Intro to Nursing Exam Review III

The nurse leader explains about ethical principles to the student nurse. Which example would the leader give for autonomy?

Accepting the client's wish to donate her or his organs after death

Which of these is an ethical issue related to the long-term care setting? Select all that apply. One, some, or all responses may be correct. Guardianship Correct2 Power of attorney Correct3 Advance directives Correct4 Responsible party designation Correct5 Do-not-resuscitate (DNR) orders Correct6 Adherence to a patient's bill of rights

Guardianship Correct2 Power of attorney Correct3 Advance directives Correct4 Responsible party designation Correct5 Do-not-resuscitate (DNR) orders Correct6 Adherence to a patient's bill of rights

An abscess develops in an obese adult after abdominal surgery. The wound is healing by secondary intention. Which diet would the nurse expect the health care provider to prescribe to meet this client's immediate nutritional needs?

High in protein and vitamin C

A client is hospitalized for intravenous antibiotic therapy and an incision and drainage of an abscess that developed at the site of a puncture wound. When would the nurse begin to teach the client about how to care for the wound?

In the preoperative period

Which legal implication would the nurse understand about applying restraints to a client?

The nurse can be charged with assault and battery for using restrains improperly.

The nurse is providing restraint education to a group of nursing students. Which reason to use restraints is incorrect to teach?

To prevent an adult client from getting up at night when there is insufficient staffing on the unit

Which statement by the nurse would reflect autonomy when the client is being discharged?

"I will independently develop and implement a discharge teaching plan."

A client who is admitted to the hospital and requires a colon resection states, "I want to be a do not resuscitate [DNR]." The nurse questions the client's understanding of a DNR order. Which response by the client best indicates to the nurse an understanding of a DNR order?

"If something happens to me, I do not want cardiopulmonary resuscitation [CPR]."

The registered nurse is teaching a student nurse about the use of a suction pump in negative-pressure wound therapy. Which statement by the student nurse indicates the need for further teaching? A suction pump is used in negative-pressure wound therapy to reduce chronic ulcers by removing the fluids from the wounds and to enhance granulation. A suction pump should not be used in the areas of skin cancer because it may cause serious bleeding and may lead to death. The wound site should be monitored at least every 2 hours. The suction pump is covered by a sponge, and the foaming dressing should be changed every 48 to 72 hours. While using the suction pump, a continuous low-negative pressure should be maintained.

"This treatment is used mostly for areas of skin cancer.

The nurse is teaching a nursing student about interventions that reduce the risk of pressure ulcers in a client. Which statements made by the nursing student indicate effective learning? Select all that apply. One, some, or all responses may be correct.

)"I will elevate the head of the client's bed to no more than 30 degrees." "I will ensure that the client is turned and repositioned at least every 2 hours." "I will ensure that the client's fluid intake is 2000 to 3000 mL/day." (The client's bed should not be elevated more than 30 degrees, which minimizes shearing and reduces the risk of pressure injuries. Turning and repositioning the client frequently improves circulation, and redistributes body weight over bony prominences, both of which reduce the risk of pressure ulcer formation. It is very important to maintain the client's fluid intake of 2000 to 3000 mL/day, which helps nourish the skin. The client should not apply talc directly to the perineum. The client should take in an adequate amount of protein and calories in the diet.

Which findings are consistent with hypercalcemia after prolonged immobility? Select all that apply. One, some, or all responses may be correct.

)-bone pain depressed deep -prolonged tendon reflexed (Increased serum calcium comes from bone demineralization, which results in bone pain. Depressed or absent deep tendon reflexes are associated with hypercalcemia. The body's excitable tissues are affected most (e.g., nerves, muscles, heart, intestinal smooth muscles). Convulsions are not a sign of hypercalcemia; convulsions can occur with hypocalcemia, hypernatremia, and hyponatremia. Muscle spasms are not a sign of hypercalcemia; muscle spasms can occur with hypocalcemia, hyponatremia, and hypokalemia. Tingling of extremities is not a sign of hypercalcemia; paresthesias are associated with hypocalcemia and hyperkalemia.Test-Taking Tip: Be alert for details about what you are being asked to do. In this question type, you are asked to select all options that apply to a given situation or client. All options likely relate to the situation, but only some of the options may relate directly to the situation.

