Docsity
Log inSign up
Docsity
Prepare for your exams
Prepare for your exams

Study with the several resources on Docsity

Earn points to download
Earn points to download

Earn points by helping other students or get them with a premium plan

Guidelines and tips
Guidelines and tips
Sell on Docsity
Sell on Docsity
Log inSign up

Prepare for your exams

Study with the several resources on Docsity

Find documents

Prepare for your exams with the study notes shared by other students like you on Docsity

Search Store documents

The best documents sold by students who completed their studies

Search through all study resources
Docsity AINEW

Summarize your documents, ask them questions, convert them into quizzes and concept maps

Explore questions

Clear up your doubts by reading the answers to questions asked by your fellow students

Earn points to download

Earn points by helping other students or get them with a premium plan

Share documents
download point icon20 Points

For each uploaded document

Answer questions
download point icon5 Points

For each given answer (max 1 per day)

All the ways to get free points
Get points immediately

Choose a premium plan with all the points you need

Study Opportunities

Choose your next study program

Get in touch with the best universities in the world. Search through thousands of universities and official partners

Community

Ask the community

Ask the community for help and clear up your study doubts

University Rankings

Discover the best universities in your country according to Docsity users

Free resources

Our save-the-student-ebooks!

Download our free guides on studying techniques, anxiety management strategies, and thesis advice from Docsity tutors

From our blog

Exams and Study
Go to the blog

NURS 225 Exam 2 GRADED A PLUS, Exams of Nursing

Liverpool Hope UniversityNursing

A client has been on a clear liquid diet for 5 days. What is an appropriate nursing diagnosis for this client? - ansImbalanced nutrition, less than body requirements A client has developed dysphasia secondary to a cerebral vascular accident. The nurse is aware that the client is at risk for? - ansAspiration

Typology: Exams

2023/2024

Available from 01/19/2024

david-maina-2
david-maina-2 🇺🇸

101 documents

1 / 13

Toggle sidebar

This page cannot be seen from the preview

Don't miss anything!

bg1
NURS 225 Exam 2
A client has been on a clear liquid diet for 5 days. What is an appropriate nursing
diagnosis for this client? - ansImbalanced nutrition, less than body requirements
A client has developed dysphasia secondary to a cerebral vascular accident. The nurse
is aware that the client is at risk for? - ansAspiration
A client is admitted to the healthcare facility for a second cycle of chemotherapy
involving vincristine. The nurse notes a small laceration on the client's leg that is
healing. The nurse plans to continue to monitor the healing process based on the
understanding that vincristine has which effect on wound healing? - ansSuppresses
antibody production
A client is brought into the emergency department with a suspected opioid overdose.
The nurse would anticipate that the client would most likely experience which acid-base
imbalance? - ansRespiratory acidosis
A client is taking a diuretic that increases her urinary output. What would be an
appropriate nursing diagnosis on which to base an educational plan? - ansRisk for
Deficient Fluid Volume
A client loses consciousness after strenuous exercise and needs to be admitted to a
health care facility. The client is diagnosed with dehydration. The nurse knows that the
client needs restoration of which of the following? - ansElectrolytes
A client who has had abdominal surgery develops an infection in the wound while still
hospitalized. Which of the following agents is most likely the cause of the infection? -
ansBacteria
A client who is NPO prior to surgery is complaining of thirst. What is the physiologic
process that drives the thirst factor? - ansDecreased blood volume and intracellular
dehydration
A client with influenza is prescribed a diet that is rich in fiber and carbohydrates. Which
would the nurse incorporate into the education plan as a major reason for the high fiber
diet? - ansmaintenance of normal bowel elimination
A client's most recent blood work indicates a K+ level of 7.2 mEq/L, a finding that
constitutes hyperkalemia. For what signs and symptoms should the nurse vigilantly
monitor? - ansCardiac irregularities
pf3
pf4
pf5
pf8
pf9
pfa
pfd

Partial preview of the text

Download NURS 225 Exam 2 GRADED A PLUS and more Exams Nursing in PDF only on Docsity!

