NURS 325 Exam 1-Fundamentals. Complete Solution. Latest 2021.Question 1
A nurse needs to begin discharge planning for a patient admitted with
... [Show More] pneumonia
and a congested cough. When is the best time the nurse should start discharge
planning for this patient?
Selected
Answer:
d.
Upon admission
Answers: a.
When the primary care provider writes
the order
b.
After the congestion is treated
c.
Right before discharge
d.
Upon admission
Response
Feedback:
Ideally, discharge planning begins at admission. Right before discharge
is too late for discharge planning. After the congestion is treated is also
too late for discharge planning. Usually the primary care provider writes
the order too close to discharge, and nurses do not need an order to
begin the teaching that will be needed for discharge. By identifying
discharge needs early, nursing and other health care professionals
begin planning for discharge to the appropriate level of care, which
sometimes includes support services such as home care and equipment
needs.
Question 2
The nurse is assessing skin turgor. Which technique will the nurse use?
Selected
Answer:
d.
Grasp a fold of skin on the sternal
area.
Answers: a.
Grasp a fold of skin on the back of
the hand.
b.
Press lightly on the fingertips.
c.
Press lightly on the forearm.
d.
Grasp a fold of skin on the sternal
area.
Response
Feedback:
To assess skin turgor, grasp a fold of skin on the back of the forearm or
sternal area with the fingertips and release. Since the skin on the back
of the hand is normally loose and thin, turgor is not reliably assessed at
that site. Pressing lightly on the forearm can be used to assess for
pitting edema or pain or sense of touch. Pressing lightly on the
fingertips and observing nail color is assessing capillary refill.
Question 3
During a routine pediatric history and physical, the parents report that their child
was a very small, premature infant that had to stay in the neonatal intensive care
unit longer than usual. They state that the infant was yellow when born and
developed an infection that required “every antibiotic under the sun” to reach a
cure. Which exam is a priority for the nurse to conduct on the child?
Selected
Answer:
c.
Hearing
acuity
Answers: a.
Cardiac
b.
Respiratory
c.
Hearing
acuity
d.
Ophthalmic
Response
Feedback:
Hearing is the priority. Risk factors for hearing problems include low
birth weight, nonbacterial intrauterine infection, and excessively high
bilirubin levels. Hearing loss due to ototoxicity (injury to auditory
nerves) can result from high maintenance doses of antibiotics. Cardiac,
respiratory, and eye examinations are important assessments but are
not relevant to this child’s condition.
Question 4
The nurse is caring for a group of patients. Which patient will the nurse see first?
Selected
Answer:
a.
A patient with Clostridium difficile in droplet precautions
Answers: a.
A patient with Clostridium difficile in droplet precautions
b.
A patient with a lung transplant in protective environment
precautions
c.
A patient with tuberculosis in airborne precautions
d.
A patient with MRSA infection in contact precautions
Response
Feedback:
A patient with Clostridium difficile should be on contact precautions,
not droplet; therefore, the nurse will see this patient first to correct the
precautions. All the rest are on correct precautions. Patients with
tuberculosis belong in airborne precautions; patients with MRSA
infection belong in contact precautions; and patients with lung
transplants belong in protective environment precautions.
Question 5
Which action by the nurse will be the most important for preventing skin
impairment in a mobile patient with local nerve damage?
Selected
Answer:
a.
Assess for pain during a bath.
Answers: a.
Assess for pain during a bath.
b.
Insert an indwelling urinary
catheter.
c.
Turn the patient every 2 hours.
d.
Limit caloric and protein intake.
Response
Feedback:
During a bath, assess the status of sensory nerve function by checking
for touch, pain, heat, cold, and pressure. When restricted from moving
freely, dependent body parts are exposed to pressure that reduces
circulation. However, this patient is mobile and therefore is able to
change positions. Limiting caloric and protein intake may result in
impaired or delayed wound healing. A mobile patient can use bathroom
facilities or a urinal and does not need a urinary catheter.
Question 6
Which nursing action will most likely increase a patient’s risk for developing a
health care–associated infection?
Selected
Answer:c.
Uses a sterile bottled solution more than once within a 24-
hour period
Answers: a.
Uses a sterile bottled solution more than once within a 24-
hour period
b.
Uses a cleaning stroke from the urinary meatus toward the
rectum
c.
Uses a clean technique for inserting a urinary catheter
d.
Uses surgical aseptic technique to suction an airway [Show Less]