The nurse assists a client on a rehabilitation unit after a cerebrovascular accident (CVA, also known as a "brain attack") with residual hemiparesis to walk with the use of a cane. To help achieve the goal of safe walking with a cane, which method would the nurse teach the client?

)Advance the can and the affected extremity simultaneously (Advancing the cane and the affected extremity simultaneously supports stability. The body's support occurs partially on the affected limb and partially on the cane as the unaffected limb moves forward. Shortening the stride of the unaffected extremity will produce an awkward gait and instability; approximate normal ambulation movement. Leaning the body toward the cane when ambulating will change the center of the client's gravity and cause instability. The cane is held on the unaffected, not the affected, side and advanced at the same time as the affected extremity to increase the base of support and provide stability.Test-Taking Tip: Look for answers that focus on the client or directed toward the client's feelings.

The nurse provides crutch-walking instructions to a client who has a left-leg cast. Where would the nurse teach the client to place their weight?

)on the hands (Body weight should be placed on the hands and not under the arms in the axillae when a client is walking with crutches to prevent damage to the brachial plexus nerves and prevent "crutch paralysis." Placing weight in the axillae during crutch walking is incorrect. Weight during walking with two crutches should be distributed equally to both sides of the body without regard to the unaffected side or either side or the side the client prefers.Test-Taking Tip: Do not select answers that contain exceptions to the general rule, controversial material, or responses that appear to be degrading.

The nurse is teaching a client about sleeping positions to follow to prevent pressure ulcers. Which statement made by the client indicates effective learning? Select all that apply. One, some, or all responses may be correct.

- "I should use pressure-relieving pads." - " I should place pillows between two bony surfaces" - I should keep the heels off the bed surface using a bed pillow under the ankles"

Which interventions can be performed by an unlicensed assistive personnel in skin care? Select all that apply. One, some, or all responses may be correct.

-Assist the client in bathing -apply wet dressings to the skin -report changes in the skin appearance (The unlicensed assistive personnel may be responsible for assisting the client in bathing, applying wet dressings to the skin, and reporting changes in the skin appearance. Teaching done by the registered nurse can be reinforced by a licensed practical nurse or a vocational nurse. The registered nurse would be responsible for determining whether the client is taking a medication that increases photosensitivity.)

A client is receiving patient-controlled analgesia (PCA) after surgery. Which benefit would this type of therapy provide? Select all that apply. One, some, or all responses may be correct. Correct1

-Client is able to self-administer pain-relieving medications as necessary -Decreases client dependency -Increases client sense of autonomy

Which problems would the nurse plan to address when dealing with ethical issues related to end-of-life care? Select all that apply. One, some, or all responses may be correct.

-Clients may be unable to communicate effectively. -All interventions for helping the clients seem futile. -Predictions regarding health outcomes are not always accurate.

The nurse has provided teaching to a client who has impaired balance and uses a walker. Which observation of the client would indicate to the nurse that further teaching is required? Slides toward the edge of the seat before standing Holds both handles of the walker while rising to stand Moves forward into the walker after transferring from sitting to standing Stands in place holding on to the walker for at least 30 seconds before walking

-Holds both handles of the walker while rising to stand (Because of the angle of force applied to a walker when a person uses it to move from a sitting to a standing position, the walker can become unstable and tip over. The arms of the chair should be used for support when rising from a sitting position. Sliding toward the edge of the seat moves the center of gravity of the body toward the desired direction of movement, which facilitates the transfer. Holding both handles and moving forward into the walker provides the maximum support afforded by a walker. Standing in place after rising allows the body's vasomotor responses to adjust to the vertical position, minimizing orthostatic hypotension.)