NURS 225 Exam 2

A client has been on a clear liquid diet for 5 days. What is an appropriate nursing diagnosis for this client? - ansImbalanced nutrition, less than body requirements A client has developed dysphasia secondary to a cerebral vascular accident. The nurse is aware that the client is at risk for? - ansAspiration A client is admitted to the healthcare facility for a second cycle of chemotherapy involving vincristine. The nurse notes a small laceration on the client's leg that is healing. The nurse plans to continue to monitor the healing process based on the understanding that vincristine has which effect on wound healing? - ansSuppresses antibody production A client is brought into the emergency department with a suspected opioid overdose. The nurse would anticipate that the client would most likely experience which acid-base imbalance? - ansRespiratory acidosis A client is taking a diuretic that increases her urinary output. What would be an appropriate nursing diagnosis on which to base an educational plan? - ansRisk for Deficient Fluid Volume A client loses consciousness after strenuous exercise and needs to be admitted to a health care facility. The client is diagnosed with dehydration. The nurse knows that the client needs restoration of which of the following? - ansElectrolytes A client who has had abdominal surgery develops an infection in the wound while still hospitalized. Which of the following agents is most likely the cause of the infection? - ansBacteria A client who is NPO prior to surgery is complaining of thirst. What is the physiologic process that drives the thirst factor? - ansDecreased blood volume and intracellular dehydration A client with influenza is prescribed a diet that is rich in fiber and carbohydrates. Which would the nurse incorporate into the education plan as a major reason for the high fiber diet? - ansmaintenance of normal bowel elimination A client's most recent blood work indicates a K+ level of 7.2 mEq/L, a finding that constitutes hyperkalemia. For what signs and symptoms should the nurse vigilantly monitor? - ansCardiac irregularities

A client's PaCO2 is abnormal on an ABG report. Which of is the most likely be the medical diagnosis? - ansChronic obstructive pulmonary disease A female client has developed an abscess following abdominal surgery, and her food intake has been decreasing over the past two weeks. Which of the following laboratory findings may suggest the need for nutritional support? - ansLow serum albumin levels A female client is on isolation because she acquired a methicillin-resistant S. aureus (MRSA) infection after hospitalization for hip replacement surgery. What name is given to this type of infection? - ansNosocomial A group of nursing students are reviewing the types of wound healing. The students demonstrate understanding of this information when they identify which of the following as healing by primary intention? - ansSurgical incision A healthy patient eats a regular, balanced diet and drinks 3,000 mL of liquids during a 24-hour period. In evaluating this patient's urine output for the same 24-hour period, the nurse realizes that it should total approximately how many mL? - ans3, A home care client reports weakness and leg cramps. Per order, the nurse draws blood and requests a potassium level. What is the rationale for this request? - ansThe nurse recognizes these symptoms of hypokalemia. A home care nurse is teaching a client and family about the importance of a balanced diet. The nurse determines that the education was successful when the client identifies which of the following as a rich source of potassium? - ansApricots A home care nurse is visiting a client with renal failure who is on fluid restriction. The client tells the nurse, "I get thirsty very often. What might help?" Which of the following would the nurse include as a suggestion for this client? - ansAvoid salty or excessively sweet fluids. A hospitalized client has been NPO with only intravenous fluid intake for a prolonged period. What assessments might indicate protein-calorie malnutrition? - ansPoor wound healing, apathy, edema A lead nurse is removing her personal protective equipment after dressing the infected wounds of a client. Which of the following is the highest priority nursing action? - ansHandwashing before leaving the client's room. A man on an airplane is sitting by a woman who is coughing and sneezing. If she has an infection, what is the most likely means of transmission from the woman to the man?

