NURS 206 midterm review 205 Questions and Answers
UNIT II Professional Standards in Nursing
Care of Special Populations
1. Which teaching method is
... [Show More] most effective when providing instruction to members of special populations? Teach-back (When providing education to members of special populations, return explanation and demonstration (teach-back) are of particular importance to ensure safety and mutual understanding. This method is the most reliable in confirming client understanding of the instructions.)
2. SATA. Which health concern(s) should the nurse be aware of as risk factors when caring for clients of African American descent? Cancer. Obesity. Hypertension. Heart disease. Diabetes mellitus.
3. The nurse is planning care for a client of Native Hawaiian descent who recently had a baby. The nurse develops a teaching plan and includes information about which measure that is related to a newborn complication within this ethnic group? Safe Sleeping (The Native Hawaiian population has a disproportionately higher rate of infant mortality compared with other ethnic groups. Sudden infant death syndrome (SIDS) is a major cause of infant mortality. Safe sleeping is an important measure to prevent this newborn complication.
4. The nurse is planning care for an assigned client. The nurse should include information in the plan of care about prevention of human immunodeficiency virus (HIV) for which individuals specifically at risk? MSM (men-who-have-sex-with-men)
5. Which therapeutic communication technique is most helpful when working with transgender persons? Using open-ended questions (The use of open-ended questions is most helpful in communicating with transgender persons because it assists in refraining from judgment and allows the client the opportunity to express their thoughts and feelings)
6. SATA. Which special population should be targeted for breast cancer screening by way of mammography? MTF. FTM. WSM. WSW.
7. The nurse is volunteering with an outreach program to provide basic health care for homeless people. Which finding, if noted, should be addressed first? Complaints of pain associated with numbness and tingling in both feet.
8. The nurse is preparing discharge resources for a client being discharged to the homeless shelter. When looking at the discharge medication reconciliation form, the nurse determines there is a need for follow-up if which medication was prescribed? Glipizide (Glipizide is an oral hypoglycemic medication and is classified as a sulfonylurea. A major side effect of this medication is hypoglycemia, which presents a safety risk to the homeless person)
9. The nurse is completing the admission assessment for a client who is intellectually disabled. Which part of the client encounter may require more time to complete? The history (Intellectually disabled clients tend to be poor historians, and it may be necessary to take more time to ask questions in a variety of different ways when collecting the history data)
10. The nurse working in a correctional facility is caring for a new prisoner. The client asks about health risks associated with living in a prison. How should the nurse respond? “Living in prison can predispose a person to different health conditions” (The environment of a prison can predispose a person to different health conditions, such as tuberculosis, human immunodeficiency syndrome, sexually transmitted infections, or other infectious diseases)
11. The nurse is caring for a female client in the emergency department who presents with a complaint of fatigue and shortness of breath. Which physical assessment findings, if noted by the nurse, warrant a need for follow-up? A reddish-purple mark on the neck (The client in this question should be screened for abuse. Battered women experience bruises, particularly around the eyes, red or purple marks on the neck, sprained or broken wrists, chronic fatigue, shortness of breath, muscle tension, involuntary shaking, changes in eating and sleeping, sexual dysfunction, and fertility issues. Mental health issues can also arise, including post-traumatic stress disorder, nightmares, anxiety, uncontrollable thoughts, depression, anxiety, low self- esteem, and alcohol and drug abuse)
12. SATA. The nurse working in a community outreach program for foster children plans care knowing that which health conditions are common in this population? Sleep problems. Bipolar disorder. Aggressive behavior. ADHD. (Foster children are at risk for a variety of health conditions later in life, including ADHD, aggressive behavior, anxiety disorder, bipolar disorder, depression, mood disorder, post-traumatic stress disorder, reactive detachment disorder, sleep problems, prenatal drug and alcohol exposure, and personality disorder)
13. The nurse planning care for a military veteran should prioritize nursing interventions targeted at managing which condition, if present, that commonly occurs in this population? PTSD (Post-traumatic stress disorder (PTSD) is extremely common in this population. Identifying and treating mental health disorders assists in mitigating suicide risk. Treatment of comorbid conditions such as PTSD may also help address any substance use disorder. Use of screening tools in identifying substance use disorder is helpful. Treatment of PTSD includes exposure therapy, psychotherapy, and family/group therapy)
