closely approximate core body temperature.
Temporal artery thermometer readings can be affected by perspiration or air blowing over the face
Temperature assessment can be delegated to the unlicensed assistive personnel
The nurse is providing care for a client diagnosed with orthostatic hypotension. When evaluating the client's blood pressure, the nurse should do which of the following? (Select all that apply)
check and record bp taken while the client is in the bed
- have client stand and wait 2-3 min before taking bp
- use the same bo cuff for all readings
- record measurements and note if the drop is >20 mm/Hg systolic and >10mm/Hg diastolic
The nurse is going to take a child's temperature using a temporal artery thermometer. For which reason(s) would the nurse choose this method of obtaining temperature in this client? Select all that apply.
-Children cannot always keep their lips closed tight enough to obtain a true reading.
-The temporal temperature is near the oral temperature readings.
-Research indicates that temporal thermometers are more accurate.
-There is a built-in verification of temperature by touching behind the ear.
Which action is acceptable for the nurse to perform when assessing blood pressure?
Elevate the client's arm above the head for 30 seconds to relieve congestion of blood in the limb, which will make the sounds louder and more distinct.
An older adult client describes dizziness when standing. The nurse takes blood pressure and pulse rate after the client has been seated and then again after standing. The nurse notes that the blood pressure has dropped 20 mm Hg and the pulse rate has increased 20 beats/min. What teaching by the nurse is significant to reduce the frequency of orthostatic hypotension for this client? Select all that apply.
rise slowly when standing from sitting or lying
drink at least 6-8 glasses of fluid daily if allowed
eat small frequent meals throughout the day
avoid prolonged periods of sitting or standing, especially after a meal
The nurse is educating a client about factors that can temporarily change blood pressure. Which fluctuation(s) will the nurse include when educating the client? Select all that apply
time of day
physical activity
acute pain
Over the course of a day, a nurse encounters many different clients whose pulse rates she must measureFor which client(s) will the nurse measure the apical pulse? Select all that apply
client who is on a med that has arrhythmia as a side effect
The nurse is teaching a client methods to enhance their cardiac output. What topic does the nurse include in the teaching?
exercise
The nurse recognizes a variation in systolic blood pressure between the client's arms. Based on this variation in blood pressures, how will the nurse plan for future readings?
The nurse will utilize the arm with the highest reading.
A client who is 86 years old and has vascular dementia and cardiomyopathy begins to show signs and symptoms of pneumonia. The nurse has tried an oral thermometer, but this client does not follow the direction to close the mouth and place the thermometer sublingually. The nurse has also tried a tympanic thermometer and the client immediately pulls her head away as soon as the nurse makes this approach. How does the nurse proceed with this temperature assessment?
Measure the temperature of this client by axilla
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An obese client has peripheral edema from a diagnosis of heart failure that makes it impossible for the student nurse to obtain an accurate palpation of the client's peripheral pulses. How does the nurse assess this client further?
Auscultate the client's apical pulse
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A nursing student is obtaining a client's vital signs and has announced to the client each of their next actions before measuring the client's temperature, pulse, and blood pressure. The nursing student does not announce their intention to obtain the client's respiratory rate prior to taking the measurement. What is the explanation for the nursing
student not announcing this action?
Changing the rate of respirations because the client is aware of the counting of his breaths.
