NSG 232 Fundamentals exam 2

The nurse is caring for a patient who is immobile and is at risk for skin impairment. The plan of care includes turning the patient. What is the best method for repositioning the patient?

Utilize a transfer sliding board and assistance to slide the patient into the new position.

In a client with amyotrophic lateral sclerosis (ALS) and respiratory distress, which finding is the earliest sign of reduced oxygenation?

increased restlessness

The nurse is caring for a client with asthma. The nurse should conduct a focused assessment to detect:

inspiratory and expiratory wheezing.

A client is receiving moderate sedation while undergoing bronchoscopy. Which assessment finding should the nurse attend to immediately?

oxygen saturation of 90%

A client with jaundice has pruritus and areas of irritation from scratching. What measures can the nurse suggest the client use to prevent skin breakdown? Select all that apply.

Add baking soda to the water in a tub bath. Keep nails short and clean. Rub the skin when it itches with knuckles instead of nails.

A client is admitted to the health care facility with bowel obstruction secondary to colon cancer. The nurse obtains a health history, measures vital signs, and auscultates for bowel sounds. Which step of the nursing process is she performing?

Assessment

The nurse uses which part of the SBAR acronym when stating, "I think the client is dry."

Assessment.

When teaching the diabetic client about foot care, what should the nurse instruct the client to do?

Avoid going barefoot.

The nurse caring for a patient with ischemia to the left coronary artery would expect to find

Decreased afterload.

Which intervention should the nurse suggest to help a client with multiple sclerosis avoid episodes of urinary incontinence?

Establish a regular voiding schedule.

The nurse is caring for a patient who has suffered a stroke and has residual mobility problems. The patient is at risk for skin impairment. Which initial interventions should the nurse select to decrease this risk?

Gentle cleaners and thorough drying of the skin

The nurse is assessing a patient with emphysema. Which assessment finding requires further follow-up with the physician?

Hemoptysis

Your body isnt receiving enough oxygen to send down to your fingers; this causes them to club and makes dexterity difficult.

I should report if I see continuous bubbling in the water-seal chamber.

A nurse is caring for a patient whose temperature is 100.2 F. The nurse expects this patient to hyperventilate owing to

Increased metabolic demands.

Which statement by the patient indicates an understanding of atelectasis?

It is important to do breathing exercises every hour to prevent

When caring for a patient with atrial fibrillation, the nurse is most concerned with which vital sign?

Oxygen saturation

The nurse would expect a patient with right-sided heart failure to have which of the following?

Peripheral edema

The nurse is careful to monitor a patients cardiac output because this helps the nurse to determine

Peripheral extremity circulation.

Upon auscultation, the nurse hears a whooshing sound at the fifth intercostal space. The nurse recognizes that this sound is

Regurgitation of the mitral valve.

A 39-year-old multigravid client at 39 weeks' gestation admitted to the hospital in active labor has been diagnosed with class II heart disease. Which measure will the nurse encourage to ensure cardiac emptying and adequate oxygenation during labor?

Remain in a side-lying position with the head elevated.

An older adult alert and oriented client is admitted to the hospital for treatment of cellulitis of the left shoulder. Which fall prevention strategy is most appropriate for this client?

Use a night-light in the bathroom.

A patient has inadequate stroke volume related to decreased preload. The nurse anticipates

Verifying that the blood consent form has been signed

A client receiving external radiation to the left thorax to treat lung cancer has a nursing diagnosis of Risk for impaired skin integrity. Which intervention should be part of this client's care plan?

avoiding using deodorant soap on the irradiated areas

The nurse is instructing the unlicensed assistive personnel (UAP) about how to prevent plantar flexion (footdrop) for a client on complete bed rest. The UAP should:

encourage active range of motion to unaffected extremities.

A client is admitted to the hospital with a diagnosis of a pulmonary embolism. Which problem should the nurse address first?

impaired gas exchange

A child with asthma has a heart rate of 160 bpm and a respiratory rate of 36 breaths/minute. The child appears restless and anxious and is given albuterol via nebulizer. Which finding would indicate that the nebulizer treatment has been effective?

increase in peak expiratory flow rate

Arrhythmias

irregular heart rhythms

After teaching the parents about the urethral catheter placed after surgical repair of their son's hypospadias, the nurse determines that the teaching was successful when the mother states that the catheter in her child's penis accomplishes which goal?

keeps the new urethra from closing

Shift your weight every 15 minutes.Which nutritional deficiency may delay wound healing?

lack of vitamin C

A client with chronic obstructive pulmonary disease (COPD) is intubated and placed on continuous mechanical ventilation. Which equipment is most important for the nurse to keep at this client's bedside?

manual resuscitation bag

A nurse is monitoring a client recovering from moderate sedation that was administered during a colonoscopy. Which finding requires the nurse's immediate attention?

oxygen saturation (SaO2) of 89%

A client is admitted to the orthopedic unit in balanced skeletal traction using a Thomas splint and Pearson attachment. The primary purpose of traction is to:

realign fracture fragments.

