Care Dynamic Exam Review

Réussis tes devoirs et examens dès maintenant avec Quizwiz!

A nurse is reviewing the laboratory findings of a client who has protein calorie malnutrition. Which of the following findings should the nurse expect? A. decreased albumin B. elevated hemoglobin c. elevated lymphocytes d. decreased cortisol

A a decrease in the albumin level can be an indication of long-term protein deleption

A nurse is assessing a client's incision and observes the drainage to be blood-tinged. which of the following terms should the nurse document+? A. sanguineous b. purulent c. serous d. hyperemia

A this type of drainage contains large amounts of red blood cells, indicating that damaged capillaries are allowing the escape of red blood cells from the plasma

A nurse is caring for a client with anorexia nervosa who has light skin , which of the following findings should the nurse expect? A. presence of lanugo B. flushed skin tone C. hyperactive bowel sounds D. clubbing of fingernails

A (fine, neonatal hair-like growth) on the body as a result of malnutrition and starvation

A nurse is providing a discharge teaching about improving gas exchange for a client who has emphysema. Which should the nurse include? A. use pursed-lip breathing during periods of dyspnea B. limit fluid intake to 1,500 mL a day C. practice chest breathing each day

A during periods of dyspnea to slow expiration, increase airway pressure & facilitate effective gas exchange

A nurse is admitting an older adult client who fell at home 3 days ago, the client has a fractured hip, malnutrition and dehydration - which of the following lab values should be an indication of prolonged malnutrition to the nurse? A. increased sodium B. decreased albumin C. increased BUN D. decreased blood glucose

B decreased albumin is indicative of inadequate protein intake, common in a client with prolonged malnutrition

A nurse is preparing to perform postural drainage for a client. Which of the following actions should the nurse take? A. give the client a bronchodilator immediately after the procedure B. Position the client for drainage of secretions by gravity C. schedule a postural drainage following meals D. Instruct the client regarding the importance of fluid restrictions

B postural drainage consists of providing drainage, positiong, and turning the client

A nurse is preparing a client for discharge and providing instructions about performing dressing changes at home. Which of the following statements should the nurse identify as an indication that the client understands medical aspesis? A. ill wrap the old dressing in a paper bag and out it in the trash B. ill wash my hands before i remove the old dressings and again before putting on the new one c. ill need to take a pain pill 30 mins before i change the dressing D. i will wear sterile gloves when i apply the new dressings

B it is essential that the client understands the importance of hand hygiene

A nurse is providing teaching to a group of unit about wound healing by secondary intention. Which of the following pieces of information should the nurse include in the teaching? A. the wound is closed at a later date B. A skin graft is placed over the wound bed C. Granulation tissue fills the wound during healing

C a beefy, red tissue called granulation tissue fills the wound during healing - the wound is left open to drain and heal by secondary intention, 5-21 days

A nurse is caring for a client who has a stage III pressure ulcer on the heel - when preparing to irrigate the wound, the nurse should do what first? A. obtain the prescribed irrigation solution B. Don personal protective equipment C. check the client's pain level D. place a water proof pad underneath the extremity

C client care is prioritized!

A nurse is caring for a client who is postoperative following a thoracic lobectomy. The client has 2 chest tubes in place: 1 in the lower portion of the thorax and the other higher on the chest wall. When a family member asks why the client has 2 chest tubes, what should the nurse respond with ? A. two tubes were necessary due to the excessive bleeding from surgery B. The tubes drain blood from 2 different lung areas C. The lower tube will drain blood, and the higher tube will remove air D. The second tube will take over if blood clots block the 1st tube

C the tube that is lower will drain blood while higher tube on thorax allows for air removal

A nurse on a surgical unit is caring for 4 clients who have healing wounds. Which of the following wounds should the nurse expect to heal by primary intention? A. Partial-thickness burn B. Stage III pressure ulcer C. Surgical incision D. Dehisced sternal wound

C with primary intention, a clean wound is closed mechanically, leaving well-approximated edges and minimal scarring

A nurse is performing a nutritional screening on a 12 yr old client who weighs 90lb (41kg) and has a height of 60in (1.5m) - which of the following values is the client's body mass index? A. 1.5 B. 3.6 C. 18.2 D. 27.3