Which instructions to minimize the risk of falls in the home would the nurse provide the caregiver of an older client who requires the use of a walker with wheels? Select all that apply. One, some, or all responses may be correct. The nurse would instruct the caregiver to remove cords, use bright lighting, and eliminate throw rugs to prevent falls. Bed alarms are used in health care facilities. Keeping the phone close by will allow the older adult to obtain help, but this action does not prevent falls.Test-Taking Tip: If you are unable to answer a multiple-choice question immediately, eliminate the alternatives that you know are incorrect and proceed from that point. The same goes for a multiple-response question that requires you to choose two or more of the given alternatives. If a fill-in-the-blank question poses a problem, read the situation and essential information carefully and then formulate your response.

-Remove cords - Use bright lightning -Get rid of throw rugs

Arrange the actions in the order the nurse should take to resolve an ethical dilemma. The nurse would begin by asking whether the problem at hand is an ethical dilemma. If one exists, the nurse would collect all relevant case-related information from multiple sources to obtain multiple points of view. The nurse would then clarify the values, making a clear distinction between facts, opinions, and values. Next, the nurse would verbalize the problem to facilitate discussion and help make the final plan effective. After this step, the nurse would determine all the possible courses of action to resolve the dilemma. The nurse would then negotiate a plan. This plan of action would be evaluated over time.Test-Taking Tip:In this question type, you are asked to prioritize (put in order) the options presented. For example, you might be asked the steps of performing an action or skill such as those involved in medication administration.

1.Collect relevant case-related information. Correct2.Clarify values. Correct3.Verbalize the problem. Correct4.Determine possible courses of action. Correct5.Negotiate a plan. Correct6.Evaluate the plan over time.

When teaching an older adult client about skincare to prevent pressure ulcers, which client statement indicates a misunderstanding?

"I should apply powders or talc on the perineum wound"

Arrange the order of pathophysiology involved with the development of pressure ulcers on the sacrum, hips, and ankles of a client with quadriplegia. Quadriplegic clients are immobile or wheelchair bound and incapable of changing position without assistance; therefore they have more chances of developing pressure ulcers. Tissue compression from pressure restricts blood flow to the skin, resulting in reduced tissue perfusion and oxygenation and, eventually, leading to cell death and the development of pressure ulcers.

1 dev of pressure ulcers 2 local tissue compression 3 restriction of blood flow 4 reduced tissue perfusion 5 local cell death

The client needs 8 mg of morphine sulfate to be given by injection. The vial on hand contains 10 mg of morphine per milliliter. How many milliliters will the nurse administer? Record your answer using one decimal place and include a leading zero if applicable. ___ mL

8

A hospitalized client newly diagnosed with rheumatoid arthritis complains of bilaterally painful knee and wrist joints. The nurse identifies impaired physical mobility related to painful, swollen joints. Which intervention would the nurse teach the client to do during the acute phase of the disease?

Avoid movement of the involved joints

The nurse manager promotes a staff nurse to assistant manager of the medical unit, because the nurse had expressed an interest in taking on more responsibilities. Which type of ethical principle is exhibited by the nurse manager by this activity?

Beneficence

According to the nursing process, which would the nurse do after administering pain medication to a postoperative client?

Determine whether the pain medicine relieved the client's pain.

When the nurse obtains vital signs of blood pressure 90/60 mm Hg, pulse 96 beats/minute, and respiratory rate 10 breaths/minute for a postoperative client who is receiving hydromorphone by a patient-controlled analgesia (PCA) pump, which nursing action would be the priority?

Give nalaxone intravenously per protocol

A client who receives morphine b y patient-controlled analgesia has a respiratory rate of 6 breaths/minute. Which intervention is needed?

Naloxone administration

Which key feature is associated with a stage 2 pressure ulcer?