  • ansAirborne route

A nurse is caring for a client who has a body mass index (BMI) of 26.5. Which of the following categories should the nurse understand this client would be placed in? - ansOverweight A nurse is caring for a client who has a malabsorption disease. The nurse should understand which of the following structures in the gastrointestinal system absorbs the majority of digested food and minerals? - ansSmall intestine A nurse is caring for a client who is being tube fed. Which of the following actions should the nurse perform when assessing a client's gastric residual volume? - ansStop the infusion of the tube-feeding formula. A nurse is caring for a client with a history of cardiac and vascular disease. Which of the following fats should the nurse allow in the client's diet for his condition? - ansUnsaturated fats A nurse is caring for a client with chronic anemia. Which of the following should be included in the diet of this client? - ansRed meat A nurse is caring for a client with dehydration at the health care facility. The client is receiving glucose intravenously. What type of dressing should the nurse use to cover the IV insertion site? - ansTransparent A nurse is caring for a client with draining wounds. The nurse needs to apply a dressing to the client that has a highly absorbent nature. Which of the following types of dressing should the nurse use for this client? - ansGauze A nurse is caring for a client with rubella. Which nursing action is an important precaution to be taken when caring for this client? - ansWearing a mask when working within 3 feet (1 metre) of the client A nurse is caring for a female client who is of child-bearing age in the clinic setting. Which of the following vitamins or minerals should the nurse recommend to prevent neural tube defects during pregnancy? - ansFolic Acid A nurse is caring for a patient who has a PICC line. Which nursing action is recommended? - ansFlush using normal saline and/or heparin solution according to facility policy. A nurse is caring for a patient who is diagnosed with tuberculosis. Which nursing intervention promotes infection control based on the QSEN competency of safety? - ansThe nurse places the patient in a private room with monitored negative air pressure. A nurse is caring for a visually impaired client. How should the nurse manage the feeding for this client? - ansInform the client about what kind of food is being offered with each mouthful.

A nurse is caring for an elderly client at a long-term health care facility. Which of the following infections poses a risk to long-term care residents and elderly clients admitted to health care facilities? Select all that apply. - ans• Pneumonia

  • Skin infection
  • Influenza A nurse is changing the bed linen of a client admitted to the health care facility. Which of the following isolation precautions should the nurse follow? - ansStandard precautions A nurse is changing the soiled bed linens of an older adult client who has urinary incontinence and is hospitalized. The nurse monitors the client closely based on the understanding that this client is at greater risk for which of the following? - ansBacteremia A nurse is collecting contaminated items and depositing the bag in a second bag, held by another nurse, outside the client's room. Which of the following infection control measures are the nurses performing? - ansDouble-bagging A nurse is educating a rural community group on how to avoid contracting West Nile virus by using approved insect repellant and wearing proper coverings when outdoors. By what means is the pathogen involved in West Nile virus transmitted? - ansVectors A nurse is feeding a client. Which of the following statements would help a person maintain dignity while being fed? - ans"What part of your dinner would you like to eat first?" A nurse is inspecting the skin of a client and notes a wound with ragged edges and torn tissue. The nurse documents this wound as which of the following? - ansLaceration A nurse is measuring intake and output for a patient who has congestive heart failure. What does not need to be recorded? - ansFluid consumption A nurse is obtaining a blood glucose level on an infant. The nurse would use which site to obtain the specimen? - ansHeel A nurse is performing a sterile dressing change. If new sterile items or supplies are needed, how can they be added to the sterile field? - ansWith sterile forceps or hands wearing sterile gloves A nurse is performing a venipuncture on a client and notices that there is a hole in one of the sterile gloves. What would be the appropriate action to take to maintain a sterile field? - ansStop the procedure, remove damaged gloves, perform handwashing, and open new sterile gloves.

A nurse measures a client's 24-hour fluid intake and documents the findings. To be an accurate indicator of fluid status, what must the nurse also do with the information? - ansCompare the total intake and output of fluids for the 24 hours. A nurse needs to send the blood and urine specimen of a client with acute diarrhea to the pathology laboratory. Which of the following precautions is of highest priority to be taken by the nurse when collecting and delivering the specimens to the laboratory? - ansUse sealed containers in a plastic biohazard bag A nurse observes that a client coughs and chokes when eating. What instructions should the nurse prepare for this client? - ansTell the client to chew his or her food very thoroughly A nurse performing a nutritional assessment determines the BMI of a 5' 11" (180 cm) male patient who weighs 180 pounds (82 kg). What would be the BMI for this patient? - ans25. A nurse prefers to use an alcohol-based hand rub when providing care for patients. In which case is this practice contraindicated? - ansThe nurse is caring for a client with a C. difficile infection. A nurse who has diagnosed a patient as having "fluid volume excess" related to compromised regulatory mechanism (kidneys) may have been alerted by what symptom? - ansDistended neck veins A nurse who is planning a diet for a patient who has anorexia chooses nutrients that supply energy to the body including: (Select all that apply.) - ans• Carbohydrates

