Download NU 311 Final Exam Questions with complete solutions. GET IT 100%. and more Exams Nursing in PDF only on Docsity!
NU 311 Final Exam Questions with complete
solutions. GET IT 100%.
The nurse is caring for a patient requiring seizure precautions. Which actions may the nurse safely delegate to the non-licensed assistive personnel (NAP)? *To administer the IV medication if a seizure occurs *To restrain the patient during the seizure *To place a tongue blade in the patient's mouth to keep them from swallowing their tongue
*To inform the nurse if seizure activity is observed - CORRECT ANSWER -To
inform the nurse if seizure activity is observed Match the following *Airborne precautions (droplet nuclei smaller than 5 microns) *Droplet precautions (droplet larger than 5 microns; being within 3 feet of the patient *Contact precautions (direct patient or environmental contact) 1.) Private room or cohort, gloves, gown 2.) Private room or cohort patients, mask or respirator 3.) Private room, mask or respiratory protection device, negative-airflow room, N
respirator depending on the patient condition - CORRECT ANSWER --Airborne
Precautions: * -Droplet Precautions: * -Contact Precautions: * The Centers for Disease Control (CDC) guidelines for preventing tuberculosis (TB) transmission include: (select all that apply) *Placing the client on contact precautions *Requiring health care workers to wear special respirators (N(95) when caring for clients with suspected TB *Placing the client in a negative pressure airflow room *Wearing a N95 mask respirator when planning to come within 3 feet of the patient -
CORRECT ANSWER --Placing the client in a private negative-pressure airflow
room -Wearing a N95 respirator when planning to come within 3 feet of the patient -Requiring health care workers to wear special respirators (N(95) when caring for clients with suspected TB -Placing the client on contact precautions It is your first day of clinical as a University of South Alabama Student Nurse and you are assigned to care for a client requiring precautions. You understand: *Protective eyewear is necessary at all times *standard precautions are for use with all clients
*standard precautions apply only to clients who are HIV positive
*Gowns, masks, and gloves are required for contact with all clients - CORRECT
ANSWER -Standard precautions are for use with all clients
Reducing the risk for patient harm is a national health care priority. The nurse reduces the risk for patient harm by: (select all that apply) *Using 2 ways to identify patients *Assessing the patient's environment *Using a teach-back method for call button instructions
*Safely using extremity restraints on all confused patients - CORRECT
ANSWER --Using 2 ways to identify patients
-Assessing the patient's environment -Using a teach-back method for call button instructions The student nurse is planning to assist the client with ambulation. Which action causes the clinical instructor concern? *Reviews the client's medications *Performs a fall risk assessment prior to ambulation *Plants to use a gait belt *Quickly runs to the nurses station for help when the patient starts to fall -
CORRECT ANSWER -Quickly runs to the nurses station for help when the
patient starts to fall All are "Never Events" with the exception of: *ventilator associated pneumonia *IV infiltration *Poor blood glucose control
*Patient death associated with a medication error - CORRECT ANSWER -IV
Infiltration The nurse has completed the admission assessment on an elderly patient. The patient has never been admitted to a hospital, takes 5 different medications, and has vision problems. The nurse plans priority care to reduce the risk for *Disorientation *Falls *Fear
*Suicide - CORRECT ANSWER -Falls
Hand hygiene is an important aspect of providing high quality care for clients. When is hand hygiene with soap and water necessary? (select all that apply) *After removing sterile gloves *After using the toilet *Before eating
*EBP.org *Facebook/Twitter
*CINAHL - CORRECT ANSWER -CINAHL
One of the 2022 National Patient Safety Goals is the prevention of infection. An infection contracted in the hospital that was not present or incubating at the time of admission is known as a/an: *Health care associated infection (HAI) *Pathogen *Opportunistic infection
*Multi Drug-resistant organism (MDRO) - CORRECT ANSWER -Health care
associated infection (HAI)
Match the following: - CORRECT ANSWER --A problem solving approach to the