Presence of nonintact skin

The nurse reviews the medical record of a client with terminal cancer and notes the presence of a do-not-resuscitate (DNR) order. The order was written with the client's admission orders. The nurse recalls that which factor is relevant to the legal aspects of the DNR order?

The policies of the agency establish the status of DNR orders.

Which role does vitamin C have in wound healing?

Vitamin C is required for collagen production by fibroblasts.

Which instruction would the nurse provide to an older client using ice and heat to treat pain from back strain? Select all that apply. One, some, or all responses may be correct.

apply for 30 min time intervals

Which age-related skin change occurs in older adult clients and increases their potential for developing pressure ulcers?

decreased subq fat

Which action would the nurse implement for a client who has a portable wound drainage system in place after surgery?

maintain compression of the drainage system

Which is appropriate for the nurse to include in the education of the ethical principal of nonmaleficence to a group of nursing students?

Act in ways to prevent harms to clients

How is the term beneficence in health ethics different from nonmaleficence?

Beneficence involves taking positive actions to help others whereas nonmaleficence is the avoidance of harm or hurt.

The nurse has provided discharge instructions to a client who received a prescription for a walker. The nurse determines that the teaching has been effective when the client does which?

Moves the walker no more than 12 inches (30.5 cm) during use (Safety is always a consideration when teaching a client how to use an assistive device. The correct procedure regarding using a walker is to move the walker no more than 12 inches (30.5 cm) in front to maintain balance and to be effective in forward movement. Carrying the walker when ambulating is incorrect. Once the client is instructed and can demonstrate correct use of a walker, there is no need for someone to be present every time the client uses the walker. If the client is ordered to use a walker as part of the discharge plan, it needs to be provided before the client leaves the hospital.Test-Taking Tip:Once you have decided on an answer, look at the stem again. Does your choice answer the question that was asked? If the question stem asks "why," be sure the response you have chosen is a reason. If the question stem is singular, then be sure the option is singular, and the same for plural stems and plural responses. Many times, checking to make sure that the choice makes sense in relation to the stem will reveal the correct answer.)

A primary health care provider writes a prescription of "Restraints PRN (as needed)" for a client who has a history of violent behavior. Which action would the nurse take?

Notify the provider that PRN prescriptions for restraints are unacceptable.

The registered nurse (RN) delegates the tasks of caring for a client with pressure ulcers. The client suffers further tissue necrosis during treatment. Which intervention could result in further tissue necrosis to the client with a pressure ulcer? The PCA is not authorized to irrigate the wound because improper technique can lead to tissue damage. The RN is qualified to perform wound care; therefore cleaning the wound is not likely to lead to tissue necrosis. Pressure ulcers are associated with pain. The LPN administering oral analgesics may relieve the pain, but it will not cause tissue necrosis. Having the LPN reposition the client every 1 to 2 hours will minimize the risk of tissue necrosis due to pressure ulcers.

Performing irrigation of the wound by the patient care associate (PCA)

Which instruction provides a client the best description of how to use a prescribed, stationary (nonrolling) walker? There are three critical concepts to this instruction: Stability, position, and weight bearing. Having all of the walker's four leg tips on the floor provides stability. Positioning the walker's front (not the back) leg tips at about an arm's length forward is a safe distance ahead to transfer weight. Putting weight on the walkerequalizes weight bearing on the upper and lower extremities. Conversely, placing the walker's back leg tips at about arm's length in front of the feet, shifting the body weight to the walker, and stepping forward places the walker too far in front of the client for safe transfer of body weight and all four legs must be touching the floor. Movement of the walker while also having it simultaneously bear weight is not possible. All of the walker's leg tips should be touching the floor when the client is stepping forward.

Put the walker's front leg tips about an arm's length ahead of the feet, shift the body weight to the walker, and step forward.

Which mechanism of action for wet-to-damp saline-moistened gauze for wound debridement is correct?