14. The nurse caring for a refugee considers which health care need a priority for this client? Access to mental health care services. (Mental health problems are the primary issue for this population as a result of tortuous events)
15. Which action by the nurse will best facilitate adherence to the treatment regimen for a client with a chronic illness? Arranging home health care (Nursing follow-up visits are important in promoting health for individuals with chronic illness; therefore, arranging for home health care is an important strategy)
Ethical and Legal Issues
16. The nurse hears a client calling out for help, hurries down the hallway to the client’s room, and finds the client lying on the floor. The nurse performs an assessment, assists the client back to bed, notifies the primary health care provider, and completes an occurrence report. Which statement should the nurse document on the occurrence report? The client was found lying on the floor. (The occurrence report should contain a factual description of the occurrence, any injuries experienced by those involved, and the outcome of the situation. The correct option is the only one that describes the facts as observed by the nurse)
17. A client is brought to the emergency department by emergency medical services (EMS) after being hit by a car. The name of the client is unknown, and the client has sustained a severe head injury and multiple fractures and is unconscious. An emergency craniotomy is required. Regarding informed consent for the surgical procedure, which is the best action? Transport the victim to the OR for surgery. (In general, there are two situations in which informed consent of an adult client is not needed. One is when an emergency is present and delaying treatment for the purpose of obtaining informed consent would result in injury or death to the client. The second is when the client waives the right to give informed consent)
18. The nurse has just assisted a client back to bed after a fall. The nurse and primary health care provider have assessed the client and have determined that the client is not injured. After completing the occurrence report, the nurse should implement which action next? Reassess the client. (After a client’s fall, the nurse must
frequently reassess the client, because potential complications do not always appear immediately after the fall. The client’s fall should be treated as private information and shared on a “need to know” basis)
19. The nurse arrives at work and is told to report (float) to the intensive care unit (ICU) for the day because the ICU is understaffed and needs additional nurses to care for the clients. The nurse has never worked in the ICU. The nurse should take which best action? Clarify the ICU client assignment with the team leader to ensure that it is a safe assignment. (Floating is an acceptable practice used by the hospitals to solve understaffing problems. Legally, the nurse cannot refuse to float unless a union contract guarantees that nurses can work only in a specified area or the nurse can prove the lack of knowledge for the performance of assigned tasks. When encountering this situation, the nurse should set priorities and identify potential areas of harm to the client. That is why clarifying the client assignment with the team leader to ensure that it is a safe one is the best option)
20. The nurse who works on the night shift enters the medication room and finds a coworker with a tourniquet wrapped around the upper arm. The coworker is about to insert a needle, attached to a syringe containing a clear liquid, into the antecubital area. Which is the most appropriate action by the nurse? Call the nurse supervisor. (Nurse practice acts require reporting impaired nurses. The board of nursing has jurisdiction over the practice of nursing and may develop plans for treatment and supervision of the impaired nurse. This occurrence needs to be reported to the nursing supervisor, who will then report to the board of nursing and other authorities, such as the police, as required)
21. A hospitalized client tells the nurse that an instructional directive is being prepared and that the lawyer will be bringing the document to the hospital today for witness signatures. The client asks the nurse for assistance in obtaining a witness to the will. Which is the most appropriate response to the client? “I will call the nursing supervisor to seek assistance regarding your request” (Instructional directives (living wills) are required to be in writing and signed by the client. The client’s signature must be witnessed by specified individuals or notarized)
22. SATA. The nurse has made an error in documentation of the dose administered of an opioid pain medication in the client’s record. The nurse draws 1 mg from the vial and another registered nurse (RN) witnesses wasting of the remaining 1 mg. When scanning the medication, the nurse entered into the medication administration record (MAR) that 2 mg of hydromorphone was administered instead of the actual dose administered, which was 1 mg. The nurse should take which action(s) to correct the error in the MAR? Right click on the entry and modify it to reflect the correct information. Document the correct information and end with the nurse’s signature and title. Obtain a co-signature from the RN who witnessed the waste of the remaining 1mg. Document in a nurses note in the clients record detailing the corrected information.
