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NU 136 EXAM 1 LATEST EXAM | QUESTIONS AND
CORRECT ANSWERS | GRADED A+ | LATEST
VERSION (JUST RELEASED) | VERIFIED ANSWERS
The nurse assesses that her 83-year-old client has a temperature of 96.9. What should the nurse do next? ---------CORRECT ANSWER----------------- document the findings The nurse preceptor should step in and correct the nursing student if the preceptor observes which of the following? ---------CORRECT ANSWER---- -------------1. The student returns unused linens to the linen cart
- the student log rolls the client without any assistance When caring for a client diagnosed with C. Diff what. should the nurse implement ( select all that apply) ---------CORRECT ANSWER-----------------
- Wash hands with soap and water before and after care of the client
- place the client on contact precaution isolation The nurse understands that reasons for not taking blood pressure readings in the arm includes ---------CORRECT ANSWER-----------------1. intravenous (IV)access in the arm
- a mastectomy that was previously performed
- Hemodialysis shunt that is present Which of the following clients are at a higher risk of injury while admitted to the hospital? (select all that apply) ---------CORRECT ANSWER--------------- --1. The client diagnosed with dementia
- the client using mobility aids
- the use of ventilators to maintain proper airways
Taking the client's temperature from the site requires extreme caution so as to not injure the client ---------CORRECT ANSWER-----------------Rectal Place these in order of the client you would see first to the client that you would see last (from top to bottom) ---------CORRECT ANSWER--------------- --1. The client complaining that they have to take more than usual of albuterol.
- The 56 yr client that weights 95 pounds asking for a 2nd breakfast tray
- the client complaining of new pain in their bilateral lower extremities
- the 67 yr client with questions about their discharge orders Based on Meslow's hierarchy of needs, which client should the nurse assist first> ---------CORRECT ANSWER-----------------The client who is visually impaired and needs help cleaning their glasses The client who ensures they eat a proper diet and exercises regularly is engaging in which type of prevention ---------CORRECT ANSWER------------ -----Primary prevention A suspected rape victim is brought into the ER, but they don't remember anything that happened. This defense mechanism is ---------CORRECT ANSWER-----------------Repression
The nurse assists with the evaluation of a client's plan of care. it is determined that the client has not met their goals. Which of the following should the nurse expect to happen next? ---------CORRECT ANSWER------- ----------The care plan will be reviewed and revised as needed The nurse is caring for a client who states, "I'm burning up and think I might have a fever." the nurse proceeds with checking the client's temperature. The nurse is preforming which of the following steps of the nursing process? ---------CORRECT ANSWER-----------------Data collection The nurse is preparing to implement nursing intervention for an assigned client. The nurse should remember to ---------CORRECT ANSWER----------- ------Maintain client safety when performing intervention The nurse is assisting with the development of care plan. which of the following should the nurse recognize as a correctly written goals regarding pain management ---------CORRECT ANSWER-----------------The client will have a pain level of 3 or less by the end of the shift as evidenced by the client's rating of pain The nurse demonstrated to a new mother how to safely bathe their newborn baby. which of the following steps of the nursing process is the nurse performing? ---------CORRECT ANSWER----------------- Implementation The nurse preceptor is discussing with a newly hired nurse about the best time to perform data collection on a client. The nurse preceptor should include to preform this ---------CORRECT ANSWER-----------------With each client encounter
The nurse has received the change of shift report and is preparing to start their day. which of the following situations requires the nurse to follow up first ---------CORRECT ANSWER-----------------Obtaining further information from a client who is reporting crushing chest pain The nurse is caring for a client who has been admitted for an elective surgery. While preparing the client for surgery, the nurse notices that the client's oxygen saturation (sa02) has fallen below the normal level and is at 84%. Using critical thinking, the best action by the nurse is to --------- CORRECT ANSWER-----------------Hold the client form surgery and notify the surgeon The student nurse has learned about the steps in the nursing process. which of the following describes data collection ---------CORRECT ANSWER-----------------Gathering and reviewing client information The student nurse ask "How does knowing the nursing diagnosis assist the LPN/LVN the best response is based on understanding that --------- CORRECT ANSWER-----------------Nursing diagnosis which step of the nursing process is it when an LPN/LVN is assisting the RN in the development of goals and intervention for a patient's plan of care ---------CORRECT ANSWER-----------------Planning The student nurse ask "How does knowing the nurse diagnosis assist the LPN/LVN" The best response is based on understanding that --------- CORRECT ANSWER-----------------Nursing diagnosis identifies the patient's problems
The RN head nurse is having a busy day. When the LPN/LVN reports data she has collected, the RN states "incorporate that into the nursing care plan and write down the intervention you would use. I will cosign the entry" The LPN/LVN should ---------CORRECT ANSWER-----------------Tell the RN that this action is not within the LPN/LVN scope of practice The LPN/LVN learns at the report that a patient's priority problems are pain and inability to ambulate associated with arthritis. During the patient's bath, he becomes short of breath. The LPN/LVN should implement interventions based on ---------CORRECT ANSWER-----------------The patient's changing status Which outcome would be appropriate to include in the nursing care plan of a patient who has undergone total knee replacement ---------CORRECT ANSWER-----------------The patient will transfer from the bed to chair with assistance of a walker and one staff member by the third postoperative day For client baths what should the nurse ensure she should do for her elderly clients? select all that apply ---------CORRECT ANSWER-----------------1. Take into consideration the client's personal preferences
- pat dry their skin instead of wiping them dry with a towel.