C the nurse should divide the client's weight in kilograms by the square of the height in meters - therefore 41kg divided by the square of 1.5 is 18.2

A nurse in a dermatology clinic is using the ABCDE method while screening several skin lesion for skin cancer on a client. Which of the following findings should the nurse report to the provider? A. Symmetric shape B. Border regularity C. Color variation within a lesion D. Diameter > 4mm

C the C in ABCDE method of screening for skin cancer stands for color variation within a lesion. thE stands for evolving for changing in any feature of the lesion

a nurse is teaching a client who has type two diabetes mellitus about foot care, which statement indicates the client understands? A. i will apply moisturizer between my toes B. i will soak my feet daily C. ill be sure to wear cotton socks everyday D. ill use a heating pad to warm my feet

C the nurse should instruct the client to wear cotton to absorb moisture and reduce risk of infection

A nurse is caring for a client who is scheduled to have his chest tube removed - what action should the nurse take ? a. cover insertion site with a hydrocolloid dressing after removing B. provide pain meds after removal C. instruct client to perform Valsalva maneuver during removal

C. instruct client to perform Valsalva maneuver during removal to maintain appropriate amount of - pressure in chest in order to prevent air entry in the pleural space

A nurse is collecting a client's health history. Which of the following findings is the HIGHEST risk factor for the client developing skin cancer? A. age over 60 b. genetic predisposition c. light-skinned race d. exposure to sunlight

D the nurse should apply the safety and risk-reduction priority setting framework when caring for the client

A nurse is providing teaching about nutrients to a client. Which statement should the nurse include? A. carbohydrates transport nutrients throughout the body B. Fats prevent ketosis C. Protein builds and repairs body tissue D. Carbohydrates help regulate body temperature

Protein builds and repairs body tissue this is proteins primary function

A nurse is preparing to change a dressing on a client who is receiving negative pressure wound therapy (NPWT). What is the correct sequence of steps?

Turn off the vacuum on the NPWT device and administer prescribed analgesic Remove the soiled dressing and perform hand hygiene apply sterile or clean gloves to irrigate the wound apply skin protectant or barrier film place prepared foam into the wound bed and cover with a transparent dressing connecting the tubing to transparent film and turn on the NPWT unit

A nurse is monitoring a client who has heart failure related to mitral stenosis - the client reports shortness of breath on exertion. which of the following conditions should the nurse expect? A. increased cardiac output b. increased pulmonary congestion c. decreased left atrial pressure d. decreased pulmonary artery pressure

B its a manifestation of mitral stenosis because the defect is when L atrial pressure rises and left atrium dilates - increased pressure due to blood black flow

A nurse is evaluating a client's understanding of discharge teaching about dressing changes. Which of the following actions by the client indicates they understand? A, the client nods and smiles in response B. the client restates the information in her own words c. the client does not ask questions when given the opportunity d. the client's body language shows they are listening

B this shows they interpreted it and can explain

A nurse is caring for a client who reports feeling a pop after coughing without properly splinting an abdominal incision. On assessment, the nurse notes that the client's wound has eviscerated. Which of the following should the nurse do? A. Carefully reinsert the intestine through the opening of the wound B. Place the client in a supine position with the hips and knees flexed C. Leave the room, call the surgeon D. Cover the wound and intestine with a sterile, moistened dressing E. Monitor the client for manifestations of shock

B, D, E the position will help prevent further tearing, cover the wound the prevent further contamination, monitor for a physiological stimulus

A nurse is assessing a client. Which of the following findings should the nurse identify as an indication of protein calorie malnourishment? A. gingivitis B. dry, brittle hair C. edema D. spoon-shaped nails E. poor wound healing

B, E,C B because hair falling out easily suggests inadeuqate intake E can occur when albumin levels are lower than normal C adequate wound healing depends on sufficient proteins!

