NUR350 exam 1 NCLEX questions

which situation would require the nurse to obtain a focused assessment?

*a patient reports a new symptom during rounds. *a previously identified problem needs reassessment

the nurse assigns the nursing diagnosis of "risk for unstable blood glucose level". his goal is "patients fasting blood glucose level will be consistently <120mg/dL by the end of the week". which of the following will be appropriate interventions

*dietitian will provide low glycemic value menu options for patient. *monitor fasting blood glucose before each meal *patient will restrict simple sugar intake this week

a 65 year old stroke patient with limited Mobility has a purple area of suspected deep tissue injury on the left greater trochanter. which nursing diagnosis are MOST appropriate?

*impaired skin integrity related to immobility and decreased sensation *impaired tissue Integrity related to inadequate circulation secondary to pressure

you're caring for a patient with newly diagnosed type 1 diabetes. what information is ESSENTIAL to include in your patient teaching before discharge

*insulin Administration *use of portable blood glucose *hypoglycemia prevention symptoms and treatment

which of the appropriate therapies for patients with diabetes mellitus

*use of statins to reduce cvd risk *use of ACE inhibitors to treat nephropathy *use of laser photocoagulation to treat retinopathy

the nurse is assigned to care for a newly admitted patient. number in order the steps for using the nursing process to prioritize care

1 (A) collect patient information 2 (D) identify any health problems 3 (P) determine a plan of action 4 (I) carry out the plan 5 (E) evaluate whether the plan was effective

the nurse is preparing to examine the patient's abdomen. identify the proper order of steps in the assessment 1-4

1 inspection 2 auscultation 3 percussion 4 palpation

during skin assessment a nurse finds a nickel-sized area of redness on the patients left inner ankle that is not blanchable. the nurse should document

1.5 CM area of non blanchable erythema on left medial malleolus

analyze the following diagnostic findings for your patient with type 2 diabetes and say which result will need further assessment

A1C 9%

which statement by the patient with type 2 diabetes is accurate

I will limit my alcohol intake to one drink

an 85 year old patient is assessed to have a score of 16 on the Braden Scale. based on this information how should the nurse plan for this patient's care?

Implement a one-hour turning schedule with skin assessment

when providing a patient education for a diabetic regarding alcohol the nurse would accurately say that alcohol use

In excess often mimics symptoms of hypoglycemia

the nurse is planning to replace a client's wound dressing. the deep wound bed is to remain moist and requires packing. which of the following actions is appropriate?

Loosely packed the dampened dressing material to prevent too much pressure on the wound bed

the nurse is preparing to measure the depth of a client tunneled wound. which of the following implements should the nurse use to measure the depth accurately?

a sterile flexible applicator moistened with saline

a wound dressing that contains an alginate is appropriate to

absorb a moderate to large amount of exudate

a patient in the unit has a 103.7 temperature. which intervention would be MOST effective in restoring normal body temperature?

administer antipyretics on an around-the-clock schedule

the nurse is caring for a client who has a heavy exudating wound that needs autolytic debridement which of the following wound dressings is most appropriate?

an alginate dressing; algicell

what is the PRIORITY action for the nurse to take if the patient with type 2 diabetes complains of blurred vision and irritability

check patients blood glucose level

which one of these orders should a nurse question in the plan of care for an elderly and mobile stroke patient with stage 3 pressure ulcer?

clean the wound with Dakin's solution *This can damage new epithelium and delay healing

an example of a nursing activity that best reflects the American Nurses Association definition of nursing is

diagnosing a patient with a feeding tube as being at risk for aspiration

a patient is assessed at a score of 18 on the Braden scale an appropriate intervention would be

encourage maintenance of activity level

when a nurse knows his patient is diabetic he needs to be sure to assess his patients

feet

polydipsia and polyuria related to diabetes mellitus are primarily due to

fluid shifts resulting from the osmotic effect of hyperglycemia

slow wound healing in patients with diabetes is often related to having had______blood glucose levels over a long period of time

high

symptoms of polyuria polydipsia and headache are common symptoms of

hyperglycemia

a nurse is caring for a patient with diabetes who is scheduled for amputation of his necrotic left great toe. the patients WBC count is 15x10/uL and he has coolness of the lower extremities, weighs 75 pounds more than his ideal body weight, and smokes 2 packs of cigarettes per day. which PRIORITY nursing diagnosis addresses the primary factor affecting the patient's ability to heal?