- never leave the client during the duration of the shower Secondary illness means ---------CORRECT ANSWER-----------------it is an illness that results from or is caused by a primary ilness ____ _______ on the part of the nurse is essential in meeting the client's security needs ---------CORRECT ANSWER-----------------Active listening
A student who does not study for a test blames his "F" on the teacher's poor lecturing ability; this is an example of... ---------CORRECT ANSWER--- --------------Rationalization which of these is an example of primary prevention ---------CORRECT ANSWER-----------------wearing sunscreen and sunglasses if the stage of resistance is prolonged, what happens? ---------CORRECT ANSWER-----------------The response becomes maladaptive When working 3 feet of the client a regular face mask is required for this type of precaution ---------CORRECT ANSWER-----------------droplet Medical asepsis must be used during a Foley catheter insertion procedure. ---------CORRECT ANSWER-----------------False How many inches from the edge of the sterile field is considered non-sterile ---------CORRECT ANSWER-----------------1 inch The best way to break the chain of infection is by ---------CORRECT ANSWER-----------------implementing standard precautions In an older adult the base temperature is what ---------CORRECT ANSWER-----------------97.2 degrees fahrenheit
Which of these sets of vital signs are abnormal ---------CORRECT ANSWER-----------------BP 190/90, Pulse 98, Respirations 20 The best method for checking a client's pulse would be to do what --------- CORRECT ANSWER-----------------auscultate the apical pulse for 1 full minute which of these is the best definition of an arrhythmia ---------CORRECT ANSWER-----------------period of normal heart rhythm broken by periods of irregular heartbeats use of this is the most accurate noninvasive way to measure body temperature ---------CORRECT ANSWER-----------------The temporal artery thermometer which of these is considered a use of protective devices (restraints) --------- CORRECT ANSWER-----------------raising all 4 side rails (full side rails) when ambulating a client and they begin to fall, what should you do --------- CORRECT ANSWER-----------------assist them to the floor Proper lifting methods of heavy objects includes jerking or sudden pulling movements to allow momentum to aid you ---------CORRECT ANSWER----- ------------false
which of these positions is used for rectal exams, giving enemas, and inserting suppositories for unconscious client's ---------CORRECT ANSWER-----------------sims position When repositioning a client in bed which of the following would be incorrect (select all that apply_ ---------CORRECT ANSWER-----------------The nurse should drag the patient over their sheets the nurse should not call for help because it's not manly an example of a secondary health prevention measure would include which of the following ---------CORRECT ANSWER-----------------a colonoscopy The nurse notes crowing sounds on inspiration. The nurse properly documents this as ---------CORRECT ANSWER-----------------strider Decreased subcutaneous fat and thinner skin put the elderly patients at risk for... ---------CORRECT ANSWER-----------------impaired skin integrity Dry, rattling lung sounds are also known as.... ---------CORRECT ANSWER-----------------rhonchi transition stage ---------CORRECT ANSWER-----------------May deny feeling ill, but recognize symptoms of illness are present
chronic illness ---------CORRECT ANSWER-----------------irreversible illness that causes permanent physical impairment and requires long-term health care Secondary illness ---------CORRECT ANSWER-----------------Results from or is caused by a primary illness terminal illness ---------CORRECT ANSWER-----------------a disease or condition that will eventually cause death Maslow's Hierarchy of Needs ---------CORRECT ANSWER----------------- (level 1) Physiological Needs, (level 2) Safety and Security, (level 3) Relationships, Love and Affection, (level 4) Self Esteem, (level 5) Self Actualization steps to sterile field ---------CORRECT ANSWER-----------------don't Touch. Only sterile can touch sterile and remain sterile. Don't Add. Only sterile objects can be put on a sterile field to remain a sterile field. Keep in Sight. Keep the sterile field in sight. Keep High. Keep field at or above waist level at all times. Time. ... No Water. ... 1 Inch Border. ... Don't Intrude. droplet ---------CORRECT ANSWER-----------------spit when talking, use mask and goggles
Airborne precautions ---------CORRECT ANSWER-----------------Methods of infection control that must be used for patients known or suspected to be infected with pathogens transmitted by airborne droplet nuclei. assessment older adult home ---------CORRECT ANSWER----------------- Make sure their are no rugs on the floor or fall hazard Donning PPE ---------CORRECT ANSWER-----------------gown, mask, goggles, gloves Doffing PPE ---------CORRECT ANSWER-----------------gloves, goggles, gown, mask If patient refuses a bath, the nurse should ---------CORRECT ANSWER------ -----------offer the bath later in the day restraints should: ---------CORRECT ANSWER-----------------be ordered by the doctor, have 3 rails up, check on patient every 2 hours. isolation ---------CORRECT ANSWER-----------------is a means of preventing contact between a patient and others to prevent spread of infection R
