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NUR2214 / NUR 2214 EXAM (Latest 2023 /
2024): Nursing Care of the Older Adult -
Rasmussen
What sign is most likely to alert a nurse manager that one of her nurses is stealing medications for personal use? A. The nurse complains of never being able to control her patients' pain even though other nurses never seem to have any problems controlling the same patient's pain B. The nurse who has a spouse with a history of drug abuse C. The nurse once made a treatment error and immediately notified the physician, nurse manager, and wrote an incident report D. The nurse has a teenager daughter, who is currently undergoing a long chemotherapy regimen to fight ovarian cancer - ANSWER A. The nurse complains of never being able to control her patients' pain even though other nurses never seem to have any problems controlling the same patient's pain Which nursing intervention is a priority for a patient who is post-op from having a lobectomy? A. Position the patient on the side of their body that was not operated on B. Position the patient in the semi-fowler's position at all times C. Monitor vital signs every day D. Teach incentive spirometry when patient is 12 hours post-op - ANSWER A. Position the patient on the side of their body that was not operated on
Rationale: Positioning the patient on their "opposite side" allows for the operated side to drain properly A 21-year-old female patient sates she is the victim of interpersonal violence (IPV) from her boyfriend, with whom she lives with. She states to the nurse, "There is no escaping my situation unless...". How should the nurse respond? A. "Why are you afraid to go to the police?" B. "I will to call the police for you so this can be documented." C. "What methods have you used in the past to deescalate a bad situation between you and your boyfriend" D. "Have you ever thought about hurting yourself or someone else?" - ANSWER D. "Have you ever thought about hurting yourself or someone else?" What criteria must be met for a patient to be admitted to hospice care? A. A patient must cancer B. A patient who has 6 months or less to live C. A patient who is suffering from an incurable illness D. A patient who wants to have their pain controlled E. A patient who is 65+ years of age F. A patient who lives alone - ANSWER B. A patient who has 6 months or less to live C. A patient who is suffering from an incurable illness D. A patient who wants to have their pain controlled A neurology nurse assesses a 75-year-old male patient with Parkinson's Disease (PD) and notices his face appears drooping and "mask-like." What does the nurse fear the patient may be at risk for?
A 27-year-old female patient with rheumatoid arthritis is suspected of having Sjogren's disease. Why did her HCP instruct the nurse to get the Snellen Chart? A. The HCP suspects the patient's eyes are drying out and wants to exam her vision B. Vision loss is a normal sign of rheumatoid arthritis (RA) C. Sjogren's disease usually alters the patient's color perception D. Permanent vision loss is a normal sign of Sjogren's disease - ANSWER A. The HCP suspects the patient's eyes are drying out and wants to exam her vision Rationale: Sjogren's disease dries out the mucus membranes of the eyes, mouth, and vagina A nurse works in a cardiology clinic and she suspect one of her patients is experiencing digoxin toxicity. What are some signs and symptoms of digoxin toxicity? Select all that apply: A. Vomiting B. Jaundice C. Diarrhea D. Petechiae E. Temperature of 100 F F. Nausea - ANSWER A. Vomiting C. Diarrhea F. Nausea Rationale: vomiting is usually one of the first signs
Which component is most important when it comes to fostering a culture of safety? A. Honor system B. Non-inclusive communication C. Open communication D. The Joint Commission - ANSWER C. Open communication Rationale: open communication fosters a "just culture" which in return keeps a "culture of safety" Which immunizations are contraindicated in a patient with HIV? A. Hepatitis A B. Polio C. Flu D. MMR - ANSWER D. MMR The HCP asks the nurse to describe an example of primary prevention of skin cancer. A. Limit sun exposure only between the hours of 11AM to 3PM B. Consult with a dermatologist C. Wearing sunscreen D. Limit tanning bed use - ANSWER C. Wearing sunscreen The patient complains of serious pain and the nurse suspects he may be experiencing a Vaso-occlusive crisis. What signs and symptoms are most likely to be observed?
