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NURS 322 Exam 1 2025 LATEST Nursing of Adults in
the Acute Care Setting I COMPLETE EXAM WITH
CASE STUDIES 100% VERIFIED CSUSM EXAM WITH
RATIONALE
A 21-year-old client presents to the student health center reporting vomiting and diarrhea all night. She has not eaten or drunk in the past 24 hours. Which prescription does the nurse anticipate the health care provider will recommend? A. IV fluid replacement B. Drink 8 glasses of water C. No fluid replacement is needed at this time D. Oral rehydration therapy with a solution containing glucose and electrolytes D. Oral rehydration therapy with a solution containing glucose and electrolytes Whenever possible, fluids are replaced by the oral route. When dehydration is severe or life threatening, or the client is not able to tolerate oral fluids, IV fluid replacement is needed. Oral rehydration therapy (ORT) is a cost-effective way to replace fluids for the client with dehydration. Specifically formulated
solutions containing glucose and electrolytes are absorbed even when the client is vomiting or has diarrhea. A new nurse is preparing to insert a vascular access device in a client. Which action by the new nurse requires intervention by the experienced nurse? A. Performing hand hygiene prior to insertion. B. Preparing for insertion immediately following cleaning with iodophors. C. Using friction to clean the skin around the insertion site. D. Clipping the hairs in the preferred insertion area. B. Preparing for insertion immediately following cleaning with iodophors. Current recommendations call for using friction when cleaning the skin to penetrate the layers of the epidermis. Iodophors such as povidone-iodine require contact with the skin for a minimum of 2 minutes to be effective. Skin should never be shaved before venipuncture, but excessive amounts of hair should be clipped.
During IV catheter insertion, a client with dehydration reports feeling "pins & needles" in the arm. What is the appropriate nursing response? A. "Nerve puncture may have occurred." B. "That is a normal sensation that will go away." C. "It is likely that the vein I was accessing has collapsed." D. "That means that the catheter is placed in the appropriate location." A. "Nerve puncture may have occurred." Reports of tingling, feeling "pins and needles" in the extremity, or numbness during the venipuncture procedure can indicate nerve puncture. The procedure should be stopped immediately, the catheter removed, and a new site chosen. Transsection of the nerve can result in permanent loss of function, and local nerve damage can become a chronic systemic pain syndrome. Infectious Disease Case Study (Q# 1 of 4) Scenario:
A 51-year-old patient is in the ED with cellulitis of the right leg. Laboratory results from a culture taken earlier in the week by the primary health care provider indicate that the wound is positive for MRSA. Q1.) Based on the information provided from the ED during the SBAR report, what type of isolation room should the medical-surgical nurse prepare for the patient? The patient should be admitted to a private room under Contact Isolation precautions. Infectious Disease Case Study (Q# 2 of 4) Scenario: A 51-year-old patient is in the ED with cellulitis of the right leg. Laboratory results from a culture taken earlier in the week by the primary health care provider indicate that the wound is positive for MRSA. Q2.) When providing care, what special precautions does the nurse implement based on the patient's diagnosis? (Select all that apply, 3 correct answers)
results from a culture taken earlier in the week by the primary health care provider indicate that the wound is positive for MRSA. Q3.) An hour later, the nurse is preparing to administer the patient's medications. Which drug was likely ordered by the health care provider to address MRSA? A. Amoxicillin B. Ciprofloxacin C. Vancomycin D. Erythromycin C. Vancomycin MRSA is susceptible to only a few antibiotics such as vancomycin (Vancocin) and linezolid (Zyvox), as well as ceftaroline fosamil. Infectious Disease Case Study (Q# 4 of 4) Scenario: A 51-year-old patient is in the ED with cellulitis of the right leg. Laboratory results from a culture taken earlier in the week by the primary health care provider indicate that the wound is positive for MRSA.
Q4.) After lunch, the patient asks how MRSA was contracted. What is the appropriate nursing response? A. "MRSA is spread by direct contact in the hospital and community settings." B. "People who travel to third-world countries always return with MRSA." C. "MRSA is transmitted through the air like TB." D. "The most common way to get MRSA is when someone coughs on you." A. "MRSA is spread by direct contact in the hospital and community settings." MRSA is spread by direct contact, such as with indwelling catheters, vascular access devices, and endotracheal tubes, in the hospital and community settings. The nurse is conducting a handwashing refresher session. For which situation will the the nurse remind all staff that cleansing hands with an alcohol-based hand rub is
B. 31-year-old with chronic kidney disease The patient's immune status plays a large role in determining risk for infection. Congenital abnormalities, acquired health problems (for example, kidney injury, steroid dependence, cancer, AIDS) and advancing age can increase a patient's risk of developing immunologic deficiencies. Chronic physical and psychological stress can also depress the immune system, making the patient more susceptible to infection. When caring for a patient with MRSA, which precaution will the nurse institute? A. Droplet B. Contact C. Airborne D. Neutropenic B. Contact MRSA is spread by contact; therefore, the nurse will institute contact precautions.