delivery of health care that integrates the best evidence from scientific studies and patient care data along with clinician's expertise and patient values: Evidence Based Practice -The first step of evidence based practice (EBP):Question what is costly, time consuming, or doesn't make sense -An electronic library of published scientific studies:Database -A brief summary of an article including major themes or finding:Abstract -A detailed background and summary of past research on a topic:*Literature review Which type of evidence is considered stronger in the evidence pyramid? *Opinion of expert clinicians *Systematic reviews of randomized control trials *Observational studies
*A properly designed randomized control trial (RCT) - CORRECT ANSWER -
Systematic reviews of randomized control trials (RCTs) The student nurse is reviewing an article for the upcoming EBP assignment. To determine the research design, the student will explore the? section of the article. *Literature review *Application to practice *PICOT question
*Methods or design - CORRECT ANSWER -Methods or design
The following statements regarding client restraints are true: (select all that apply) *Restraints prevent falls and are necessary for older adults with dementia *Research has shown that clients suffer fewer injuries if left unrestrained *If a client is restrained in an emergency situation because of violent or aggressive behavior that presents an immediate danger, a face to face health care provider assessment within 1 hour is necessary
*Restraints may be ordered PRN - CORRECT ANSWER --Research has shown
that clients suffer fewer injuries if left unrestrained -If a client is restrained in an emergency situation because of violent or aggressive behavior that presents an immediate danger, a face to face health care provider assessment within 1 hour is necessary Before exiting the room of a client on transmission based isolation precaution requiring the use of all protective barriers, the nurse removes the? last. *mask or respirator *gloves *gown
*goggles - CORRECT ANSWER --mask or respirator
(gloves>goggles>gown>mask) The RN may delegate which action related to fall precautions to the nursing assistive personnel (NAP)? *maintaining the bed in the lowest position *calling the physician to clarify a restraint order *completing a fall assessment
*teaching the family in fall prevention - CORRECT ANSWER --maintaining the
bed in the lowest position Which action demonstrates the application of evidence into nursing practice? *Questioning what does not make sense or needs clarification *Implementing a new hand off reporting protocol *Reviewing research articles that address the PICO question *Presenting a poster related to EBP during the National Student Nurses Association
(NSNA) conference - CORRECT ANSWER --Implementing a new hand off
reporting protocol The clinical instructor determines the student nurse needs further education regarding restraints when the student: *Carefully secures the restrain strap with a double knot for patient safety *Informs the instructor that restraints do not necessarily prevent falls *Ties the restraint straps to the bed frame *Removes the restraint every 2 hours to assess skin integrity, provide comfort
measures, and evaluate continued need for restraints - CORRECT ANSWER --
carefully secures the restrain strap with a double know for patient safety
Hand hygiene: - CORRECT ANSWER --Is the most important technique in
preventing and controlling transmission of infection -With alcohol based hand rub is appropriate after touching equipment in patient room -Is to be performed with soap and water when hands are visibly soiled
-Ink pens:Do not use on manikins or dressings -Practice w/dressing:Remove all adhesive residue w/adhesive remover -Manikin parts:Do not remove, report anything that is broken -Disobey the lab rules:Will be asked to leave Patients at risk for complications and/or injury from improper positioning include patients with which of the following? (select all that apply) *Poor nutrition *Loss of sensation *Impaired muscle development
*Poor circulation - CORRECT ANSWER --Poor nutrition
-Loss of sensation -Impaired muscle development -Poor circulation The term? refers to correct positioning to maintain comfort and reduce the risk of physical complications *Muscle tone *range of motion *body alignment
*orthostatic posture - CORRECT ANSWER --Body alignment
To position a patient with hemiplegia in high Fowler's the nurse should: *elevate the HOB 30 degrees *place the patient on their stomach *use a hand roll for positioning