infusion. What intervention should the nurse use before the patient has her second dose of therapy? A. Explain to the patient these are normal side effects of chemotherapy B. Offer the pill form of chemotherapy because there are less side effects when chemotherapy is administered the PO route C. Administer an antiemetic during the patient's chemotherapy session D. Administer an antiemetic 1 hour prior to the start of her infusion time - ANSWER D. Administer an antiemetic 1 hour prior to the start of her infusion time What are some signs of inflammation? Select all that apply: A. Skin cool to touch B. Redness C. Swollen D. Jaundice E. Scabbing F. Skin warm to touch - ANSWER B. Redness C. Swollen F. Skin warm to touch A patient receives a blood transfusion and appears to be having a reaction. What type of hypersensitivity reaction has the patient suffered from? Type 1 Type 2 Type 3 Type 4
Rationale: A blood transfusion is good example of a type 2 hypersensitivity reaction. This is why a Type and Screen needs to be performed on a patient prior to receiving the transfusion. - ANSWER B. Type 2 Rationale: A blood transfusion is good example of a type 2 hypersensitivity reaction. This is why a Type and Screen needs to be performed on a patient prior to receiving the transfusion. A patient diagnosed with fibromyalgia states she wants to stop using her Cymbalta medication to control her pain. What other types of treatment should the nurse educate the patient on? A. Imagery B. Meditation C. Meperidine (Demerol) D. Yoga E. Tai Chi F. Swimming G. Acupuncture - ANSWER A. Imagery B. Meditation D. Yoga E. Tai Chi F. Swimming G. Acupuncture Why are people with a lower economic status at an increased risk for infection? A. Malnutrition
An HCP instructs a 7-year-old male patient to start carrying an EpiPen with him at all times. What should be included in the teaching? A. Administer the EpiPen injection to the thigh and right through the clothes B. Administer the EpiPen injection to the arm after you roll up the sleeve C. If the child uses his EpiPen successfully he does not need to see the HCP D. Administer the EpiPen injection directly to the heart - ANSWER A. Administer the EpiPen injection to the thigh and right through the clothes A nursing instructor provides teaching on a pediatric patient who just came back from having heart surgery. The instructor knows the teaching has been successful when the student is able to verbalize: A. Hyperoxygenation (give supplemental oxygen before and after suctioning) must be applied B. Force the patient to ambulate C. Conduct a neurovascular check D. Expect to find a disparity between the upper and lower extremity pulses - ANSWER A. Hyperoxygenation (give supplemental oxygen before and after suctioning) must be applied What protocol should nurses always follow when providing care to patients with a positive HIV status? A. Isolation precautions B. Standard precautions C. Wear personal protective equipment D. N-95 mask - ANSWER B. Standard precautions
A nurse provides patient education to a woman who was recently diagnosed with Rheumatoid Arthritis (RA). What signs, symptoms, and features should be included in the teaching? A. Symptoms can be reduced if managed earlier B. Bilateral joint pain C. Joint stiffness that is the worst at night D. Autoimmune disease E. Antibodies that attack the body F. It is incurable - ANSWER A. Symptoms can be reduced if managed earlier B. Bilateral joint pain D. Autoimmune disease E. Antibodies that attack the body F. It is incurable What type of medication is an ACE inhibitor? A. Gabapentin B. Epogen C. Lisinopril D. Narcan Rationale: "Pril" is what you want to look for; these are almost always ACE inhibitors - ANSWER C. Lisinopril Rationale: "Pril" is what you want to look for; these are almost always ACE inhibitors
D. Educate the patient to only report signs or symptoms that occur after a few days - ANSWER A. Prepare for a hypersensitivity reaction A nurse receives education from a NP on dietary factors that lead to osteoporosis. The NP knows the teaching has been successful when the nurse is able to verbalize which dietary factors increase the risk for osteoporosis (Select all that apply): A. Green leafy vegetables B. Carbonated beverages C. Soybeans D. Alcohol E. Fish F. Caffeine - ANSWER B. Carbonated beverages D. Alcohol F. Caffeine A chemotherapy patient states they are experiencing extreme fatigue every time they receive chemotherapy. What are some interventions the patient's nurse can implement to accommodate the patient? Select all that apply: A. Only meet with the patient one time during the day B. Allow patient time to rest C. Spread care throughout the day D. Prioritize each episode of care E. Honor their sleep schedule as much as possible F. Consolidate all care to the early morning hours - ANSWER B. Allow patient time to rest C. Spread care throughout the day
D. Prioritize each episode of care E. Honor their sleep schedule as much as possible Children who are HIV positive usually contracted the virus through:
- Drug use
- Blood transfusions
- Sexual abuse
