Principles of Nursing Exam 2 Powerpoint Questions

4. Spend time in the clinical area with seasoned nurses. Aesthetic knowing is the art of nursing and is expressed by the individual nurse through creativity and style in meeting the needs of clients. Understanding how other nurses meet the needs of their clients, and seeing a variety of methods to provide the same care, will help improve this type of knowledge for the students. The other options are ways to improve empirical knowledge.

During a midterm evaluation, the nurse educator tells the students they need to work on improving their aesthetic knowing. What is a good way for the students to accomplish this? 1. Study harder. 2. Take better notes. 3. Read about the same topic from a variety of sources. 4. Spend time in the clinical area with seasoned nurses.

Asthma Question One Rationale: The client's assessment findings are consistent with exercise-induced asthma. The causative factor for the client's condition is not consistent with those of ARDS, which include shock, inhalation injuries, infections, trauma, and drug overdose. A client with bronchitis or pneumonia would report productive cough. A client with pneumonia would also report fever and sore throat.

The ED nurse is caring for a college-age client complaining of shortness of breath and chest tightness while jogging on campus. The client denies fever, sore throat, or productive cough. The nurse would accurately conclude that the client's clinical manifestations are consistent with which condition? 1. ARDS 2. Asthma 3. Bronchitis 4. Pneumonia

The nail beds, lips, and buccal mucosa should be used. Question One Rationale: Cyanosis is best assessed on an individual with dark skin on the nail beds, lips, and buccal mucosa. The areas with less pigment can also be assessed for oxygenation, but for cyanosis the areas listed are best.

The charge nurse is sharing with the new nurse the difficulties in assessing cyanosis in an individual with dark skin. The charge nurse would state which physical locations are the best to assess cyanosis in an individual with dark skin? 1. Cyanosis should not be assessed in individual with dark skin. 2. The nail beds, lips, and buccal mucosa should be used. 3. The sclera of the eyes, the palms of the hands, and soles of the feet should be used. 4. The tip of the nose, behind the ears, and between the fingers should be used.

Coaching the client on the correct use of the incentive spirometer The nurse caring for a client with pneumonia-related atelectasis would implement which incentive spirometer use and coaching to open alveoli that are closed in atelectasis. Postural drainage, percussion and vibration are used to mobilize secretions. Intermittent high flow oxygen as no benefit in this scenario.

The nurse caring for a client with pneumonia-related atelectasis would implement which one of the following interventions to improve oxygenation? -Performing vibration and percussion -Applying high flow oxygen intermittently -Implementing postural drainage -Coaching the client on the correct use of the incentive spirometer

Taught, shiny, or indurated when light pressure is applied Question Three Rationale: In patients with darker skin, pressure ulcer assessment should include the application of light pressure and observation for an area that is darker than the surrounding skin or that is taught, shiny, or indurated

The nurse is completing a pressure ulcer skin assessment on a client with dark skin. The nurse is aware that a client with dark skin will exhibit what characteristics when assessed for potential skin breakdown? 1. Taught, shiny, or indurated when light pressure is applied 2. Dull, cool, or firm when light pressure is applied 3. Tenting, cold, or spongy when light pressure is applied 4. Warm, yellow, or moist when light pressure is applied

Cleanse the wound with 0.9% sodium chloride saline irrigation before obtaining the specimen. The nurse should remove all wound exudate and any residual antimicrobial ointment or cream to avoid altering the culture results.

A nurse is caring for a client who has a wound infection. Which of the following actions should the nurse take when obtaining a wound-drainage specimen for culture? -Cleanse the wound with 0.9% sodium chloride saline irrigation before obtaining the specimen. -Irrigate the wound with an antiseptic prior to obtaining the specimen. -Include intact skin at the wound edges in the culture. -Swab an area of skin away from the wound to identify the usual flora.

28%

A nurse is caring for a client who is receiving oxygen at 2 L/min via a nasal cannula. The nurse recognizes the client is receiving which of the following inspired oxygen (FiO2) concentration? -28% -36% -50% -27%

-Use pillows to keep heels off the bed surface.The nurse should keep the heels off the bed to prevent skin breakdown on the client's heels. -Minimize skin exposure to moisture.The nurse should minimize skin exposure to moisture to prevent skin breakdown.

A nurse is developing a plan of care to prevent skin breakdown for a client with a spinal cord injury and paralysis. Which of the following nursing actions are appropriate? (Select all that apply.) -Massage over erythematous bony prominences. -Implement turning schedule every 4 hr. Correct! -Use pillows to keep heels off the bed surface. -Keep the client's skin dry with powder. -Minimize skin exposure to moisture.