*position the patient's head w/slightly hyperextension of the neck - CORRECT
ANSWER --Use a hand roll for positioning
The nurse plans to use a trochanter roll when repositioning a patient. Where should the nurse place the trochanter roll? *Under the small of the back *Behind the knees when supine *Alongside the patient's legs
*In the palm of the hand with fingers flexed - CORRECT ANSWER --Alongside
the patient's legs The patient is elderly and has been on bed rest for the past several days. When getting the patient up, the nurse should: *Teach the patient not to move his legs when dangling *Teach the patient to hold his breath while dangling *Raise the HOB and allow a few minutes before dangling
*Have the patient standing without dangling - CORRECT ANSWER --Raising the
HOB and allow a few minutes before dangling
A nurse encourages a patient to prevent venous stasis by: *Crossing the legs when sitting in a chair *Wearing thigh-length nylon stockings or garters *Maintaining strict bed rest
*Increasing early ambulation - CORRECT ANSWER --Increasing early
ambulation Antiembolic stockings (TEDs) are prescribed for the patient on bed rest after surgery. The nurse explains to the patient that the primary purpose for the elastic stockings is to: *Keep the skin warm & dry *Prevent abnormal joint flexion *Apply external pressure
*Prevent bleeding - CORRECT ANSWER --Apply external pressure
The patient has been using crutches for the past 2 weeks. When they come for their follow up exam, they complain of tingling and numbness in their hands and upper torso. Possible causes of these symptoms are: *The patient's elbows are flexed 15-30 degrees when using the crutches *Crutch pad is approximately 2 inches below the patient's axilla *Patient holds the cane 4-6 inches to the side of her foot
*Handgrip does not allow for elbow flexion - CORRECT ANSWER -Handgrip
does not allow for elbow flexion While washing the patient's face, the nurse should: *wash the eyes using soap and warm water *wash the eyes from outer canthus to inner canthus *Wash the eyes with plain warm water
*Use the same portion of the washcloth - CORRECT ANSWER -Wash the eyes
with plain warm water While evaluating the hygienic care practices of a female patient, the nurse recognizes that additional instruction is necessary if the patient: *washes the perineal are from back to front *washes the labia majora before the labia minora *avoids tension on the indwelling catheter
*uses separate sections of the washcloth for each cleansing stroke - CORRECT
ANSWER -Washes the perineal are from back to front
The nurse is about to provide oral hygiene to an unconscious patient. To do so, the nurse places the patient in which position? *Fowler's *Dorsal recumbent *Sims' with HOB elevated 30 degrees
*discharge teaching
*provide privacy and assist to dress - CORRECT ANSWER -discharge teaching
A? is a confidential, permanent legal document containing information relevant to a patient's health care *nursing note *chart or patient's record *documentation
*health insurance portability and accountability act - CORRECT ANSWER -chart
or patient's record The nurse discovers a patient who has fallen in their room. The nurse knows this is an adverse event and an occurrence report must be completed regardless if there is an injury. The nurse requires further education when planning to *document in the medical record that an occurrence report was completed *notify the risk management department per agency protocol *call the healthcare provider immediately
*assess the extent of any injury - CORRECT ANSWER -Document in the medical
record that an occurrence report was completed Which statement/s are true regarding phases of full-thickness wound healing? (select all that apply) *during the homeostasis phase clot formation seals the disrupted vessels *leukocytes arrive in the wound to begin wound clean up in the proliferative phase *in non-complicated wounds, the result of the inflammatory phase is a clean wound bed *collagen is remodeled to become stronger during the maturation phase -
CORRECT ANSWER --during the homeostasis phase, clot formation seals the
disrupted vessels -in a non-complicated wound, the result of the inflammatory phase is a clean wound bed -collagen is remodeled to become stronger during the maturation phase The nurse is planning a staff teaching intervention on wound debridement. What will the nurse include in the teaching? *Nonviable tissue in a wound speeds wound healing *Moisture should be avoided in the wound treated with collagenase *Enzymatic debridement is accomplished by injecting enzymes into the periwound area *Collagenase digests necrotic tissue by dissolving the collagen in dead tissue -