(RACE)
which of the following best describes pulse deficit ---------CORRECT ANSWER-----------------One nurse assesses the apical pulse another nurse assesses the radial pulse. When transferring the client from bed to wheelchair the nurse should (select all that apply) ---------CORRECT ANSWER-----------------1. Call another nurse to assist with the transfer
- Place the wheelchair on the patients strong side
- lock the wheels of the wheelchair principles of sterility that the nurse should remember includes which of the following? (select all that apply) ---------CORRECT ANSWER----------------- When opening a sterile package open the first flap away from the body should be 1 inch border around the sterile field is considered sterile The home health nurse suspects that pt's 4 year old child has ingested the pt's meds. What should the nurse do next? ---------CORRECT ANSWER---- -------------1. Call poison control center
- assess the approximate amount the child ingested during a chemical spill what should the nurse do first ---------CORRECT ANSWER-----------------locate and review the MSDS
which of the following interventions should the nurse implement when doing oral care on an unconscious client ---------CORRECT ANSWER----------------
- Turn the patient laterally ( to their side)
- assess for gag reflex which of the following best describes an idiopathic illness ---------CORRECT ANSWER-----------------there is no known origin or cause of the disease which of the following are examples of tertiary prevention ---------CORRECT ANSWER-----------------going to physical therapy after a hip fracture has healed The first step of the nursing process is ---------CORRECT ANSWER---------- -------assess the patient complications from improper body alignment and lack of repositioning includes which of the following ---------CORRECT ANSWER----------------- 1 decreased circulation 2 contractures 3 muscle atrophy 4 pressure injuries The nurse assessed the client's pulse as full and bounding. The proper documentation for this is ---------CORRECT ANSWER-----------------3+ Which of the following client's would be at greatest risk for infection? (select all that apply) ---------CORRECT ANSWER-----------------The client on chemotherapy
Proper care of a client in restrains includes all the following except --------- CORRECT ANSWER-----------------Assess the client's circulation only before placing the restraints The nurse caring for a client with bacterial meningitis should implement which of the following interventions ---------CORRECT ANSWER--------------- --Place the client in droplet isolation The third line of defense against infection is ---------CORRECT ANSWER--- --------------The immune response Age-related changes to the skin includes (select all that apply) --------- CORRECT ANSWER-----------------Decreased sweat activity Decreased subcutaneous adipose tissue Decreased sebaceous activity In order to help a newly admitted client feel safe the nurse should (select all that apply) ---------CORRECT ANSWER-----------------Allow the client to ask questions Explain all procedures Place the bed low and locked with the call light in reach implement active listening techniques
The nurse assesses that the client's respiration are dyspneic followed by periods of apnea. This is also known as ---------CORRECT ANSWER--------- --------Cheyne-Stokes respiration Health ---------CORRECT ANSWER-----------------The state of complete physical, mental, and social well-being, as defined by the World Health Organization (WHO). It is subjective and can be influenced by an individual's values, experiences, and ways of living. Illness ---------CORRECT ANSWER-----------------A disease of the body or mind that can be acute, chronic, or terminal. It can be primary or secondary, and may be congenital or idiopathic. Stages of Illness ---------CORRECT ANSWER-----------------The stages individuals go through when dealing with illness: Transition Stage (initial recognition and reaction), Acceptance Stage (acknowledgment and adjustment), and Convalescence Stage (recovery and rehabilitation). Variables influencing health and wellness ---------CORRECT ANSWER------ -----------Factors that impact an individual's health and well-being: Healthy Behaviors (positive actions that promote well-being), Illness Behaviors (actions taken in response to illness), and a Holistic Approach (considering the interrelatedness of the body and mind). Holistic Approach ---------CORRECT ANSWER-----------------An approach that recognizes the interconnectedness of the body and mind. It involves strategies to help patients manage illness and achieve optimal health.
