NURS 262 Exam 2 Answers

A nurse administers the wrong medication to a client. Which of the following actions should the nurse take first? a. Check the client's vital signs b. Notify the provider c. Fill out an incident report d. Document the client's condition in the electronic medical report

a. Check the client's vital signs Rationale: The first action the nurse should take when using the nursing process is to check the client's vital signs. The client is at risk for an adverse reaction due to the medication error. The nurse should collect data from the client to monitor for any changes in the client's condition

A nurse is planning care for a client who has a superficial wound with no exudate. The nurse should plan to use which of the following dressings to cover the wound? a. Film dressing b. Alginate dressing c. Hydrofiber dressing d. Foam dressing

a. Film dressing Rationale: Film dressings or self-adhesive dressings are used to cover superficial wounds that have minimal exudate

A nurse is ordering equipment for a medical-surgical unit. Which of the following equipment should the nurse identify as being ergonomic? (Select all that apply). a. Height-adjustable beds b. Wrist supports for computer keyboards c. IV stands that are at a fixed height d. Standard height toilets e. Shower chairs

a. Height-adjustable beds b. Wrist supports for computer keyboards e. Shower chairs

A nurse is assessing a client who has a stage 2 pressure injury. Which of the following findings should the nurse expect? a. Partial-thickness skin loss with red tissue in the wound bed b. Intact skin with localized erythema c. Full-thickness skin loss with visual adipose tissue d. Full-thickness skin loss with visible bone

a. Partial-thickness skin loss with red tissue in the wound bed Rationale: Partial-thickness skin loss with red tissue in wound bed is a stage 2 pressure injury

A nurse is teaching a class about reducing the risk of medication errors. Which of the following information should the nurse include? a. Provide the nurse administering medication with an identifying vest b. Wait to document medications given to client until the end of a shift c. Remove medications from automatic dispensing systems before they are reviewed by pharmacists d. Prepare medications for multiple clients at the same time

a. Provide the nurse administering medication with an identifying vest Rationale: The nurse should provide the nurse administering medications with a vest to indicate they should not be interrupted. Interruptions while dispensing medications can result in medication administration errors

A nurse opens a unit-dose of a prescribed medication prior to administering it to a client. The client refuses to take the medication. Which of the following actions should the nurse take? a. Report the incident to the provider b. Notify the facility's ethics committee c. Fill out an incident report d. Return the opened medication to the medication cart

a. Report the incident to the provider Rationale: The client has the right to refuse a medication. The nurse should investigate the reason for the refusal, educate the client about the potential adverse effects of the refusal, and notify the provider

A nurse is preparing to reposition a client towards the head of the bed. In which of the following positions should the nurse place the client before repositioning them to the head of the bed? a. Supine b. High-Fowler c. Lateral d. Prone

a. Supine Rationale: The nurse should lower the head of the client's bed and place the client in a supine position to reduce the risk of injury to the client or the nurse

A nurse is performing a mobility assessment on a client. Which of the following data should the nurse collect as part of this assessment? (Select all that apply). a. The client's ability to sit b. The condition of the client's skin c. The client's health literacy level d. The client's need for assistance with ADLs e. The client's daily calcium intake

a. The client's ability to sit b. The condition of the client's skin d. The client's need for assistance with ADLs

A nurse is caring for a group of clients. Which of the following clients should the nurse identify is at highest risk for developing a pressure injury? a. A client who is alert and responsive and eats 25% of each meal b. A client who is unresponsive to verbal commands and changes position occasionally c. A client who is receiving enteral feeding and can change their position independently d. A client who makes frequent slight changes in position and walks occasionally

b. A client who is unresponsive to verbal commands and changes position occasionally Rationale: This client is at the greatest risk for a pressure injury because they have a very limited sensory perception. The nurse should monitor the client for a pressure injury

A nurse is assessing a client who has a stage 1 pressure injury. Which of the following findings should the nurse expect? a. Partial-thickness skin loss with red tissue in the wound bed b. Intact skin with localized erythema c. Full-thickness skin loss with visual adipose tissue d. Full-thickness skin loss with visible bone

b. Intact skin with localized erythema Rationale: intact skin with localized erythema is a stage 1 pressure injury

A nurse is performing pulmonary hygiene for a client who has pneumonia and positions the client on his left side in Trendelenburg position. From which of the following lung segments should the nurse expect secretions to be mobilized with the client in this position? a. Lateral segment of the left lower lobe b. Lateral segment of the right lower lobe c. Posterior segment of the right middle lobe d. Posterior segment of the right lower lobe

b. Lateral segment of the right lower lobe Rationale: The nurse would position the client in a left lateral Trendelenburg position