CORRECT ANSWER -Collagenase digests necrotic tissue by dissolving the
collagen in dead tissue A sterile dressing with no absorbent capacity that is impermeable to fluids and bacteria and is used as prophylaxis for high risk intact skin, superficial wounds with minimal or no exudate best describes: *wound vac (negative pressure wound therapy) *Abdominal pad
*Transparent film
*moist to dry - CORRECT ANSWER -transparent film
When aseptic procedures are performed, the nurse must have a sterile work area or sterile field. Which of the following statements regarding maintenance of sterile fields are true? (select all that apply) *once a sterile filed is outside of the vision of the nurse, the sterile field is considered contaminated *a 2.5 inch border around the sterile field is considered contaminated *a sterile field is considered contaminated if any of the edges hang over the table *a sterile object (including sterile gloved hands of the student nurse) is considered contaminated if held above the waist *if there is doubt about the sterility of an item, regardless of cost, consider the item to be contaminated *a sterile field having a puncture, tear, or moisture is considered contaminated -
CORRECT ANSWER --a sterile field having a puncture, tear, or moisture is
considered contaminated -if there is doubt about the sterility of an item, regardless of cost, consider the item to be contaminated -once a sterile field is outside of the vision of the nurse, the sterile field is considered contaminated -a 2.5 inch border around the sterile field is considered contaminated The RN caring for a client following recent abdominal surgery finds the wound edges are not approximated and the wound healing is expected to occur by granulation tissue formation and contraction of the wound edge. Scar tissue will close the wound and the process is slow. The RN knows the wound is healing by: *Granulation *Tertiary Intention *Secondary Intention
*Primary Intention - CORRECT ANSWER -Secondary intention
When repositioning an immobile client, the student nurse notices redness over a bony prominence. When the area is further assessed, it does not blanch indicating: *a need for the student to vigorously massage the area in order to increase blood flow and decrease the risk of pressure injury formation *a stage 3 pressure injury needing appropriate dressing *normal reactive hyperemia, a reaction that causes the blood vessels to dilate in the injured area *the area is a site for potential breakdown and is considered a Stage 1 pressure injury -
CORRECT ANSWER -the area is a site for potential breakdown and is
considered a Stage 1 pressure injury Which of the following statements regarding the application of ice or cryotherapy are true? (select all that apply)
Which statement/s is/are TRUE regarding sterile wound irrigations? (select all that apply) *wound irrigation are useful for decreasing bacterial counts *skin cleansers such as chlorhexidine may be substituted for wound irrigation cleansers *position the client supine when performing abdominal wound irrigations *protective equipment such as gown and eye wear should be used by the nurse *sterile wound irrigations may be safely delegated to experienced nursing assistive
personnel - CORRECT ANSWER --wound irrigations are useful for decreasing
bacterial counts -protective equipment such as gown and eye wear should be used by the nurse Which statement made during clinical by the student nurse regarding moist to dry dressings is correct? *I will moisten the inner dressing w/sterile saline in order to ease the pain of removing the gauze since it has adhered to the wound *I know that the purpose of moist to dry dressings is to mechanically debride the wound *Dr. Lynch taught me that moist to dry dressings are primarily for wound healing by primary intention *Dr. Swanzy taught me to tightly pack the wound with gauze soaked in povidone-iodine (betadine) in order to cover all areas of the wound bed and reduce the chance of
infection - CORRECT ANSWER -I know that the purpose of moist to dry
dressings is to mechanically debride the wound What would the RN consider obtaining a wound culture? *when the client is afebrile *when the wound is clean & dry *when the client is worried about having an infection *when the surrounding area is red and the wound has yellow drainage foul odor -