Removing the necrotic tissue mechanically

The nurse assesses the client's incision site after bariatric surgery for signs of dehiscence. Which clinical finding supports the nurse's conclusion that the client is experiencing wound dehiscence? Serosanguineous drainage from the wound or on the dressing forewarns separation of the wound edges (dehiscence); dehiscence may progress to movement of abdominal organs outside of the abdominal cavity (evisceration). Loosening of sutures may occur after the initial wound edema subsides but is not a sign of failure of the suture line. A purplish incision is the expected coloration of a healing wound.Test-Taking Tip: Do not spend too much time on one question because it can compromise your overall performance. There is no deduction for incorrect answers, so you are not penalized for guessing. You cannot leave an answer blank, so guess. Go for it! Remember: You do not have to get all the questions correct to pass.

Sharp increase in serosanguineous drainage

The nurse assessed a client who experienced a recent brain attack (stroke) and has a residual right-sided hemiplegia. Which rationale explains the importance of the nurse identifying mobility restrictions or neuromuscular abnormalities when assessing this client?

Shortening and eventual atrophy of the affected muscles will occur.

Which clinical finding demonstrates to the nurse that the client can use a standard walker? A walker with four rubber tips on the legs requires more upper body strength than a rolling walker. A client who is non-weight bearing on the affected extremity is able to use a standard walker. A rolling walker is more appropriate for a client with weak upper arm strength and impaired stamina who is less able to lift up and move a walker with four rubber tips. A client with unilateral paralysis is not a candidate for a standard walker; the client must be able to grip and lift the walker with both upper extremities and move the walker forward. A rolling walker is more appropriate for this client. A client with kyphosis is less able to lift up and move a walker with four rubber tips.

Strong upper arm strength and non-weight bearing on the affected extremity

A client with a known history of opioid addiction has a surgical repair of multiple stab wounds to the abdomen. After surgery, the client's pain is not relieved by the prescribed morphine injections. The nurse realizes that the failure to achieve pain relief indicates that the client is probably experiencing which phenomenon?

Tolerance

How would the nurse classify a wound that exhibits some soft necrotic tissue with a semiliquid slough and exudate?

YellowA yellow wound has soft necrotic tissue with a liquid to semiliquid slough and exudate ranging from creamy ivory to yellow-green. A red wound has pink to bright or dark red healing or is a chronic wound with granulating tissue; serosanguinous drainage may be noted. A black wound has black, gray, or brown adherent necrotic tissue; pus may be present. Wounds are not classified as green. However, a yellow wound may contain ivory or yellowish-green exudate.

The nurse is teaching a postoperative client about the importance of vitamin C for wound healing. Which food selection demonstrates the client is applying the information correctly?

cantaloupe

The nurse is changing the soiled bed linens of a client with a wound that is draining seropurulent exudate. Which personal protective equipment (PPE) would the nurse wear?

clean gloves

Which finding in a newborn is a behavioral response to pain? Select all that apply. One, some, or all responses may be correct.

crying

A client who had a right total hip replacement is progressing from the use of a walker to the use of a cane. In which hand would the nurse teach the client to hold the cane? A cane should be used on the unaffected side. Weight-bearing can be shared by a cane and an affected leg when they are advanced forward together. Teaching the client to use the right hand promotes leaning toward the affected side and does not permit sharing of weight by the stronger left side of the body. Teaching the client to use the stronger hand is unsafe; the stronger hand may not be the left hand. Teaching the client to use the dominant hand is unsafe; the dominant hand may not be the left hand.

left hand

A client who recently experienced a brain attack (cerebrovascular accident [CVA]) and has limited mobility reports constipation. Which is most important for the nurse to determine when collecting information about the constipation?

length of time the problem has existed

A client who underwent surgery feels pain in the lower abdomen. The nurse provides pain relief, but the client is still reporting pain. Which actions of the nurse would help the client get relief? Select all that apply. One, some, or all responses may be correct.

looking for different distraction techniques Involving the client's family in creating a new plan for pain relief