A nurse is teaching a class about the function of cells in the epidermis. The nurse should include that which of the following cells determine skin color? a. Keratinocytes b. Melanocytes c. Merkel Cells d. Langerhans Cells

b. Melanocytes Rationale: Melanocytes produce melanin that determines skin and hair color. Melanocytes absorb radiant energy from the sun and protect the skin from ultraviolet radiation

A nurse is evaluating ergonomic practice in the workplace. Which of the following should the nurse identify as an example of safe ergonomic practice? a. Nurses are required to work frequent overtime b. Nurses are required to take breaks during a shift c. A nurse lifts a client by themselves d. A nurse reaches across a client's bed to lift an object

b. Nurses are required to take breaks during a shift Rationale: Breaks provide time for rest and muscle recovery, which reduces the risk for injury

A nurse is caring for a client who is at risk for a pressure injury. Which of the following actions should the nurse take? a. Massage the client's bony prominences b. Provide the client with a high-calorie diet c. Reposition the client every 4 hours d. Elevate the head of the client's bed 45 degrees

b. Provide the client with a high-calorie diet Rationale: The nurse should provide the client with a high-calorie diet to promote wound healing and strengthen tissue to reduce the risk of a pressure injury

A nurse is teaching a client about how to administer a topical medication. After showing the client the procedure, the nurse asks the client to perform the skill. Which of the following types of teaching strategies is the nurse using? a. Discussion b. Return demonstration c. Role play d. Question and answer

b. Return demonstration Rationale: Return demonstration is an active teaching method based on the psychomotor domain of learning. The nurse demonstrates a procedure, then the client returns the demonstration

A nurse is teaching a class about skeletal muscles. Which of the following should the nurse identify as a function of skeletal muscles? a. Skeletal muscles enable the heart to contract with each heartbeat b. Skeletal muscles enable a hand to contract and form a fist c. Skeletal muscles enable the bladder to contract during voiding d. Skeletal muscles enable the bronchioles to dilate in the lungs

b. Skeletal muscles enable a hand to contact and form a fist Rationale: The contraction and relaxation of skeletal muscles enable movement in bones and joints, such as forming a fist with the hand

A nurse is caring for a client who has a chest tube. Which of the following actions should the nurse take? a. Place the chest tube drainage system above the level of the client's heart b. Tape the connections on the client's chest tube c. Strip the client's chest tube every 4 hours d. Loop the tubing of the chest tube on the clients bed

b. Tape the connections on the client's chest tube Rationale: The connections on the chest tube should be securely taped to reduce the risk of disconnection which can cause air to enter the client's pleural cavity

A nurse preparing to lift a heavy object. Which of the following actions by the nurse indicates an understanding of body mechanics? a. They twist their spine when lifting b. They stand close to the object being moved c. They bend at the hip when lifting d. They keep their feet together when lifting an object

b. They stand close to the object being moved Rationale: The nurse should stand close to the object being moved to reduce reaching and decrease the risk of injury. This action indicates an understand of the teaching

A nurse is performing a mobility assessment on a client. Which of the following actions should the nurse take first? a. Ask the client to stand for 5 seconds b. Ask the client to place their feet on the floor c. Ask the client to sit on the edge of the bed for 2 minutes d. Ask the client to march in place

c. Ask the client to sit on the edge of the bed for 2 minutes Rationale: According to evidence-based practice, the first step the nurse should take when performing a mobility assessment is to ask the client to sit on the edge of the bed for 2 minutes

A nurse is caring for a client who has pneumonia. Which of the following actions should the nurse take to promote thinning of respiratory secretions? a. Encourage the client to ambulate frequently b. Encourage coughing and deep breathing c. Encourage the client to increase fluid intake d. Encourage regular use of the incentive spirometer

c. Encourage the client to increase fluid intake Rationale: Increasing fluid intake to 1,500 to 2,500 mL/day promotes liquefaction and thinning of pulmonary secretions, which improves the client's ability to cough and remove the secretions

A nurse is assessing a client who has bradycardia. Which of the following findings should the nurse expect? a. Constipation b. Nausea c. Headache d. Hypotension

c. Headache Rationale: Obstructive sleep apnea can cause morning headache, fatigue, irritability, snoring, and restlessness

A nurse is teaching a class about routes of medication administration. The nurse should include that which of the following routes has the fastest rate of absorption? a. Enteral b. Intramuscular c. Intravenous d. Topical

c. Intravenous Rationale: Evidence-based practice indicates that medications administered via the intravenous route have the fastest rate of absorption because these medications are injected directly into the circulatory system