A client is being treated for left lower lobe pneumonia. In what position should the nurse position the toddler to maximize oxygenation?

right lateral

cholecystectomy

surgical removal of the gallbladder

Which intervention is essential when performing dressing changes on a client with a diabetic foot ulcer?

using sterile technique during the dressing change

The nurse is completing a skin assessment on a medical-surgical patient. Which nursing assessment questions should be included in a skin integrity assessment? (Select all that apply.)

Can you easily change your position? Do you have sensitivity to heat or cold? How often do you need to use the toilet? Is movement painful?

Which action should the nurse include when developing the plan of care for a neonate prior to surgical repair of a myelomeningocele?

Cover the defect with moist, sterile saline dressings.

Which question should the nurse ask first when obtaining a history from the parent of a school-age child with a fever, malaise, and swelling around the eyes?

"Does the child urinate as much as usual?"

A nurse notes that a client has had no visitors, seems withdrawn, avoids eye contact, and refuses to take part in conversation. In a loud and angry voice, the client demands that the nurse leave the room. The nurse formulates a nursing diagnosis of Social isolation. Based on this diagnosis, what is an appropriate goal of care for this client?

The client will permit the nurse to speak with them for a 5-minute period by day 2 of hospitalization.

The nurse has placed the intubated client with acute respiratory distress syndrome (ARDS) in prone position for 30 minutes. Which factors would require the nurse to discontinue prone positioning and return the client to the supine position? Select all that apply.

The face has increased skin breakdown and edema. The client is tachycardic with drop in blood pressure. The SpO2 and PO2 have decreased.

The nurse is instructing an unlicensed assistive personnel (UAP) to collect a urine specimen from an indwelling catheter. Which statement indicates that the UAP understands the instructions?

"I'll get a sterile syringe and remove urine from the catheter through the collection port to place in the specimen container.

The unlicensed assistive personnel (UAP) states to the nurse, "My client talks about how awful and useless she is. Sometimes, she sounds angry for no reason. I'm tired of listening to her." Which response by the nurse is most appropriate?

"It's important for you to listen to her because she needs to verbalize how she's feeling."

For healing by secondary intention, a client's wound has been packed with medicated dressings. The nurse assesses the wound. Which finding indicates wound healing?

The granulation tissue is at the wound edges.

Secondary intention healing

A wound involving loss of tissue such as a burn or a pressure ulcer or laceration heals by

An obese client taking warfarin has dry skin due to decreased arterial blood flow. What should the nurse instruct the client to do? Select all that apply.

Apply lanolin or petroleum jelly to intact skin. Encourage a reduced-calorie, reduced-fat diet. Inspect the involved areas daily for new ulcerations. Use an electric razor to shave.

The nurse from the postanesthesia care unit (PACU) is transferring the client to an orthopedic unit. Which is the most appropriate way for the nurse in the PACU to communicate the "hand-off-of-care" report with the nurse on the orthopedic unit?

Call the nurse on the orthopedic unit and give a verbal report.

The nurse is caring for a patient who has a wound drain with a collection device. The nurse notices that the collection device has a sudden decrease in drainage. What would be the nurses next best step?

Call the physician; a blockage is present in the tubing.

Which of these findings if seen in a postoperative patient should the nurse associate with dehiscence?

Complaint by patient that something has given way

The nurse is caring for a patient with a healing stage III pressure ulcer. Upon entering the room, the nurse notices an odor and observes a purulent discharge, along with increased redness at the wound site. What is the next best step for the nurse?

Complete the head-to-toe assessment, and include current treatment, vital signs, and laboratory results.

A patients heart rate increased from 80 bpm to 160 bpm. The nurse knows that what will follow is a(n)

Decrease in cardiac output.

The nurse needs to closely monitor the oxygen status of an elderly patient undergoing anesthesia because of which age-related change?

Decreased lung defense mechanisms may cause ineffective airway clearance.

The cyanosis that accompanies bacterial pneumonia is primarily caused by which of the following?

Decreased oxygenation of the blood.

The nurse is completing an assessment on an individual who has a stage IV pressure ulcer. The wound is odorous, and a drain is currently in place. The nurse determines that the patient is experiencing issues with self-concept when the patient states which of the following?

I am ready for my bath and linen change as soon as possible.