Skin Case Study (Q# 1 of 5) Scenario: The nurse is preparing to admit a patient who is 80 years old from a long- term care facility. The patient has end-stage COPD, is on oxygen, is unable to ambulate, & is incontinent of bowel & bladder. Q1.) Upon inspection, the patient has an area of redness that is non- blanchable on his sacral & coccyx area. How does the nurse document this finding? This is a stage 1 pressure injury. Based on the patient's diagnosis of COPD, he or she is probably positioned in a high-Fowler's position much of the time, & pressure is exerted on the sacral & coccyx areas. Skin Case Study (Q# 2 of 5)
Q3.) What interventions should be started to prevent further deterioration of the patient's skin?
- The nurse & staff should check the patient for any moisture during hourly rounds.
- The nurse may ask the provider about pressure relief devices, as well as a topical protective barrier to coat the skin.
- The patient is probably in a high- Fowler's position most of the time due to COPD, which puts pressure on the sacral & coccyx areas, so the nurse should assess the skin carefully & often.
- Ensure adequate fluid, protein, & caloric intake for the patient. Skin Case Study (Q# 4 of 5) Scenario: The nurse is preparing to admit a patient who is 80 years old from a long- term care facility. The patient has end-stage COPD, is on oxygen, is unable to ambulate, & is incontinent of bowel & bladder.
It was previously noted that the patient has a stage 1 pressure injury on his sacral & coccyx area. Q4.) Two days later, the patient's sacral area appears to have an abrasion where the skin is not intact. What is the nurse's interpretation of this new finding? A. Stage I pressure injury B. Stage II pressure injury C. Stage III pressure injury D. Stage IV pressure injury B. Stage II pressure injury With stage II pressure ulcers, the skin is not intact. There is partial thickness loss of the epidermis or dermis. The ulcer is superficial & may look like an abrasion, a blister, or a shallow crater. Skin Case Study (Q# 5 of 5) Scenario: The nurse is preparing to admit a patient who is 80 years old from a long- term
A. Avoid outdoor activity. B. Use a sauna to relieve pain. C. Apply tea bags to the lesions. D. Consume 1 to 2 alcoholic beverages. A. Avoid outdoor activity. Management of urticaria (hives) focuses on removing the triggering substance & relieving symptoms. The patient should stay indoors at this time, as something in the woods likely triggered the reaction. Because the skin reaction is caused by histamine release, topical &/or oral antihistamines such as diphenhydramine (Benadryl) are helpful. Teach the patient to avoid overexertion, alcohol consumption, & warm environments such as warm or hot showers, which contribute to blood vessel dilation & make the symptoms worse. Nothing further needs to be applied to the lesions at this time. Upon removing a dressing from a wound, the nurse notices a strong odor. What is the appropriate nursing action?
A. No action is necessary at this time. B. Notify the health care provider of a possible wound infection. C. Clean the wound & reassess for presence of infection. D. Culture the wound & anticipate an order for antibiotics. C. Clean the wound & reassess for presence of infection. Wound fluid & debris often interact with the dressing & may result in an odor when the dressing is removed. Gently clean the wound & reassess. Signs of infection are most frequently stalled wound healing, presence of purulent exudate, increased wound size or depth, fever, elevated WBC count, & increased pain. Cultures are not usually obtained. An older adult patient with a long history of congestive heart failure is being treated for a pressure injury over the coccyx that is 4 cm wide & 5 cm long, with eschar present. Which technique does the nurse anticipate will be used to remove the necrotic tissue? A. Surgical removal B. Biologic dressing C. Continuous dry gauze dressing
Venous thromboembolism (VTE) prophylaxis may involve devices and drug therapy, depending on a specific patient's evaluated risk. Devices may be used during and after surgery along with leg exercises and early ambulation to promote venous return. As the nurse evaluates a laboratory report for a client scheduled for surgery, which finding requires nursing intervention? A. Hemoglobin 10.4 g/dL B. Serum potassium 2.5 mEq/L C. Serum sodium level 145 mEq/L D. Fasting blood glucose 110 mg/dL B. Serum potassium 2.5 mEq/L Although all the laboratory results listed are not within normal ranges, the presence of hypokalemia (normal serum potassium levels should be between 3.0 and 5.5 mEq/L) increases the risk for toxicity if the patient is taking digoxin, slows recovery from anesthesia, and increases cardiac irritability. Potassium
problems must be corrected before the surgery. While monitoring a client with fluid overload, which assessment findings requires immediate nursing intervention? A. Bounding pulse B. Neck vein distention C. Pitting edema in the feet D. Presence of crackles in the lungs D. Presence of crackles in the lungs Fluid overload may lead to pulmonary edema and heart failure. Any client with fluid overload, regardless of age, is at risk for these complications. Older adults or those with cardiac problems, kidney problems, pulmonary problems, or liver problems are at greater risk. The presence of crackles in the lungs may be indicative of pulmonary edema, which can occur very quickly and lead to death in clients with fluid overload.