impaired tissue Integrity related to decreased blood flow secondary to (AEB) diabetes and smoking

which of the following puts a patient at greater risk for skin breakdown

incontinence

one of the properties of a hydrocolloid dressing is that it keeps the wound bed

moist

for a patient for whom the nursing diagnosis "impaired skin integrity" has been assigned the goal; "patience when will show evidence of healing within one week"has been written. which of the following statements best states an evaluation that the school has been met?

patience wound is 1.5 CM by 1.2 cm by 0.1 CM today compared to 1.7 CM by 1.2 CM by 0.3 CM 7 days ago.

which statement would be correct for a patient with type 2 diabetes who was admitted to the hospital with pneumonia

patient may have sufficient endogenous insulin to prevent ketosis but is at risk for hyperosmolar hyperglycemic syndrome

the linkages among NANDA diagnosis, NOC outcomes, and NIC interventions can be used to

provide guides for planning care

a patient with diabetes has a serum glucose level of 800 and 24 and is unresponsive. after assessing the patient the nurse suspects diabetic ketoacidosis rather than hyperosmolar hyperglycemic syndrome based on which finding

rapid deep respirations also known as kussmaul respirations

the nurse is caring for a client who has a deep wound and whose saline moistened wound dressing has been changed every 12 hours. while removing the old dressing the nurse notes that the packing material is dry and adheres to the wound bed. which of the following modifications is most appropriate?

reduce the time interval between dressing changes *the interval should be reduced to prevent the dressing from drying out but too much moisture in the dressing may cause maceration.

after the nurse assesses a diabetic patients feet and finds that there is evidence of diaphoresis present between the toes she assigns which nursing diagnosis

risk for impaired skin integrity

a nurse is caring for a patient who has a pressure ulcer that is treated with debridement, irrigations, and moist gauze dressings. how should the nurse anticipate healing to occur?

secondary intention healing

which of the following is an appropriate goal for a patient who has no abnormalities of their skin at this time?

skin will remain intact throughout Hospital stay

while performing a bed bath and the nurse notes and area of tissue injury on the sacrum. the wound is shallow, open ulcer with a red pink wound bed and partial thickness loss of dermis which of the following is the correct name of this wound?

stage 2 pressure ulcer

an 82 year old man is being cared for at home by his family. a pressure ulcer on his right buttock measures 1 by 2 by 0.8 centimeters in depth and pink subcutaneous tissue is completely visible on the wound bed. which stage would the nurse document on the wound assessment form

stage 3

the nurse assigns the nursing diagnosis of"impaired skin integrity" for a patient with a stage 3 pressure injury to the sacrum. he writes the goal "patience wound will show evidence of wound healing within one week". which of the following outcomes will be appropriate?

surrounding skin of sacral wound will show gently sloping into the wound bad within 7 days.

the patient one day post-operative after abdominal surgery has incisional pain, 99.5 degrees Fahrenheit temperature, slight erythema at the incision margins, and 30 ml serosanguinous drainage in the Jackson Pratt drain. based on this assessment what conclusion would the nurse make?

the patient is having a normal inflammatory response

COMPREHENSIVE skin assessment is performed

upon admission

the nurse is removing a client's dressing and encounters resistance while removing tape from the client's skin. which of the following strategies is most appropriate?

use a silicone-based adhesive remover

when using evidence based practice the nurse

uses clinical decision-making and judgement to determine what evidence is appropriate for a specific clinical situation

the nurse is assessing a patient with a chronic leg wound find local signs of erythema and the patient complains of pain at the wound site. what would the nurse anticipate being ordered to assess the patient's systemic response?

white blood cell count and differential

you're applying a ceiling moistened dressing to a client's wound. the client asks wouldn't it be better to let my wound dry out so is scab can form. which of the following responses is most appropriate?

wounds heal better when a moist wound bed is maintained because that enhances the cellular migration necessary for tissue repair and healing.