A client with acute respiratory distress syndrome (ARDS) has fine crackles at lung bases, and the respirations are shallow at a rate of 28 breaths/min. The client is restless and anxious. In addition to monitoring the arterial blood gas results, what should the nurse do? Select all that apply.

Monitor serum creatinine and blood urea nitrogen levels. Administer humidified oxygen. Auscultate the lungs.

The nurse is caring for a patient with wound healing by tertiary intention. Which factors does the nurse recognize as influencing wound healing? (Select all that apply.)

Nutrition Tissue perfusion Infection Age

The nurse is caring for an African American patient with COPD. The nurse knows that the best location to assess for hypoxia is the

Oral mucosa.

A nurse is performing a baseline assessment of a client's skin risk assessment. Which finding will most impact the goal of the plan of care?

Overall potential of developing pressure ulcers

A nurse is developing a care plan for a client with disseminated intravascular coagulation (DIC). Which nursing intervention should the nurse include?

Place a pressure-reducing mattress on the client's bed.

The nurse is updating the plan of care for a patient with a stage III pressure ulcer and a nursing diagnosis of Impaired skin integrity. Which of the following outcomes when met indicate progression toward goals? (Select all that apply.)

Prevent injury to the skin and tissues. Reduce injury to the skin. Reduce injury to the underlying tissues. Restore skin integrity.

The nurse is caring for a patient who has experienced a laparoscopic appendectomy. The nurse recalls that this type of wound heals by

Primary intention.

What would the nurse recognize as a common goal of discharge planning in all care settings?

Providing continuity of care for the client

A diabetic client with peripheral vascular disease is ordered to wear knee-high elastic compression stockings continuously until discharge. Which would be the priority after the stockings are applied?

Remove elastic stockings once per day and observe lower extremities.

A client who was transferred from a long-term care facility is admitted with dehydration and pneumonia. Which nursing interventions can help prevent pressure ulcer formation in this client? Select all that apply.

Reposition the client every 2 hours. Perform range-of-motion exercises. Encourage the client to eat a well-balanced diet.

The nurse is assessing a client who is immobile and notes that an area of sacral skin is reddened, but not broken. The reddened area continues to blanch and refill with fingertip pressure. What should the nurse do next?

Reposition the client off the reddened skin and reassess in a few hours.

The toddler with nephrotic syndrome exhibits generalized edema. Which measure should the nurse institute for this child with impaired skin integrity related to edema?

Separate opposing skin surfaces with soft cloth.

To reduce the risk of pressure ulcer formation, which activity should the nurse teach the client who is wheelchair-bound as a result of a spinal cord injury?

Shift your weight every 15 minutes.

A nurse assigned to a client with emphysema is providing shift report. Which nursing interventions would be appropriate to include? Select all that apply.

Teach diaphragmatic, pursed-lip breathing. Administer low-flow oxygen as needed. Encourage alternating client activity with rest periods. Teach the use of postural drainage and chest physiotherapy.

A client in acute respiratory distress is brought to the emergency department. After endotracheal (ET) intubation and initiation of mechanical ventilation, the client is transferred to the intensive care unit. Before suctioning the ET tube, the nurse hyperventilates and hyperoxygenates the client. What is the rationale for these interventions?

They help prevent cardiac arrhythmias.

A patient with COPD asks the nurse why he is having increased difficulty with his fine motor skills, such as buttoning his shirt. Which response by the nurse is most therapeutic?

Your body isnt receiving enough oxygen to send down to your fingers; this causes them to club and makes dexterity difficult.

A nurse is caring for a client with status asthmaticus. Which medication should the nurse prepare to administer?

an inhaled beta2-adrenergic agonist

The nurse is instructing the client with chronic obstructive pulmonary disease to do pursed-lip breathing. What is the expected outcome of this exercise?

better elimination of carbon dioxide

The nurse is assessing for oxygenation in a client with dark skin. Where will oxygenation be most evident on this client?

buccal mucosa

During the planning step of the nursing process, the nurse

establishes short- and long-term goals.

After having a blood sample drawn, a 5-year-old child insists that the site be covered with a bandage. When the parent tries to remove the bandage before leaving the office, the child screams that all the blood will come out. The nurse encourages the parent to leave the bandage in place and tells the parent that the child's reaction is based on which factor?

lacking understanding of body integrity

The nurse is documenting care of a client who is restrained in bed with bilateral wrist restraints. Following assessment of the restraints, what should the nurse's documentation include? Select all that apply.

nutrition and hydration needs capillary refill continued need for restraints skin integrity

The nurse is teaching the client with a platelet disorder about signs of bleeding. What statement from the client indicates the client has understood the teaching?

"Ecchymoses are large, purple skin bruises."