NUR 2811C EXIT 5 UPDATED WITH 84 QUESTIONS AND ANSWERS GRADED A

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NUR 2811C EXIT 5 UPDATED 1. A swishing sound associated with blood turbulence created by a heart or valvular defect ­ 2. During a home visit , the nurse observes an elderly client with di... abetes slip and fall. What action should the nurse take first? 3. After the nurse witnessess a preoperative client sign the surgical consent form, the nurse signs the form as a witness. What are the legal implications of the nurses signature on the clients surgical consent forms? 4. A client with hyperthyroidism is being treated with radioactive iodine. Which explaination should be included in preparing this client for this treatment? ­ 5. A woman w/anxiety disorder calls her OB office and tells the nurse of an increased anxiety since the normal vaginal delivery of her son three weeks ago. Since she is breastfeeding, she stopped taking her antianxiety meds, but thinks she may need to start them again bc of her increased anxiety. What response is best for the nurse to provide this woman? 6. The charge nurse of a critical care united is informed at the beginning of the shift that less than the optimal number of RN's will be working that shift. In planning assignments, which client should receive the most care hours by an RN? ­ 7. The nurse is caring for a group of clients w/the help of a LPN and an experienced UAP. WHich procedures can the nurse delegate to the UAP? SATA ­ 8. What pathophysiological mechanisms are responsible for ascites related to liver failure? SATA ­ 9. A mother os an adolescent tells the clinic nurse "my son has athletes foot. I have been applying triple antibiotic ointment for 2 days, but has no improvement". What instruction should the nurse provide? 10. The nurse notes that a client has been receiving hydromorphine (Dilaudid) q 6 hrs for 4 days. What assessment is most important for the nurse to compolete? 11. A client receives a new prescription for simvastin (zocor) 5 mg PO daily at bedtime. What action 12. A group of nurse managers is asked to engage in a needs assessment for a piece of equipment that will be expensed to the organizations budget. Which question is most important to consider when analyzing the cost­benefit for this piece of equipment? 13. A client is receiving a full strength continuous enternal tube feeding at 50 ml/hr and has developed diarrhea. The client has a new prescription to change the feeding to half strength. What intervention should the nurse implement? ­ 14. A male client experiences a gasoline tank fire when riding his motorcycle & is admitted to the emergency dept. w/full thickness burns to all surfaces of both lower extremities. What percentage of body surface area should the nurse document in the electronic medical record? ­ 15. The nurse performs a prescribed neurological check at the beginning of shift on a client who was admitted to the hospital w/ subarachnoid brain attack (stroke). The clients glasgow coma scale score is 9. What info is most important for the nurse to determine? ­ 16. A mother brings her 3 year old son to the emergency room and tells the nurse that he has an upper respiratory infection for the past 2 days. Assessment of child reveals a rectal temp of 102. He is drooling and becoming increasingly more restless. What action should the nurse take first? ­ 17. The nurse working in the psych clinic has phone messages from several clients. Which call should the nurse return first? ­Answer: A family member of a client with dementia who has been missing for 5 hrs. 18. A male client who is 24 hr post op for an exploratory lapartomy, complains that he is "starving" bc he has had no "real food" since before surgery. Prior to advancing his diet, which intervention should the nurse implement? 19. A 60 yr old female client asks the nurse about hormone replacement therapy (HRT) as a means to preventing osteoporosis. Which factor in the clients history is a possible contraindication for use of HRT? 20. The nurse receives a newborn within the first minutes after a vaginal delivery and intervenes to establish adequate respirations. What priority issue should the nurse address to ensure the newborn's survival? 21. An elderly client seems confused and reports the onset of nausea, dysuria and urgency w/incontinence. Which action should the nurse implement? 22. A nurse manager is preparing the curricula for a class for charge nurses. The staffing formula based on what data ensures quality client care and is most cost effective? ­Answer: Skills of staff and client acuity. 23. After placing a stethoscope as seen in the picture, the nurse ausculates S1 and S2 heart sounds. To determine if an S3 heart sound is present, what action should the nurse take next? ­ 24. Following discharge teaching, a male client with a duodenal ulcer tells the nurse that he will drink plenty of dairy products, such as milk, to coat and protect his ulcer. What is the best follow up action by the nurse? 25. A client with a hisotry of chronic pain requests a nonopiod analgesic. The client is alert but has difficulty describing the exact nature and location of the pain to the nurse. What action should the nurse implement first? 