NURSING 101 -Essentials Final Exam (100% correct)
A postoperative client will need to perform daily dressing changes
after discharge. Which outcome
response best demonstrates the
client's readiness to manage wound care after discharge?
A postoperative client will need to perform
daily dressing changes after discharge. Which outcome response best
demonstrates the client's readiness to manage wound care after discharge?
Asking relevant questions regarding the dressing change.
Stating theability to complete the wound care regimen.
Demonstrating the wound care procedure correctly.
Showing all the necessary supplies for wound care.
Rationale
A return demonstration of a procedure provides an objective
assessment of a client's ability to perform a task, while client
statements or questions are subjective measures.Showing that the
client possesses the necessary supplies is important, but it is less of
a priority prior to discharge than the nurse's assessment of the
client's ability to complete the wound care.
The nurse is completing a mental assessment for a client who is
demonstrating slow thought processes, personality changes, and
emotional lability. Which area of the brain controls these neurocognitive functions?
The nurse is completing a mental assessment for a client who
is demonstrating slow thought processes, personality changes, and
emotional lability. Which area of the brain controls these neuro-cognitive
functions?
Thalamus.
Hypothalamus.
Frontal lobe.
Parietal lobe.
Rationale
The frontal lobe of the cerebrum controls higher mental activities,
such as memory, intellect, language, emotions, and personality. On
the other hand, the thalamus is an afferent relay center in the brain
that directs impulses to the cerebral cortex. The hypothalamus
regulates body temperature, appetite, maintains a wakeful state,
and links higher centers with the autonomic nervous and endocrine
systems, such as the pituitary. The parietal lobe is the location of
sensory and motor functions.
A male client being discharged with a prescription for the
bronchodilator theophylline tells the nurse that he understands he
is to take three doses of the medication each day. Since, at the time
of discharge, timed-release capsules are not available, which dosing
schedule should the nurse advise the client to follow?
A male client being discharged with a prescription for the
bronchodilator theophylline tells the nurse that he understands he is to take
three doses of the medication each day. Since, at the time of discharge,
timed-release capsules are not available, which dosing schedule should the
nurse advise the client to follow?
9 a.m., 1 p.m., and 5 p.m.
8 a.m., 4 p.m., and midnight.
Before breakfast, before lunch, and before dinner.
With breakfast, with lunch, and with dinner.
Rationale
Theophylline should be administered on a regular, around-the-clock
schedule to provide the best bronchodilating effect and to reduce
the potential for adverse effects. Food may alter absorption of the
medication, so it should not be taken with meals.
The nurse is instructing a client with high cholesterol about diet and
life style modification. What comment from the client indicates that
the teaching has been effective?
The nurse is instructing a client with high
cholesterol about diet and life style modification. What comment from the
client indicates that the teaching has been effective?
"If I exercise at least two times weekly for one hour, I will lower my
cholesterol."
"I need to avoid eating proteins, including red meat."
"I will limit my intake of beef to 4 ounces per week."
"My blood level of low density lipoproteins needs to increase."
Rationale
Limiting saturated fat from animal food sources to no more than 4
ounces per week is an important diet modification for lowering
cholesterol. To be effective in reducing cholesterol, the client should
exercise 30 minutes per day, or at least 4 to 6 times per week. Red
meat and all proteins do not need to be eliminated to lower
cholesterol, but should be restricted to lean cuts of red meat and
smaller portions (2-ounce servings). The low density lipoproteins
need to decrease rather than increase.
The nurse notices that the Hispanic parents of a toddler who returns
from surgery offer the child only the broth that comes on the clear
liquid tray. Other liquids, including gelatin, popsicles, and juices,
remain untouched. What explanation is most appropriate for this
behavior?
The nurse notices that the Hispanic parents of a toddler who
returns from surgery offer the child only the broth that comes on the clear
liquid tray. Other liquids, including gelatin, popsicles, and juices, remain
untouched. What explanation is most appropriate for this behavior?
The belief is held that the "evil eye" enters the child if anything cold is
ingested.
After surgery the child probably has refused all foods except broth.
Eating broth strengthens the child's innate energy called "chi."
"Hot" remedies restore balance after surgery, which is considered a "cold"
condition.
Rationale
Common parental practices and health beliefs among Hispanic,
Chinese, Filipino, and Arab cultures classify diseases, areas of the
body, and illnesses as "hot" or "cold" and must be balanced to
maintain health and prevent illness. The perception that surgery is
a "cold" condition implies that only "hot" remedies, such as soup,
should be used to restore the healthy balance within the body.
