NUR 2349 / NUR2349: Professional Nursing I / PN1 Exam 2 (Latest 2021/2022) Rasmussen

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A nurse plans for care of the skin prior to administering a topical medication. Which action should the nurse perform first? Wash the area with soap and water. 2. A nurse is caring for a client who ... requires teaching about the dietary regimen. Which of these outcomes would be most appropriate to include in the plan of care? The client will eat a variety of foods from all the different food groups. 3. A nurse is assessing the dietary tray for a client whose been ordered a clear liquid diet. Which of these items would a nurse remove from the tray? Ice cream. 4. An infant has severe diarrhea. A nurse understands that the major problem associated with severe diarrhea is electrolyte and fluid loss. 5. A nurse is assessing several clients for increased surgical risk. Which of these clients should the nurse recognize as having the greatest risk for a poor surgical outcome? A 30 y/o obese housewife 6. A client who received general anesthesia for a surgical procedure is admitted to the post anesthesia care unit (PACU). Which action should a nurse take first? Assess the airway for patency. 7. At 2000 hours a nurse notes that a male client who returns from the PACU at 1200 has not voided, which action should a nurse take first? Assist the client to stand at the bedside in an attempt to void in the urinal. 8. When a preoperative client asks for an explanation how palliative surgery differs from other types of surgeries, the nurses best response would be "Palliative surgery is performed to provide temporary relief of distressing symptoms rather than to cure a problem or condition". 9. A nurse understands an appendectomy is considered which of these types of surgical procedures? Ablative 10. When a client is transferred from the post anesthesia care unit (PACU) to the clinical surgical unit, the first action by the nurse on the surgical unit should be to take the clients vital signs. 11. A nurse has a legal responsibility to document medication administered to clients. The nurse documents the medication after giving it. 12. A nurse plans to call the HCP to report the O600 serum K of 2 mEq. When the charge nurse tells the nurse not to call because the HCP will visit the pt later in the morning. The best action by the nurse would be to? Disregard the advice of the charge nurse and contact the HCP immediately to report the lab values. 13. Which of these clients is at greatest risk for fluid and electrolyte imbalance? An adult with severe diarrhea. 14. A nurse obtains assessment data for a client with congestive heart failure (CHF). She develops a nursing diagnosis of fluid volume excess. Which of these observations would be the most significant finding in this client? Hypertension 15. A nurse wants to determine the fluid status of a client using the most accurate method and asks the UAP to assist. Which of these measures to assess fluid status should the nurse delegate to the UAP? Checking the daily body weight. 16. A nurse is assessing an older adult client who is receiving D 5 1/2 normal saline in 125 mL/hr. Which of these findings require immediate follow-up by the nurse? Dyspnea, headache, increased blood pressure. This study source was downloaded by 100000832361371 from CourseHero.com on 07-20-2022 02:37:18 GMT -05:00 https://www.coursehero.com/file/61622642/foundations-exam-3docx/ 17. When assessing a clients who has excess fluid volume the nurse would expect to identify the clients skin is taunt and shiny. 18. A nurse is caring for a client with excessive fluid loss, which of these measures should the nurse delegate to the UAP? Provide straws and offer fluids between meals. 19. A nurse is caring for a client with a diagnosis of acute renal failure and hypernatremia. Which of these actions should the nurse delegate to the UAP? Provide oral care every 4 hours and PRN. 20. When a preoperative client has a serum Na of 139, which action should a nurse take initially? Document the finding. 21. A client who is 5'2' who has a baseline weight of 136 lbs prior to hospitalization for fluid volume deficiency, The clients weight on admission is 60 kg the client asks how much weight have I lost? The best response by a nurse would be, you lost 4 lbs. 22. A UAP informs a nurse that the intake and output (I/O) is total intake 2,000 mL total output 1,000 mL. The priority action for the nurse at this time is it auscultate the clients breath sounds. 23. A nurse checks the ADH results of a client and notices an elevated value, which of these findings should a nurse expect to see in this client? A decrease in urinary output. 24. When assessing a client after a parathyroidectomy, a nurse notices that a client has left facial twitching and notices the vital signs are temperate 37 C, pulse 92, RR 20, BP 132/70, 1200: 37 C temp, pulse 72, RR 24, BP 118/60. Which of these actions should the nurse take first? Check the clients morning Calcium leve [Show More]

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