Self-destructive behavior despite alternative interventions Mechanical restraints are warranted to protect a client from self-destructive behavior when other methods of controlling the client are unsuccessful.

A nurse is discussing the use of mechanical restraints with a newly licensed nurse. Which of the following situations should the nurse include as an indication for placing a client in mechanical restraints? -Punishment for verbally abusing other clients -Discipline for throwing objects at staff -Coercion to take prescribed medications -Self-destructive behavior despite alternative interventions

Keep the padded portion of the restraints against the wrists. The nurse should keep the padded portion of the restraints against the client's wrist to protect the skin from abrasion and breakdown.

A nurse is preparing to apply wrist restraints to a client to prevent her from pulling out an IV catheter. Which of the following actions should the nurse take? -Keep the padded portion of the restraints against the wrists. -Ensure enough room to fit one finger between the restraint and the wrist. -Attach the ties of the restraint to the bed rails. -Use a knot that will tighten as the client moves.

-Check for personal items when changing the bed linens. -Keep the bath water temperature between 43.3° C (110° F) and 46.1° C (115° F). -Shave the client's hair in the direction of the hair growth.

A nurse is providing hygiene care for a client who is immobile. Which of the following actions should the nurse take? (Select all that apply.) Check for personal items when changing the bed linens. Place a clean gown on the strongest arm first. Correct! Keep the bath water temperature between 43.3° C (110° F) and 46.1° C (115° F).

"They improve your circulation to keep blood from pooling in your legs." Antiembolism stockings promote venous return from the legs, thus helping to prevent venous thrombosis, also known as clot formation, and peripheral edema.

A nurse is providing preoperative teaching for a client who will undergo surgery. The nurse explains that the client will wear antiembolism stockings during and after the procedure. When the client asks what the stockings do, which of the following responses should the nurse make? -"They protect your legs and heels from skin breakdown." -"They help keep you warm after your surgery." -"They improve your circulation to keep blood from pooling in your legs." -"They make it easier for you to do leg exercises after your surgery."

Protein Protein is the major structural and functional component of every cell. It is required in increased amounts during times when the body needs to heal itself and protein will promote wound healing.

A nurse is teaching a client about nutritional requirements necessary to promote wound healing. Which of the following nutrients should the nurse include in the teaching? -Protein -Calcium -Vitamin B1 -Vitamin D

3. "Infants experience pain, and there are several nursing interventions that can comfort the infant during a painful procedure." Research shows that infants experience pain with some ordered procedures and treatments. The nurse would be an advocate for the infant, providing possible nursing interventions that could assist with comfort and discuss with the healthcare provider possible medications and protocols to address pain management.

A nurse preceptor is working with a newly licensed nurse in the newborn nursery. The newly licensed nurse asked if infants experience pain, and if so, how it is managed. What is the nurse preceptor's best response? 1. "Research shows that infants do not experience pain so there is no need to provide any interventions to address this." 2. "Infants experience pain, but the healthcare providers do not choose to treat it unless it is severe." 3. "Infants experience pain, and there are several nursing interventions that can comfort the infant during a painful procedure." 4. "The nursing staff can only intervene if the healthcare provider writes an order for an intervention."

The nurse is able to carve out time for a favorite hobby at least once a week. It is imperative that nurses attend to their own needs, because caring for self is central to caring for others. As nurses take on multiple commitments to family, work, school, and community, they risk exhaustion, burnout, and stress. None of the other options depicts the nurse caring for self, but rather caring for other individuals or trying to stay on top of the many tasks involved in a daily routine.

A nurse educator teaches students about caring nursing practice. Which situation shows that the nurse is able to best implement the whole idea of caring? 1. The nurse is able to carve out time for a favorite hobby at least once a week. 2. The nurse is a volunteer at church and school events. 3. The nurse makes lists every morning so the day stays organized and planned. 4. The nurse takes care of aging parents in addition to providing care to the immediate family.

Agitation The nurse should expect agitation due to neurological changes from poor oxygen exchange.

A nurse is assessing a client for hypoxemia during an asthma attack. Which of the following manifestations should the nurse expect? -Nausea -Dyshpagia -Agitation -Hypotension

"I'll check my feet every day for sores and bruises." The client should check his feet daily to monitor for any problems and observe any other changes before they become serious. He can use a hand mirror to examine areas that are difficult for him to see.