23. Which identifies accurate nursing documentation notation(s)? A client slept through the night. Abdominal wound dressing is dry and intact without drainage. The client left lower medial leg wounds is 3cm in length without redness, drainage, or edema. Factual documentation contains descriptive, objective information about what the nurse sees, hears, feels, or smells.
24. A nursing instructor delivers a lecture to nursing students regarding the issue of clients’ rights and asks a nursing student to identify a situation that represents an example of invasion of client privacy. Which situation, if identified by the student, indicates an understanding of a violation of this client right? Observing care provided to the client without the client permission
25. Nursing staff members are sitting in the lounge taking their morning break. Assistive personnel (AP) tells the group that she thinks that the unit secretary has acquired immunodeficiency syndrome (AIDS) and proceeds to tell the nursing staff that the secretary probably contracted the disease from her husband, who is supposedly a drug addict. The registered nurse should inform the AP that making this accusation has
violated which legal tort? Slander (Defamation in writing (libel) or verbally (slander). An assault occurs when a person puts another person in fear of a harmful or offensive contact. Negligence involves the actions of professionals that fall below the standard of care for a specific professional group)
26. An older woman is brought to the emergency department for treatment of a fractured arm. On physical assessment, the nurse notes old and new ecchymotic areas on the client’s chest and legs and asks the client how the bruises were sustained. The client, although reluctant, tells the nurse in confidence that her son frequently hits her if supper is not prepared on time when he arrives home from work. Which is the most appropriate nursing response? “As a nurse, I am legally bound to report abuse. I will stay with you while you give the report and help find a safe place for you to stay”
27. The nurse calls the primary health care provider (PHCP) regarding a new medication prescription, because the dosage prescribed is higher than the recommended dosage. The nurse is unable to locate the PHCP, and the medication is due to be administered. Which action should the nurse take? Contact the RN supervisor
28. The nurse employed in a hospital is waiting to receive a report from the laboratory via the facsimile (fax) machine. The fax machine activates and the nurse expects the report, but instead receives a sexually oriented photograph. Which is the most appropriate initial nursing action? Call the RN supervisor and report the occurrence
Prioritizing Client Care: Leadership, Delegation, and Emergency Response Training
29. The nurse is assigned to care for four clients. In planning client rounds, which client should the nurse assess first? A client with asthma who requested a breathing treatment during the previous shift.
(Airway is always the highest priority, and the nurse would attend to the client with asthma who requested a breathing treatment during the previous shift. This could indicate that the client was experiencing difficulty breathing.)
30. The nurse employed in an emergency department is assigned to triage clients coming to the emergency department for treatment on the evening shift. The nurse should assign priority to which client? A client with chest pain who states that he just ate pizza that was made with a very spicy sauce.
31. A nursing graduate is attending an agency orientation regarding the nursing model of practice implemented in the health care facility. The nurse is told that the nursing model is a team nursing approach. The nurse determines that which scenario is characteristic of the team-based model of nursing practice? An RN leads 2 LPNs and 3Aps in providing care to a group of 12 clients.
32. The nurse has received the assignment for the day shift. After making initial rounds and checking all of the assigned clients, which client should the nurse plan to care for first? A client with a WBC 14,000 mm3 and a temp of 38.4C (101.2F)
33. The nurse is giving a bed bath to an assigned client when assistive personnel (AP) enters the client's room and tells the nurse that another assigned client is in pain and needs pain medication. Which is the most appropriate nursing action? Cover the client, raise the side rails, tell the client that you will return shortly, and administer the pain medication to the other client.
34. The nurse manager has implemented a change in the method of the nursing delivery system from functional to team nursing. An assistive personnel (AP) is resistant to the change and is not taking an active part in facilitating the process of change. Which is the best approach in dealing with the AP? Confront the UAP to encourage verbalization of feelings regarding the change. Confrontation is an important strategy to meet resistance head-on. Face-to-face meetings to confront the issue at hand will allow verbalization of feelings, identification of problems and issues, and development of strategies to solve the problem
35. The registered nurse is planning the client assignments for the day. Which is the most appropriate assignment for an assistive personnel (AP)? A client who requires urine specimen collections.
36. SATA The nurse manager is discussing the facility protocol in the event of a tornado with the staff. Which instructions should the nurse manager include in the discussion? Move beds away from windows. Close window shades and curtains. Place blankets over clients who are confined to bed. In this weather event, the appropriate nursing actions focus on protecting clients from flying debris or glass.