CORRECT ANSWER -When the surrounding area is red and the wound has
yellow drainage and foul odor The postoperative client with a closed abdominal wound reports a sudden "pop" after coughing. The student nurse examines the surgical site and sees separation of the wound layers and internal organs protruding through the wound. The priority response
is to: - CORRECT ANSWER -cover the wound with a sterile moist saline
dressing, stay at bedside to monitor vital signs, and notify the healthcare provider The student nurse is changing a dressing and is preparing to cleanse the intact suture
line. The proper technique for cleaning an intact suture line includes: - CORRECT
ANSWER -cleaning the wound from an area of least contamination to an area of
most contamination
Occurrence of pressure injuries: - CORRECT ANSWER --because of tissue
ischemia
-related to decreased activity and malnutrition -on any area of skin subjected to pressure A surgical wound is expected to drain approximately 100-200 mL/24 hrs. Which type of
treatment does the RN anticipate? - CORRECT ANSWER -Jackson-Pratt drain
The client has an order for the application of an elastic bandage for compression. Which
action by the nurse indicates proper understanding of the procedure? - CORRECT
ANSWER -wrapping the bandage from distal point to proximal point
The RN is documenting the Braden scale assessment on the electronic health record at the patient bedside. Which Braden score indicates that the patient is at very high risk for
developing a pressure ulcer? - CORRECT ANSWER -
*high risk=< *low risk= *<16=at risk
Silver impregnated dressings are primarily used to: - CORRECT ANSWER -
control bacteria burden in wound Which of the following wounds would benefit from the application of an alginate
dressing? - CORRECT ANSWER -Stage 4 pressure injury to the sacrum with a
large amount of exudate The nurse is caring for a patient who has a full thickness pressure ulcer. Which type of tissue will the nurse observe in the wound bed that indicates the wound is healing? -
CORRECT ANSWER -Granulation
The following statements about applying an abdominal binder are true: - CORRECT
ANSWER --an abdominal binder over midline abdominal incisions should not have
any effect on the patient's pulmonary function -abdominal binder and surgical dressing should be removed to assess skin and wound characteristics at least every 8 hours -a nurse assesses the condition of any incision, the skin, and patient's ability to breathe before binder applicaton Select the patient's assessment data below indicating clinically significant malnutrition -
CORRECT ANSWER --Serum albumin level 2.5 g/dL
-weight decreased by 5% since admission 2 weeks ago
AspergumTM is the? name for aspirin - CORRECT ANSWER -trade name
Third check of accuracy - CORRECT ANSWER -At the patient bedside
The medication order is an example of right documentation: NPH insulin 10u subQ every AM
True or False - CORRECT ANSWER -False
*"U" is an abbreviation on the DO NOT USE list (should be written as unit) *sub-Q should be written out as subcutaneous A patient admitted to the hospital with pneumonia has IV antibiotics ordered. They receive the first does with no problem, but during the second dose, they begin to report shortness of breath and difficulty breathing. The nurse notes wheezes throughout the lung fields. The nurse understands these symptoms are the clinical manifestations of
which of the following? - CORRECT ANSWER -Anaphylactic reaction
The nurse is calculating a medication dosage. A vial contains 1mL of fluid, and the nurse calculates the correct dosage to be half of the medication in the vial. How should
the nurse document the correct dosage? - CORRECT ANSWER -0.5 mL
The nurse administers a medication to the wrong patient but the patient suffers no harm
from the medication error. What action/s should the nurse take? - CORRECT
ANSWER --prepare a written incident report
-notify the health care provider The patient is unable to sit upright for medication administration. The nurse should
assist the patient to decrease the risk for aspiration? - CORRECT ANSWER -
Side-lying The nurse receives prescriptions on several patients for oral medications. The nurse will
question the order on patients with which conditions? - CORRECT ANSWER --
inability to swallow food -decreased level of consciousness -use of gastric suction Medications in the form of drops or ointments will have the word? on the container to