A nurse is evaluating the lab values of a client who is in the resuscitation phase following a major burn. Which of the following lab findings should be expected? A. Hemoglobin 10g/dL B. Sodium 132mEq/L C. Albumin 3.6 g/dL D. Potassium 4.0mEq/L

B. Sodium 132mEq/L this finding is below the expected reference range - the nurse should anticipate low sodium as it is trapped in the interstitial space

A nurse is teaching breathing techniques to a client who has emphysema. Which of the following statements indicates that the client understands the mechanics of pursed-lip breathing? A. ill inhale slowly through pursed lips to help me breathe better B. When I do this technique, I'll lie down C. When I breathe out through pursed lips, my airways don't always collapse between breaths D. Ill relax my stomach muscles when i am doing pursed-lip breathing excersisse

C pursed-lips slows exhalation and maintains inflation of the distal airways , enhancing respiration

A nurse is measuring a client's vital signs. The client heart rate is 105/min - the nurse should document this finding as which of the following alterations? A. palpitation B. bradycarida C. tachycardia d. disrhythmia

C tachy because HR is over 100 and that is abnormal, normal is 60-100

A nurse is planning care for a client who had a stroke. Which of the following goals should the nurse identify as the priority for this client? A. the client's skin will remain intact during hospitalization B. the client will verbalize one new word each week c. the client will begin to help turn himself in bed, indicating improved mobility d. the client'x airway will remain clear, AEB by clear breath sounds

D ABC priority, emphasizes the basic core of human functioning

A nurse is preparing to provide tracheostomy care for a client. Which of the following actions should the nurse perform first? A. open all sterile supplies and solutions b. stabilize the tracheostomy tube c. put on sterile gloves d. perform hand hygiene

D ALWAYS WASH YA HANDS B4 TOUCHING THE CLIENT OR SKILLS

a nurse manager is providing teaching to a group of newly licensed nurses about ways clients can acquire healthcare-associated infections (HAIs). Which of the folllowing route of infections should the manager identify as an iatrogenic HAI? A. infection accquired from improper hygeine B. infection due to drug resistance C. infection due to inappropriate waste disposal D. Infection accquired from a diagnostic procedure

D iatrogenic HAIs directly result from diagnostic/therapeutic procedures

A nurse is changing the dressings for a client who is 3 days postoperative following a cholecystectomy. the nurse observes yellow, thick drainage on the dressing - this should be document how? A. sanguineous exudate B. Serous exudate C. Serosanguineous exudate D. Purulent exudate

D purulent exudate is thick, yellow/green/brown drainage usually indicating wound sloughing or infection

A nurse is receiving report on a client who has C. Diff and is being transferred from another unit, what precautions should the nurse take? A. place client in negative airflow B. clean the client's room with antibacterial disinfectant c. wear a mask when entering a client's room d. perform hand hygiene with nonantimicrobial soap and water after client care

D this spore forming organism is resistant to alcohol-based soaps / sanitizers

A nurse is caring for a client who has a chest tube. The nurse notes that the chest tube has become disconnected from the chest drainage system. What following action should the nurse take? A. place the drainage system at the head of the client's bed B. increase the suction to the chest drainage system C. place the client on low-flow oxygen via nasal cannula D. immerse the end of the chest tube in a bottle of sterile water

D if the chest tube/drainage system became disconnected, air can enter the pleural space, producing a pneumothroax resulting in severe resp. distress therefore create a temporary water seal

A nurse manager observes a nurse entering the room of a client who is on contact precautions without donning personal protective equipment (PPE). Which of the following is the priority the nurse manager should take? A. speak with the nurse in a private location B. complete an incident report C. review the competencies with the staff members regarding PPE D. have the nurse exit room and on proper PPE

D. the nurse manager should apply the safety and risk reduction priority setting framework by intervening

A nurse is employing a thorough, systematic method while obtaining objective data about a client. Through which of the following methods should the nurse collect this information? A. health history B. physical examination C. review of systems D. interview

physical examination these findings are objective , the nurse should collect this info in a systematic way


Ensembles d'études connexes

POSC 432: Criminal Justice Final Exam

View Set

Early Adulthood to Later adulthood Quiz Questions

View Set

ch. 40 Mechanisms of Endocrine Control

View Set

bio 121 clicker questions chapter 6, 8, and 10

View Set

Quizlet Live: Chapter 17 Human Resource Issues: Laws and Regulations for Employers and Employees. WITH IMAGES

View Set

Data Modeling with the Entity-Relationship Model

View Set