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NU 136 EXAM 1 | ALL QUESTIONS AND
CORRECT ANSWERS | ALREADY
GRADED A+ | LATEST VERSION | JUST
RELEASED | VERIFIED ANSWERS
The nurse has assisted with the development of care plan for a newly admitted client. Which of the following nursing diagnoses should the nurse suggest as the priority? ---------CORRECT ANSWER-----------------Fluid volume deficit related to vomiting The nurse is participating in the nursing and care planning process. Which of the following steps in the process does the nurse recognize as the sole responsibility of the registered nurse (RN) ---------CORRECT ANSWER------ -----------Diagnosis The nurse is assisting with development of nursing intervention on assigned client's plan of care. The nurse understands that the interventions are? ---------CORRECT ANSWER-----------------Focused on what the nurse will do to assist with reaching client goals 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
When the LPN/LVN participates in the evaluation phase of the nursing process, she or he compares the patient's responses with the --------- CORRECT ANSWER-----------------Outcome criteria When a nurse uses Maslow's Hierarchy of Needs to priorities patients problems, which problem would be considered the highest priority --------- CORRECT ANSWER-----------------The patient is acutely short of breath The patient's problem has been identified as insufficient intake of oral fluids. Which outcome statement is best? ---------CORRECT ANSWER------- ----------The patient will ingest 1500 mL of oral fluids during each 24-hour period A student nurse ask, "What the primary purpose of the evaluation phase of the nursing process?" The best response is ---------CORRECT ANSWER---- -------------To compare actual patient outcomes with desired outcomes Which phases of the nursing process does the LPN/LVN participate in with the greatest degree of independence ---------CORRECT ANSWER------------ -----Data collection and implementation 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
If the immobile client refuses their morning bed bath which of the following is an appropriate response by the nurse ---------CORRECT ANSWER-------- ---------Give the client an option to shower later in the day A client has sat in their wheelchair, unmoving, for 1 hour, what should the nurse do next? ---------CORRECT ANSWER-----------------shift the position A complete bed bath would be appropriate for which type of client --------- CORRECT ANSWER-----------------A patient with unsteady gait and poor balance A written order is needed to trim the nails of a diabetic patient --------- CORRECT ANSWER-----------------True Which position is best to place an unconscious client when performing mouth care ---------CORRECT ANSWER-----------------lateral When assessing respiratory rate, which of the following is the most appropriate intervention for the nurse to do? ---------CORRECT ANSWER--- --------------Take the client's pulse and watch for the rise and fall of the client's chest 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
defense mechanisms ---------CORRECT ANSWER-----------------Strategies that protect us from increasing anxiety primary prevention ---------CORRECT ANSWER-----------------prevention that lowers the chances that a disease will develop secondary prevention ---------CORRECT ANSWER-----------------Efforts to limit the effects of an injury or illness that you cannot completely prevent. tertiary prevention ---------CORRECT ANSWER-----------------actions taken to contain damage once a disease or disability has progressed beyond its early stages congenital illness ---------CORRECT ANSWER-----------------present at birth acute illness ---------CORRECT ANSWER-----------------one that develops suddenly and resolves in a short time 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.
D- Drainage A-Approximation Place the following in the correct order for donning PPE (from top to bottom) ---------CORRECT ANSWER-----------------1. Grown
- Mask
- Eyewear (goggles/face shield)
- Gloves The LVN walks into a clients room who has all 4 rails up but has no physicians order for restraints the nurse should ---------CORRECT ANSWER-----------------Place the side rails down until only 2 side rails are up Place the following in the correct order for doffing (removing) PPE (From top to bottom) ---------CORRECT ANSWER-----------------1. Gloves
- eyewear
- gown
- mask Place the following in the correct order (from top to bottom) --------- CORRECT ANSWER-----------------1. Rescue
- Activate the fire alarm 3 contain the fire
- extinguish the fire (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
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 student nurse asks her preceptor what terminal illness means. The preceptor correctly states ---------CORRECT ANSWER-----------------This occurs when there is no longer a cure available Which of the following may occur due to the prolongation of the general adaptation syndrome (GAS)? ---------CORRECT ANSWER----------------- Fatigue, loss of appetite, and malaise When preparing to reposition a client the nurse should ---------CORRECT ANSWER-----------------Slowly reposition the patient by first allowing them to dangle their legs The nurse assessed the client's pulse as full and bounding. The proper documentation for this is ---------CORRECT ANSWER-----------------3+
Use gait belt 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.