identify them as eye medications - CORRECT ANSWER -opthalmic
The nurse is teaching a patient how to mix 5 units of regular insulin and 15 units of NPH insulin in the same syringe. The nurse determines that further instruction is needed if
the patient does which of the following? - CORRECT ANSWER -Injects 5 units of
air into the regular insulin vial first and withdraws 5 units of regular insulin The nurse is preparing to administer an intramuscular medication. In determining which gauge/length needle and syringe to use to administer the medication, the nurse must
consider which of the following? - CORRECT ANSWER --the viscosity of the
medication -the size and weight of the patient The HCP has ordered an IV solution with an osmolarity greater than 900 mOsm/L with a high or low pH. Which type of device will be required for administration of the fluid? -
CORRECT ANSWER -Central venous access device (CVAD)
The 20 yo client is admitted to the ED following an accident while riding a motorcycle. The patient has multiple fractures and is being evaluated for additional injuries. The
following size IV catheter is appropriate - CORRECT ANSWER -16 gauge
Gauge indications - CORRECT ANSWER -*14, 16, 18: trauma, surgery, rapid
blood transfusion, and rapid fluid replacement *20: adults; administration of blood transfusions in adults *22: continuous or intermittent infusions in adults, pediatrics, neonates, and the elderly; administration of blood or blood product *24: continuous or intermittent infusions in adults, pediatrics, neonates, and the elderly; administration of blood or blood product The institute for healthcare improvement recommends a central line bundle for clients with intravascular central catheters. Which intervention is NOT part of the HI central line
bundle? - CORRECT ANSWER -Providone iodine (betadine)skin antisepsis
Shortly after receiving a central line, the client complains of chest pain and dyspnea.
The RN suspects an air embolus. What is the priority action? - CORRECT
ANSWER -Administer O2 as ordered and position the client on the left side with head
down
The following statement regarding parenteral nutrition (PN) is true: - CORRECT
ANSWER -The most frequent complication of PN is catheter related bloodstream
infection (CRSBI) Which task related to IV therapy may be delegated to nursing assistive personnel
(NAP)? - CORRECT ANSWER -Reporting leakage around the tubing
The tip of the non-femoral CVAD is located: - CORRECT ANSWER -in the
superior vena cava and the junction of the right atrium. Which of the following are types of central vascular access devices (CVADs)? -
CORRECT ANSWER --Implanted venous ports
-Nontunneled percutaneous access lines
Regarding blood transfusions, which of the following statements are true? -
CORRECT ANSWER --When blood is stored, there is a continual destruction of
red blood cells, which releases potassium (K+) into the plasma. -Blood transfusions must be initiated within 30 minutes after release from the blood bank.
The USASN causes the clinical instructor concern when - CORRECT ANSWER -
carefully reinserting the stylet into the catheter for a second attempt at venipuncture.
The student nurse is correct when making the following statement: - CORRECT
ANSWER -"One kilogram or 2.2 lbs. of body weight is equivalent to gain or loss of 1
liter of fluid." Blood transfusions require a Y-tubing administration set (meaning 2 solutions may be hung on the same line). Which IV solution is used to prime the tubing initially and to
clear the line post transfusion? - CORRECT ANSWER -0.9% normal saline
A peripherally inserted central catheter (PICC) is inserted into the: - CORRECT
ANSWER -arm and ends in the superior vena cava.
Can lipids be piggybacked? - CORRECT ANSWER -yes
What time should blood be started once it has been received from the blood bank -
CORRECT ANSWER -30 minutes
True or False: Blood needs to be done in 4 hours from the time it was started -
CORRECT ANSWER -True
The IV just stopped working and the pump is beeping like crazy. What do you do first? -
CORRECT ANSWER -Make sure the clamp on the J-loop is open
True or False: A single clinician should not make more than 2 attempt at starting an IV.
Limit total attempts to 4 - CORRECT ANSWER -True
The nurse washed their hands but forgot to have gloves on when applying the
tourniquet and palpating for the vein. Did they break sterility? - CORRECT
ANSWER -No, sterility was not broken