37. SATA The charge nurse is planning the assignment for the day. Which factors should the nurse remain mindful of when planning the assignment? The acuity level of the clients. Client needs and workers needs and abilities. There are guidelines that the nurse should use when delegating and planning assignments. These include the following: ensure client safety; be aware of individual variations in work abilities; determine which tasks can be delegated and to whom; match the task to the delegatee on the basis of the nurse practice act and appropriate position descriptions; provide directions that are clear, concise, accurate, and complete; validate the delegatee understanding of the directions; communicate a feeling of confidence to the delegatee and provide feedback promptly after the task is performed; and maintain continuity of care as much as possible when assigning client care.
UNIT III Foundations of Care
Fluid and Electrolytes
38. The nurse is caring for a client with heart failure. On assessment, the nurse notes that the client is dyspneic, and crackles are audible on auscultation. What additional manifestations would the nurse expect to note in this client if excess fluid volume is present? An increase in B/P and increased RR
39. The nurse reviews a client's record and determines that the client is at risk for developing a potassium deficit if which situation is documented? Requires nasogastric suction
40. SATA The nurse reviews a client's electrolyte laboratory report and notes that the potassium level is
2.5 mEq/L (2.5mmol/L). Which patterns should the nurse watch for on the electrocardiogram (ECG) as a result of the laboratory value? U waves. Inverted T waves. Depressed ST segment. Serum potassium level is 3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L).
Hypokalemia EKG changes will include prominent U waves, shallow, flat or inverted T waves. Depressed ST segment. Thready weak irregular pulse, weak peripheral pulses, Orthostatic hypotension, dysrhythmias. It is potentially life threatening because every-body system is affected. Caused by diuretic use, increase secretion of aldosterone, vomiting diarrhea, wound drainage (GI), prolonged nasogastric suction, excessive diaphoresis, kidney disease, alkalosis, hyperinsulinism.
Hyperkalemia EKG changes will include tall peaked T waves, flat P waves, widened QRS complexes, and prolonged PR interval. Slow weak, irregular HR decreased B/P, dysrhythmias. Caused due to excessive K intake and/or rapid infusion, adrenal insufficiency (Addison’s disease) antidiuretics, kidney disease, tissue damage (burns), acidosis.
Hypocalcemia EKG changes will include a prolonged QT interval and prolonged ST segment. Decreased HR. Hypotension. Diminished peripheral pulses. Signs include paresthesia followed by numbness, hyperactive deep tendon reflexes, and a positive Trousseau's or Chvostek's sign. Additional signs include increased neuromuscular
excitability, muscle cramps, twitching, tetany, seizures, irritability, and anxiety. GI symptoms include increased gastric motility, hyperactive bowel sounds, abdominal cramping, and diarrhea. Lactose intolerance
Hypercalcemia EKG changes will include shortened ST segment, widened T wave, heart block. Increased HR in early stages and bradycardia that can lead to cardiac arrest in late stages. Increased B/P. Bounding full peripheral pulses. Signs include kidney disease, thiazide diuretics, hyperparathyroidism, hyperthyroidism, malignancy, immobility, dehydration, use of lithium, adrenal insufficiency
Hypomagnesemia EKG changes will include tall T waves, Depressed ST segment. Tachycardia and hypertension. Signs and causes malnutrition, starvation, vomiting, diarrhea, malabsorption syndrome, celiac disease, Crohn’s disease, diuretics, chronic alcoholism, hyperglycemia, insulin administration, sepsis.
Hypermagnesemia EKG changes will include prolonged PR interval, widened QRS complexes. Bradycardia, dysrhythmias (cardiac arrest if severe), hypotension. Signs and causes Mg containing laxatives or antacids, excessive IV admin, decreased renal excretion of Mg due to renal insufficiency.
Hyponatremia can occur in the client taking diuretics. Signs are muscle weakness, increased urinary output, and decreased specific gravity of the urine would be noted. Hypernatremia occurs in the client taking corticosteroids, the client with hyperaldosteronism or Cushing's syndrome. Signs are muscle twitching, decreased urinary output, increase specific gravity of urine. HR and B/P respond to vascular volume status.