26. In assessing an adult client w/a partial rebreather mask, the nurse notes that the oxygen reservoir bag does not deflate completely during inspiration and the clients respiratory rate is 14 breaths/min. What action should the nurse implement? ­ 27. Before preparing a client for the first surgical case of the day, a part time scrub nurse asks the circulating nurse if a 3 minute surgical hand scrub is adequate preparation for this client. Which response should the circulating nurse provide? ­Answer: Direct the nurse to continue the surgical hand scrub for a 5 minute duration 28. Following surgery, a male client w/antisocial personality disorder frequently requests that a specific nurse be assigned to his care and is belligerent when another nurse is assigned. What action should the charge nurse implement? ­ 29. An older male client with a history of type 1 diabetes has not felt well teh past few days and arrives at the clinic with abdominal crmapling and vomitting. He is lethargic, moderately confused, and cannot remember when he took his last dose of insulin or ate last. What action should the nurse implement first? ­ 30. After a colon resection for colon cancer, a male client is moaning while being transferred from surgery to the post anesthesia care unit. What intervention should the nurse implement first? 31. A female client reports that her hair is becoming coarse and breaking off, that the outer part of her eyebrows have disappeared, and that her eyes are all puffy. Which follow­up question is best for the nurse to ask? 32. A client presents in the er with right sided facial symmetry. The nurse ask the client to perform a series of movement that require use of facial muscles. What symptoms suggest that the client has most likely experienced bell’s palsy rather than a stroke? Answer: inability to close the affected eye, raise brow, or smile. 33. The nurse is teaching a client how to perform colostomy irrigation. When observing the client’s return demonstration, which action indicates that the client understood the teaching? . 34. What explanation is best for the nurse to provide a client who asks the purpose of using the log rolling technique for rolling? 35. A male client with htn, who has received new antihypertensive prescriptions at his last visit returns to clinic two weeks later to evaluate his bp. His bp is 150/106 and he admits that he has not been taking prescribe medication because the drugs make him “feel bad”. In explaining the need for htn control, the nurse should stress that an elevated bp places the client for which pathophysiological condition? 36. An elderly client with degenerative joint disease asks if she should use the rubber jar openers that are available. The nurse’s response should be based on which information about assistive devices? 37. When caring for a client who has acute respiratory distress syndrome (ARDS), the nurse elevates the head of the bed 30 degrees. What is the reason for this intervention? 38. A client who receives multiple antihypertensive medications experiences syncope due to the drop in bp to 70/40. What is the rationale for the nurse’s decision to hold the client’s scheduled antihypertensive medications? 39. When performing postural drainage on a client with chronic obstructive pulmonary disease (COPD), which approach should the nurse use? 40. The development of atherosclerosis is a process of sequential events. Arrange the pathophysiology events in order of occurrence. (Place the first event on top) 41. A female client who is admitted with end stage pulmonary disease is alert, oriented and complaining of shortness of breath. The client tells the nurse she wants “no heroic measures” taken is she stops breathing, and she asks the nurse to document that in her medical record. What action should the nurse implement? 42. A 60 year old female client with a positive family history for ovarian cancer has developed abdominal mass and is being evaluated for possible ovarian cancer. Her papanicolaou (pap) smear results are negative. What information should the nurse include in the client’s teaching plan? 43. Following a motor vehicle collision, an adult female with a ruptured spleen and a blood pressure 70/40, had an emergency splenectomy. Twelve hours after the surgery her urine output is 25 ml/hour for the last two hours. What pathophysiological reason supports the nurse’s decision to report this finding to the healthcare provider? 44. A male client with cirrhosis has ascites and report feeling short of breath. The client is in a semi­fowler’s position with his arms at his side. What action should the nurse implement? Answer: Raise the head of the bed to a fowler’s position and support his arms with a pillow. 45. A 66 year old women retiring and will no longer have health insurance through her place of employment. Which agency should the client referred to by the employee health nurse for health insurance needs? 46. After a third hospitalization 6 months ago, a client is admitted to the hospital with ascites and malnutrition. The client is drowsy but responds to verbal stimuli and reports recently spitting up blood. What assessment finding warrants immediate intervention by the nurse? 47. The nurse observes an unlicensed assistive personnel (UAP) positioning a newly admitted client who has a seizure disorder. The client is supine and the UAP is placing soft pillows along the side rails. What action should the nurse implement? 48. An adolescent with major depressive disorder has been taking duloxetine (Cymbalta) for the past12 days. What assessment finding requires immediate follow up? 49. The nurse is assigned to care for clients on a medical unit. Based on the notes taken during shift report, which client situation warrants the nurse’s immediate attention? Answer: A 10 year old who is receiving chemotherapy and the infusion pump is beeping. 50. What pathophysiological mechanism are responsible for ascites related to liver failure? (Select all that apply) 51. VIDEO QUESTION: The nurse is auscultating a client’s heart sounds. Which description should the nurse use to document this sound? Answer: Murmur (swishing sound) 52. A client who recently underwent a tracheostomy si being prepared for discharge to home. Which instructions is most important for the nurse to include in the discharge plan? Answer: Teach tracheal suctioning techniques. 