- The mother - ANSWER 4. The mother Rationale: In the pediatric population, the most common mode of transmission is the perinatal mode (from the birth mother) An 8-year-old male patient with leukemia complains of "extreme pain" every time he is repositioned. What is most likely causing his pain? A. The bone involvement B. Dehydration C. Shearing and pressure ulcers D. Skin breakdown from urinary incontinence - ANSWER A. The bone involvement A nurse continues to monitor post-op patient's pain status. The patient continues to state he feels no pain while constantly grimacing. What type of communication is the nurse witnessing? A. Nonverbal B. Paralinguistic C. Non-linguistic D. Linguistic - ANSWER B. Paralinguistic
Rationale: Poison ivy is a Type 4 hypersensitivity reaction and corticosteroids will need to be used A pediatric patient appears to have stomatitis and is slightly underweight. What teaching should the nurse include when educating the parents? A. Make the child only eat foods that are hot B. Do not force the child to eat food C. Try to trick the child into eating vegetables D. Recommend the child only eat cold foods - ANSWER B. Do not force the child to eat food After rereading the medication prescription that was sent from an outside pharmacy, a nurse determines she has administered the wrong treatment to a patient. What type of error has occurred? A. Sentinel event B. Communication error C. Electronic error D. Treatment error - ANSWER D. Treatment error Rationale: A medication error equals a "treatment error" A nursing instructor provides teaching on Tetralogy of Fallot (TOF). The instructor knows the teaching has been successful when the student is able to name the different types of heart defects. Select all that apply: A. Ventricular Septal Defect (VSD) B. Patent Ductus Arteriosus (PDA) C. Coarctation of the Aorta (COA)
D. Right Ventricular Hypertrophy E. Overriding Aorta F. Atrial Septal Defect (ASD) G. Pulmonary Stenosis - ANSWER A. Ventricular Septal Defect (VSD) D. Right Ventricular Hypertrophy E. Overriding Aorta G. Pulmonary Stenosis How should a patient with increased intracranial pressure (ICP) be positioned? A. Semi-Fowler's position B. Prone position C. High-Fowler's position D. Supine position - ANSWER A. Semi-Fowler's position Rationale: positioned upward at 30 degrees After performing an assessment on 75-year-old female patient. What assessment findings makes the nurse suspect osteoporosis? A. The patient's weight has increased since her last examination B. The patient states she has trouble regulating her body temperature C. The patient mentions slight knee pain especially when she works in the yard D. The patient's height has decreased since her last examination - ANSWER D. The patient's height has decreased since her last examination Rationale: Kyphosis is the physical sign of osteoporosis; there is a reduction in the patient's height
B. "Both of my parents were alcoholics and I think that had an impact on me." C. "I believe my family still cares for me despite my alcoholism." D. "I know I can quit easily and at any time." - ANSWER D. "I know I can quit easily and at any time." A nursing student wants to write a research paper on childhood leukemia. How should the pathology of leukemia be described? A. An uncontrolled production of immature white blood cells (WBCs) B. An autoimmune disease that occurs when the body's immune system attacks its own tissues and organs C. The destruction of red blood cells (RBCs) D. A serious form of skin cancer that arises from melanocytes - ANSWER A. An uncontrolled production of immature white blood cells (WBCs) A chemotherapy patient is suspected of having myelosuppression. What signs and symptoms alert the nurse that the patient may be suffering from myelosuppression? Select all that apply: A. Excessive alertness B. Bleeding around the gums C. Butterfly rash D. Pink or red-tinged urine E. Epistaxis F. WBC of 8,500 - 9,000 - ANSWER B. Bleeding around the gums D. Pink or red-tinged urine E. Epistaxis
Rationale: Myelosuppression involves destruction of RBCs, which causes a decrease in platelets and therefore a risk for bleeding; epistaxis means nosebleeds What type of scenario puts a nurse at the greatest risk experiencing physical violence from a patient? A. When working with a psychiatric patient who has a history of acting out violently B. When working with a patient who is experiencing substance withdrawal C. When the nurse has to set limits with the patient by telling them they cannot do something D. When informing a patient of bad news with regard to a disease - ANSWER C. When the nurse has to set limits with the patient by telling them they cannot do something A male patient is who has a history of anaphylaxis and instructed to inject his EpiPen every time he suffers a severe allergic reaction. What action should he take after successfully injecting the EpiPen? A. The patient should immediately lie down and rest B. The patient should continue to ambulate C. The patient should seek follow-up care even if his symptoms subside D. The patient should inject his second EpiPen about 12 hours later - ANSWER C. The patient should seek follow-up care even if his symptoms subside An established nurse determines a new nurse takes longer than any of their colleagues to complete a pass down at shift change. The established nurse deliberately decides to "call out" the new nurse in front several other nurses and patients. She states, "Nobody takes longer than you on this floor. Do you need any help?" What is this an example of?