Hypophosphatemia causative factors relate to malnutrition, starvation , the use of aluminum hydroxide–based or magnesium-based antacids, hyperparathyroidism, malignancy, hyperglycemia, respiratory alkalosis.
Hyperphosphatemia occurs in client with renal insufficiency, hypoparathyroidism, and tumor lysis syndrome, decreased renal excretion due to renal insufficiency, increase intake of phosphate or phosphate containing laxatives or enemas, hypoparathyroidism.
41. SATA Potassium chloride intravenously is prescribed for a client with heart failure experiencing hypokalemia. Which actions should the nurse take to plan for preparation and administration of the potassium? Obtain an intravenous (IV) infusion pump. Monitor urine output during administration. Monitor the IV site for signs of infiltration or phlebitis. Ensure that the medication is diluted in the appropriate volume of fluid. Ensure that the bag is labeled so that it reads the volume of potassium in the solution.
42. The nurse is assessing a client with a lactose intolerance disorder for a suspected diagnosis of hypocalcemia. Which clinical manifestation would the nurse expect to note in the client? Twitching.
Calcium level is 9 to 10.5 mg/dL (2.25 to 2.75 mmol/L).
43. SATA The nurse is caring for a client with Crohn's disease who has a calcium level of 8 mg/dL (2 mmol/L). Which patterns would the nurse watch for on the electrocardiogram? Prolonged QT interval. Prolonged ST segment. A client with Crohn's disease is at risk for hypocalcemia.
44. SATA The nurse reviews the electrolyte results of a client with chronic kidney disease and notes that the potassium level is 5.7 mEq/L (5.7 mmol/L). Which patterns would the nurse watch for on the cardiac monitor as a result of the laboratory value? Tall peaked T waves. Widened QRS complexes. The client with chronic kidney disease is at risk for hyperkalemia. Potassium level is 3.5 to 5.0 mEq/L (3.5 to
5.0 mmol/L)
45. Which client is at risk for the development of a sodium level at 130 mEq/L (130 mmol/L)? A client who is taking diuretics. Sodium level is 135 to 145 mEq/L (135 to 145 mmol/L).
46. The nurse is caring for a client with heart failure who is receiving high doses of a diuretic. On assessment, the nurse notes that the client has flat neck veins, generalized muscle weakness, and diminished deep tendon reflexes. The nurse suspects hyponatremia. What additional signs would the nurse expect to note in a client with hyponatremia? Hyperactive bowel sounds indicate hyponatremia.
47. The nurse reviews a client's laboratory report and notes that the client's serum phosphorus (phosphate) level is 1.8mg/dL (0.58 mmol/L). Which condition most likely caused this serum phosphorus level? Malnutrition. Serum phosphorus (phosphate) level is 3.0 to 4.5 mg/dL (0.97 to 1.45 mmol/L).
48. The nurse is reading a primary health care provider's (PHCP's) progress notes in the client's record and reads that the PHCP has documented “insensible fluid loss of approximately 800 mL daily.” The nurse makes a notation that insensible fluid loss occurs through which type of excretion? Integumentary output.
Insensible losses may occur without the person's awareness, they occur daily through the skin and the lungs.
Sensible losses are those of which the person is aware, such as through urination, wound drainage, and gastrointestinal tract losses.
49. The nurse is assigned to care for a group of clients. On review of the clients' medical records, the nurse determines that which client is most likely at risk for a fluid volume deficit? A client with an ileostomy.
Fluid volume deficit causes include vomiting, diarrhea, conditions that cause increased respirations or increased urinary output, insufficient intravenous fluid replacement, draining fistulas, and the presence of an ileostomy or colostomy. Sings are increased respirations and heart rate, decreased central venous pressure (CVP), weight loss, poor skin turgor, dry mucous membranes, decreased urine volume, increased specific gravity of the urine, increased hematocrit, and altered LOC.
Fluid volume excess is caused by decreased kidney function, heart failure, use of hypotonic fluids to replace isotonic fluid losses, excessive irrigation of wounds and body cavities, and excessive ingestion of sodium. Sings are lung congestion, increased urinary output, and increased blood pressure
50. The nurse caring for a client who has been receiving intravenous (IV) diuretics suspects that the client is experiencing a fluid volume deficit. Which assessment finding would the nurse note in a client with this condition? Weight loss and poor skin turgor.
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