A hospitalized male client is receiving nasogastric tube feedings via
a small-bore tube and a continuous pump infusion. He reports that
he had a bad bout of severe coughing a few minutes ago, but feels
fine now. What action is best for the nurse to take?
A hospitalized male client is receiving nasogastric tube
feedings via a small-bore tube and a continuous pump infusion. He reports
that he had a bad bout of severe coughing a few minutes ago, but feels fine
now. What action is best for the nurse to take?
Record the coughing incident. No further action is required at this time.
Stop the feeding, explain to the family why it is being stopped, and notify
the healthcare provider.
After clearing the tube with 30 ml of air, check the pH of fluid withdrawn
from the tube.
Inject 30 ml of air into the tube while auscultating the epigastrium for
gurgling.
Rationale
Coughing, vomiting, and suctioning can precipitate displacement of
the tip of the small bore feeding tube upward into the esophagus,
placing the client at increased risk for aspiration. Checking the
sample of fluid withdrawn from the tube (after clearing the tube
with 30 ml of air) for acidic (stomach) or alkaline (intestine) values
is a more sensitive method for these tubes, and the nurse should
assess tube placement in this way prior to taking any other action.
The auscultating method has been found to be unreliable for smallbore feeding tubes.
An African-American grandmother tells the nurse that her 4-year-old
grandson is suffering with "miseries." Based on this statement,
which focused assessment should the nurse conduct?
An African-American grandmother tells the nurse that her 4-
year-old grandson is suffering with "miseries." Based on this statement,
which focused assessment should the nurse conduct?
Inquire about the source and type of pain.
Examine the nose for congestion and discharge.
Take vital signs for temperature elevation.
Explore the abdominal area for distension.
Rationale
Different cultural groups often have their own terms for health
conditions. African-American clients may refer to pain as "the
miseries. " Based on understanding this term, the nurse should
conduct a focused assessment on the source and type of pain.
Fill in the blank
A client with type 2 diabetes is receiving metformin (Glucophage) 1
gram PO twice daily. The medication is available in 500 mg tablets.
How many tablets should the nurse administer? (Enter numeric
value only.)
Rationale
Using the known equivalent, 1 gram = 1000 mg, the nurse should
first convert the dose to the same unit of measurement, which is 1
gram = 1000 mg.
Using the formula, Desired / Available x 1 tablets:
1000 mg / 500 mg x 1 = 2 tablets
The nurse is assessing the nutritional status of several clients.
Which client has the greatest nutritional need for additional intake
of protein?
The nurse is assessing the nutritional status of several clients.
Which client has the greatest nutritional need for additional intake of
protein?
A college-age track runner with a sprained ankle.
A lactating woman nursing her 3-day-old infant.
A school-aged child with Type 2 diabetes.
An elderly man being treated for a peptic ulcer.
Rationale
A lactating woman has the greatest need for additional protein
intake. Orthopedic injuries, typoe 2 diabetes, and peptic ulcers are
all conditions that require protein, but do not have the increased
metabolic protein demands of lactation.
A female client with a nasogastric tube attached to low suction
states that she is nauseated. The nurse assesses that there has
been no drainage through the nasogastric tube in the last two
hours. Which action should the nurse take first?
A female client with a nasogastric tube attached to low
suction states that she is nauseated. The nurse assesses that there has been
no drainage through the nasogastric tube in the last two hours. Which action
should the nurse take first?
Irrigate the nasogastric tube with sterile normal saline.
Reposition the client on her side.
Advance the nasogastric tube an additional five centimeters.
Administer an intravenous antiemetic prescribed for PRN use.
Rationale
The nurse has identified two things suggesting the the nasogastric
tube is not functioning properly; the client is nauseated and no
drainage from the tube in 2 hours. The immediate priority is to
determine if the tube is functioning correctly, which would then
relieve the client's nausea. The least invasive intervention should be
attempted first. This includes repositioning the client to her side.
The tube may need to be irrigated or advanced but these actions
should follow repositioning the client.
The nurse assigns an unlicensed assistive personnel (UAP) to obtain
vital signs from a very anxious client. What instructions should the
nurse give the UAP?
The nurse assigns an unlicensed assistive personnel (UAP) to
obtain vital signs from a very anxious client. What instructions should the
nurse give the UAP?
Remain calm with the client and record abnormal results in the chart.
Notify the medication nurse immediately if the pulse or blood pressure is
low.
Report the results of the vital signs to the nurse.
Reassure the client that the vital signs are normal.