A nurse is teaching a client who has type 1 diabetes mellitus about foot care. Which of the following statements by the client indicates an understanding of the teaching? -"I'll wear sandals in warm weather." -"I'll put lotion between my toes after drying my feet." -"I'll check my feet every day for sores and bruises." -"I'll soak my feet in cool water every night before I go to bed."

Barrel Clients who have COPD use accessory muscles to assist with respiratory effort. The use of those accessory muscles causes the chest wall to eventually increase in anterior-posterior diameter, making it appear barrel shaped.

A nurse is assessing a client who has COPD. The nurse should expect the client's chest to be which of the following shapes? -Pigeon -Funnel -Kyphotic -Barrel

An older adult who has a hip fracture and is in Buck's traction According to evidenced-based practice, this client has multiple risk factors for skin breakdown: the aging process (decreased muscle mass, thin and fragile skin) and the limitation of movement due to traction. Therefore, this client is at the greatest risk for skin breakdown.

A nurse working on an orthopedic unit is caring for four clients. Which of the following clients should the nurse identify as being at greatest risk for skin breakdown? -An adolescent who has a cervical fracture and is in a halo brace -A young adult who has a femur fracture and is in skeletal balanced suspension traction -A middle adult who has a fractured radius and an arm cast -An older adult who has a hip fracture and is in Buck's traction

15

Chloral hydrate syrup contains 0.5 g per 5 ml. You need to prepare a 1500 mg dosage. How many ml(s) will you prepare? Number answer only.

"The size of the child's trachea is the size of the child's little finger." Question Three Rationale: The size of the child's trachea is very close to the size of the child's little finger. This is often checked in an emergency situation to determine the size of intubation equipment needed.

The nurse is talking with the nursing student about the size of a child's trachea. The nurse gives an illustration for the student to understand more clearly. Which statement is correct regarding the size of a child's trachea? 1. "The size of the child's trachea is the same size as an adult." 2. "The size of the child's trachea is the size of the child's thumb." 3. "The size of the child's trachea is the size of the child's little finger." 4. "The size of the child's trachea is the size of the child's index and middle finger combined."

"The newborn does not have much subcutaneous fat to help it hold its temperature effectively." Question Two Rationale: At birth, the newborn's skin is between 40% and 60% thinner than an adult's skin and has little underlying subcutaneous fat. As a result, the infant loses heat more rapidly, has greater difficulty regulating body temperature, and becomes chilled. Newborns lack the ability to sweat to cool their bodies in overly warm situations. There is not an issue with the subcutaneous fat becoming mature; the issue is with the lack of subcutaneous fat.

The nurse on the postpartum unit is teaching the mother how to care for the newborn. The nurse explains how the mother needs to be sure to not let the infant get too cold. The mother asks the nurse why this is a concern. What is the nurse's best response? 1. "The newborn has thicker skin than an adult and can get too cool easily." 2. "The newborn can become too cool if in a situation where sweating occurs." 3. "The newborn does not have much subcutaneous fat to help it hold its temperature effectively." 4. "The newborn subcutaneous fat is not mature enough to be able to effectively warm the newborn."

1.04

The pediatric dosage of Pyopen is 100 mg/kg/day. The child weighs 25 kg. Pyopen is available in 1 g/2.5 mL. The number of milliliters given for each individual dose given q4h would be _______________mL. Number answer only. Round to nearest hundredth.

Explaining an invasive procedure to the client, then asking whether it is alright to begin the procedure Caring practice involves connection, mutual recognition, and involvement. It is more than just performing skills adequately or even efficiently. It's a sense that the nurse has made a difference to someone else. Caring means that individuals, relationships, and things matter. Explaining a procedure, then seeking permission to begin, lets the client know that the nurse respects the client as an individual. All the other options are examples of appropriate and professional nursing care, but do not address a caring aspect.

The student nurse is following a preceptor on the assigned clinical shift. Which behavior of the nurse would the student interpret as caring? 1. Making sure that all medications and treatments ordered for the client are completed on time 2. Using aseptic technique correctly when performing all dressing changes ordered for the client 3. Advising the physician that the client wants to speak to them prior to a procedure being performed 4. Explaining an invasive procedure to the client, then asking whether it is alright to begin the procedure

Marked weight loss Question Two Rationale: Clients with emphysema are typically thin and report marked weight loss. Distended neck veins, bilateral lung rhonchi, and copious, thick secretions are clinical manifestations of chronic bronchitis.

Which finding should the nurse expect during assessment of a client diagnosed with emphysema? 1. Marked weight loss 2. Distended neck veins 3. Bilateral lung rhonchi 4. Copious, thick secretions