A nurse is assessing a client who has bradycardia. Which of the following findings should the nurse expect? a. Elevated temperature b. Anxiety c. Lightheadedness d. Fluid volume deficit

c. Lightheadedness Rationale: Bradycardia can cause lightheadedness due to decreased cerebral perfusion

A nurse is teaching a client about the musculoskeletal system. The nurse should include that which of the following is a fluid filled capsule that enables movement and flexibility? a. Tendons b. Ligaments c. Synovial joints d. Cartilage

c. Synovial joints Rationale: Synovial joints are fluid filled capsules that enable movements

A nurse is assessing a client who has COPD. Which of the following findings should the nurse expect? a. Spoon nails b. Peripheral edema c. Pleural friction rub d. Barrel chest

d. Barrel chest Rationale: Barrel chest is an expected finding in a client who has COPD due to hyperinflation of the lungs

A nurse is teaching a class about oxygen transport in the cardiopulmonary system. Which of the following transports oxygen in the blood? a. Neutrophils b. Platelets c. Lymphocytes d. Hemoglobin

d. Hemoglobin Rationale: Hemoglobin is a part of the red blood cell and transports oxygen in the blood throughout the body

A nurse is performing passive range of motion on a client who had a stroke. The nurse should identify that passive range of motion is performed to increase which of the following? a. Muscle mass b. Muscle strength c. Bone density d. Joint flexibility

d. Joint flexibility Rationale: Passive range of motion increases joint flexibility and reduces joint stiffness

A nurse is assessing a client who has hypoxia. Which of the following findings should the nurse expect? a. Bradycardia b. Somnolence c. Pallor d. Tachycardia

d. Tachycardia Rationale: The nurse should expect the client who has hypoxia to manifest tachycardia

A nurse is teaching a newly licensed nurse about the peripheral nervous system. Which of the following statements should the nurse make? a. "The peripheral nervous system regulates the body's responses to the external stimulus" b. "The brain is part of the peripheral nervous system" c. "The spinal cord is part of the peripheral nervous system" d. "The peripheral nervous system is responsible for memory"

a. "The peripheral nervous system regulates the body's responses to the external stimulus" Rationale: The peripheral nervous system is a network of thousands of nerves outside of the brain and spinal cord that regulates the body's response to external stimuli

A nurse is teaching a client who has COPD about pursed-lipped breathing. Which of the following statements should the nurse make? a. "You should inhale through your nose and exhale through your mouth during pursed-lipped breathing" b. "Your inspiration should be longer than expiration during pursed-lipped breathing" c. "You should cough forcefully during exhalation when you are pursed-lipped breathing" d. "You should be flat on your back when you perform pursed-lipped breathing"

a. "You should inhale through your nose and exhale through your mouth during pursed=lipped breathing" Rationale: The client should inhale through the nose and exhale through the mouth with purse lips to release trapped air, increase resistance, and prevent alveolar collapse

A nurse is preparing to teach a group of newly licensed nurses about the first phase of wound healing. Which of the following processes should the nurse plan to discuss? a. Inflammation b. Proliferation c. Maturation d. Remodeling Phase

a. Inflammation Rationale: Inflammation is the process that occurs during the first phase of wound healing which is also known as the inflammatory or hemostatic phase. During this phase, blood vessels constrict and clotting factors are activated

A nurse is assessing a client who has oxygen toxicity. Which of the following findings should the nurse expect? a. Muscle twitching b. Metallic taste in mouth c. Facial flushing d. Periorbital edema

a. Muscle twitching Rationale: Manifestations of oxygen toxicity can include muscle twitching in the hands, ringing in the ears, nausea, and convulsions

A nurse is providing teaching for a client about coughing and deep breathing. Which of the following statements should the nurse take? a. "Hold your breath for 5 seconds" b. "Repeat your breathing exercise every 2 hours c. "Inhale through your mouth" d. "Exhale through your nose"

b. "Repeat your breathing exercise every 2 hours Rationale: The client should repeat the breathing exercises every 1 to 2 hours to increase lung expansion and reduce the risk for atelectasis and pneumonia

A nurse is teaching a class about pulmonary circulation. The nurse should include that blood flows from the heart to the lungs from the right ventricle starting from which of the following locations? a. Pulmonary veins b. Pulmonary artery c. Left atrium d. Left ventricle

b. Pulmonary artery

A nurse is caring for a client who has a wound that requires negative pressure wound therapy. Which of the following actions should the nurse take? a. Cover the client's wound with an alginate dressing b. Expect the inner dressing to expand after the vacuum pump is initiated c. Shave hair on the client's skin surrounding the wound d. Cut a round hole in the center of the outer dressing

d. Cut a round hole in the center of the outer dressing Rationale: The nurse should cut a 1 inch round hole in the center of the outer dressing to allow for insertion of the drainage tube