Rationale
Interpretation of vital signs is the responsibility of the nurse, so the
unlicensed assistive personnel (UAP) should report vital sign
measurements to the nurse. Any instructions requiring the UAP to
interpret the vital signs causes the UAP to function beyond the
scope of the UAP's authority.
An older resident of a long-term care facility is no longer able to
perform self-care and is becoming progressively weaker. The
resident previously requested that no resuscitative efforts be
performed, and the family requests hospice care. What action
should the nurse implement first?
An older resident of a long-term care facility is no longer able
to perform self-care and is becoming progressively weaker. The resident
previously requested that no resuscitative efforts be performed, and the
family requests hospice care. What action should the nurse implement first?
Reaffirm the client's desire for no resuscitative efforts.
Transfer the client to a hospice inpatient facility.
Prepare the family for the client's impending death.
Notify the healthcare provider of the family's request.
Rationale
When a family requests hospice care, the nurse should first
communicate with the healthcare provider. Hospice care is provided
for clients with a limited life expectancy, which must be identified
by the healthcare provider. Once the healthcare provider supports
the transfer to hospice care, the nurse can collaborate with the
hospice staff and healthcare provider to determine what additional
care should be implemented.
During the admission interview, which technique is most efficient for
the nurse to use when obtaining information about signs and
symptoms of a client's primary health problem?
During the admission interview, which
technique is most efficient for the nurse to use when obtaining information
about signs and symptoms of a client's primary health problem?
Restatement of responses.
Open-ended questions.
Closed-ended questions.
Problem-seeking responses.
Rationale
Lay descriptors of health problems can be vague and nonspecific. To
efficiently obtain specific information, the nurse should use closedended questions that focus on common signs and symptoms about a
client’s health problem.Other question types are used when
therapeutically interacting and should be used after specific
information is obtained from the client.
The nurse is teaching a client proper use of an inhaler. When should
the client administer the inhaler-delivered medication to
demonstrate correct use of the inhaler?
The nurse is teaching a client proper use of an inhaler. When
should the client administer the inhaler-delivered medication to demonstrate
correct use of the inhaler?
Immediately after exhalation.
During the inhalation.
At the end of three inhalations.
Immediately after inhalation.
Rationale
The client should be instructed to deliver medication through a
metered inhaler during the last part of inhalation. After the
medication is delivered, the client should remove the mouthpiece,
keeping his/her lips closed and hold the breath for several seconds
to allow for distribution of the medication.
The nurse is administering medications through a nasogastric tube
(NGT) which is connected to suction. After ensuring correct tube
placement, which action should the nurse take next?
The nurse is administering medications
through a nasogastric tube (NGT) which is connected to suction. After
ensuring correct tube placement, which action should the nurse take next?
Clamp the tube for 20 minutes.
Flush the tube with water.
Administer the medications as prescribed.
Crush the tablets and dissolve in sterile water.
Rationale
The NGT should be flushed before, after, and in between each
medication administered. Once all medications are administered,
the NGT should be clamped for 20 minutes.Other options may be
implemented only after the tubing has been flushed.
Which nutritional assessment data should the nurse collect to best
reflect total muscle mass in an adolescent?
Which nutritional assessment data should
the nurse collect to best reflect total muscle mass in an adolescent?
Height in inches or centimeters.
Weight in kilograms or pounds.
Triceps skin fold thickness.
Upper arm circumference.
Rationale
Upper arm circumference is an indirect measure of muscle
mass.Height and weight do not distinguish between fat (adipose)
and muscularity.Triceps skin fold thickness is a measure of body fat.
A male client with a history of hypertension tells the nurse that he
is tired of taking antihypertensive medications and is going to try
spiritual meditation instead. What should be the nurse's first
response?
A male client with a history of hypertension tells the nurse
that he is tired of taking antihypertensive medications and is going to try
spiritual meditation instead. What should be the nurse's first response?
"It is important that you continue your medication while learning to
meditate."
"Spiritual meditation requires a time commitment of 15 to 20 minutes
daily."
"Obtain your healthcare provider's permission before starting
meditation."
"Complementary therapy and western medicine can be effective for you."
Rationale
The prolonged practice of meditation may lead to a reduced need
for antihypertensive medications. However, the medications must
be continued while the physiologic response to meditation is
monitored. The healthcare provider should be informed, but
permission is not required to meditate. Although it is true that this
complementary therapy might be effective, it is essential that the
client continue with antihypertensive medications until the effect of
meditation can be measured.
The nurse is teaching a client with numerous allergies how to avoid
allergens. Which instruction should be included in this teaching [Show Less]