53. During shift report the cerebral electrocardiogram (EKG) monitoring system alarm. Which client alarm should the nurse investigate first? 54. At 0600 while admitting a woman for a scheduled repeat cesarean section (c section), the client tells the nurse that she drank a cup of coffee at 0400 because she wanted to avoid getting a headache. Which action should the nurse take first? 55. A client who is taking an oral dose of a tetracycline complains of gastrointestinal upset. What snack should the nurse instruct the client to take with the tetracycline? ­ 61. Following a lumber puncture, a client voices several complaints. What complaint indicates to the nurse that the client is experiencing a complication? ­Answer: I have a headache that gets worse when I sit up. 62. The nurse is assisting the mother of a child with phenylketuria (PKU) to select foods that are keeping with the child's diet restrictions. Which foods are contraindicated for this child? ­ 63. After a third hospitalization 6 months ago, a client is admitted to the hospital with ascites and malnutrition. The client is drowsy but responds to verbal stimuli and reports recently spitting up blood. What assessment finding warrants immediate intervention by the nurse? 64. A client with cervical cancer is hospitalized for insertion of a sealed internal cervical radiation implant. While providing care, the nurse finds the radiation implant in the bed. What action should the nurse take? ­ 65. The client with which type of wound is most likely to need immediate intervention by the nurse? ­ 66. The nurse is planning care for a client admitted with a diagnosis of pheochromocytoma. Which intervention has the highest priority for inclusion in this client's plan of care? ­ 67. When caring for a client who has acute respiratory distress syndrome (ARDS), the nurse evaluates the head of the bed 30 degrees. What is the reason for this intervention? ­ 68. When assessing a mildly obese 35­yr old female client, the nurse is unable to locate the gallbladder when palpating below the liver margin at the lateral border of the rectus abdominal muscle. What is the most likely explanation for failure to locate the gallbladder by palpation? ­ 69. Which breakfast selection indicates that the client understands the nurses instructions about the dietary management of osteoporosis? 70. The nurse performs a prescribed neurological check at the beginning of the shift on a client who was admitted to the hospital for a subarachnoid brain attack (stroke). The clients Glasgow Coma Scale score is 9. What info is most important for the nurse to determine? 71. A mother brings her 6 yr old child, who has just stepped on a rusty nail to the pediatrician's office. Upon inspection, the nurse notes that the nail went through the shoe and peirced the bottom of the child's foot. What action should the nurse implement first? 72. The nurse is conduction a physical assessment of a young adult. Which info provides the best indication of the individuals nutritional status? ­ 73. A client who receives multiple antihypertensive medications experiences syncope due to drop in bp to 70/40. What is the rationale for the nurse's decision to hold the client's scheduled anti hypertensive medication? 74. A 26 yr old female client is admitted to the hospital for treatment of a simple goiter, and levothyroxine sodium (Synthroid) is prescribed. Which symptoms indicate to the nurse that the prescribed dosage is too high for this client? The client experiences: ­Answer: palpitations and shortness of breath 75. A client with a history of heart failure presents to the clinic w/ nausea, vomiting, yellow vision and palpitations. Which finding is most important for the nurse to asses in the client? 76. The heath care provider prescribes an IV solution of Isuprel 1 mg in 250 ml of D3W at 300 mcg/hr. The nurse should program the infusion pump to deliver how many ml hr? 77. The healthcare provider prescribes cefazidime 35 mg q 8 hrs IM for an infant. The 500 mg vial is labeled w/the instructions to add 5.3 ml to provide a concentration of 100 mg/ml. How many ml should the nurse administer for each does? 78. The nurse observed an UAP positioning a newly admitted client who has a seizure disorder. The client is supine and the UAP is placing soft pillows along the side rails. What action should the nurse implement? 79. A female client reports that her hair is becoming course and breaking off, that the outer part of her eyebrows have disappeared and that her eyes are all puffy. Which followup question is best for the nurse to ask? 80. A client presents to the ER with right sided facial asymmtry. The nurse asks the client to perform a series of movements that require use of facial muscles. What symptoms suggest that the client has most likely experienced a bell's palsy rather than a stroke? 81. The nurse is teaching a client how to perform a colostomy irrigations. When observing the client's return demonstrations, which action indicates that the client understood the teaching? 82. What explanation is best for the nurse to provide a client who asks the purpose of using the log­rolling technique for turning? 83. A male client w/ HTN who received a new antihypertensive presc. at his last visit returns to the clinic 2 weeks later to evaluate his BP. His BP is 158/106 and admits that he has not been taking the prescribed meds b/c the drugs make him "feel bad". In explaining the need to HTN control, the nurse should stress that an elevated BP places him at risk for what pathophysiological condition? 84. An elderly client with degenerative joint disease asks if she should use the rubber jar openers that are available. The nurse's response should be based on which information about assistive devices? [Show More]

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