A client with hemiparesis voices a reluctance to use a cane. Which rationale would the nurse use to explain the cane's purpose to the client? Hemiparesis creates instability. Using a cane provides a wider base of support and therefore greater stability. Hemiparesis affects muscle strength on one side of the body; the joints are not directly affected. Activity should strengthen, not injure, weakened muscles. The use of a cane will not prevent involuntary movements if they are present.Test-Taking Tip: Identify option components as correct or incorrect. This may help you identify a wrong answer. Example: If you are being asked to identify a diet that is specific to a certain condition, your knowledge about that condition would help you choose the correct response (e.g., cholecystectomy = low-fat, high-protein, low-calorie diet).

maintain balance to improve stability

The nurse is caring for a client with a chronic venous stasis ulcer. A negative-pressure wound treatment device has been prescribed to hasten wound healing. Which nursing action would be included in the plan of care for this client?

replace the wound sponge every 48 hours

Before beginning administration of morphine via patient-controlled analgesia (PCA), which assessment would the nurse perform first?

respirations

Which component of ethical decision-making refers to the duties and activities the nurse is employed to perform?

responsibility

A client has a pressure ulcer that is full thickness with necrosis into the subcutaneous tissue down to the underlying fascia. The nurse would document the assessment finding as which stage of pressure ulcer?

unstageable

Which action would the nurse take first when an excessive amount of serosanguinous drainage is noted on the mastectomy dressing of a client who has just had a mastectomy and has a portable wound drainage system to the axillary area in place? If the tubing is patent and negative pressure is present, the wound should be free of exudate. Drainage is expected; it is the nurse's responsibility to maintain the drainage system. The surgeon would be notified if the excessive amount of drainage continues after the nurse has assessed the situation and corrected any problems with the drainage system. Pressure dressings are not used with portable wound drainage systems because the systems are effective in removing interstitial fluid. Although elevating the arm may facilitate drainage, it is not the priority in relation to the data presented.

Checking the function of the drainage system

A client's intravenous cannula insertion site has become red, swollen, and warm to the touch. Purulent drainage is also noted. Which intervention would the nurse implement?

Clean the site with alcohol, remove the cannula, and save for culture.

A client is hospitalized with pressure ulcers. Which task(s) could be delegated to an unlicensed nursing personnel (UNP)? Select all that apply. One, some, or all responses may be correct.

Empty wound drainage containers. Report changes in wound appearance.

Which would the nurse do to comply with the ethic of nonmaleficence in the health care setting?

Focus on doing no harm

When providing care for a client with quadriplegia, which nursing intervention assists in decreasing the potential occurrence of pressure ulcers?

Frequently reposition the client on a scheduled basis. (Frequent repositioning of the client in bed or wheelchair on a scheduled basis will relieve pressure points, thereby decreasing potential development of pressure ulcers. Avoiding leg massages will decrease the risk of embolism, but does not prevent pressure ulcers. Increased intake of dietary fiber will relieve the immobilized client of constipation. Weight-bearing exercises will prevent the immobilized client from developing muscular atrophy or loss of calcium from the bone)

Which dressings would the nurse view as beneficial for the recovery of a client's red-colored wound that was caused by pressure? Select all that apply. One, some, or all responses may be correct.Hydrocolloid dressings, transparent film dressings, and non-adhering dressings with antibiotic ointment are beneficial for the healing of a red wound caused by pressure injuries. Use absorptive dressings and moist gauze dressings with antibiotics to treat yellow wounds, such as wounds with nonviable necrotic tissue.

Hydrocolloid dressings Transparent film dressings Non-adheringdressingswithantiobiotictreatment

The nurse instructs a client about safety measures and precautions when taking care of a pressure ulcer. During a follow-up visit, the nurse finds increased tissue necrosis with damaged capillary beds. Which actions by the client would the nurse expect are the reason for the client's condition? Select all that apply. One, some, or all responses may be correct.

Massaging the reddened skin areas Using donut-shaped pillows for pressure relief