  • Protein
  • Lipids A nurse who is taking the vital signs of a client with acute diarrhea is ordered to attend to another client. What is the highest priority nursing action the nurse must perform before leaving the client's room? - ansThorough handwashing A nursing instructor is preparing a class presentation for a group of nursing students on fluid balance and developmental considerations. Which of the following would the instructor most likely include when describing newborns and infants? Select all that apply. - ans• Greater amounts of water are found in the extracellular fluid compartment.
  • Water makes up a larger percentage of their body weight.
  • Insensible fluid losses are greater in this age group. A nursing responsibility in managing IV therapy is to monitor the fluid infusions and to replace the fluid containers as needed. Which of the following is an accurate guideline for IV management that the nurse should consider? - ansIt is the responsibility of the nurse to provide ongoing verification of the IV solution and the infusion rate with the physician's order.

A nutritionist helps to plan a diet for a client with diabetes. Which of the following foods is a carbohydrate that should be included to help improve glucose tolerance? - ansOatmeal A physician uses sutures during the surgery on a client at a health care facility. Which of the following describes sutures? - ansKnotted ties that hold an incision together A woman tests positive for the human immunodeficiency virus antibody but has no symptoms. She is considered a carrier. What component of the infection cycle does the woman illustrate? - ansA reservoir After reviewing the client's chart, the nurse notes that the client has been ordered a clear liquid diet. Which meal tray would the client be allowed to eat? - ansBouillon, apple juice, and gelatin An acute medicine unit of a hospital currently has a number of clients who have tested positive for methicillin-resistant Staphylococcus aureus (MRSA). Which of the following measures should the nursing staff prioritize in preventing the spread of MRSA to clients who are currently MRSA-negative? - ansDiligent handwashing practices An experienced nurse is teaching a student nurse the proper use of hand hygiene. Which of the following is an accurate guideline that should be discussed? - ansHand hygiene must be performed after contact with inanimate objects near the client. An experienced nurse is teaching a student nurse the proper use of hand hygiene. Which of the following is an accurate guideline that should be discussed? - ansHand hygiene must be performed after contact with inanimate objects near the client. An infection-control nurse is discussing needlestick injuries with a group of newly hired nurses. The infection control nurse informs the group that most needlestick injuries result from which of the following? - ansRecapping a needle An older adult client has been admitted to the hospital with dehydration, and the nurse has inserted a peripheral intravenous line into the client's forearm in order to facilitate rehydration. What type of dressing should the nurse apply over the client's venous access site? - ansA transparent film At what period of life do nutrient needs stabilize? - ansAdulthood By what route do oxygen and carbon dioxide exchange in the lung? - ansdiffusion Dehiscence is the softening of tissue due to excessive moisture. - ansFalse During a dressing change, the nurse assesses protrusion of intestines through an opened wound. What would the nurse do after covering the wound with towels

The nurse is applying a heating pad to a patient experiencing neck pain. Which nursing action is performed correctly? - ansThe nurse keeps the pad in place for 20 to 30 minutes, assessing it regularly. The nurse is caring for a client who has active tuberculosis (TB) and is in Airborne Precautions. The primary care provider orders a computed tomography (CT) examination of the chest. Which of the following actions by the nurse is appropriate? - ansPlace a surgical mask on the client and transport to the CT department at the specified time. The nurse is caring for a client who was found after spending two days without food or water in the desert and was admitted through the Emergency Department. The client is severely dehydrated. Which of the following are reasons why the human body requires fluid? Select all that apply. - ans• Facilitates cellular metabolism

  • Helps maintain normal body temperature
  • Acts as a solvent for electrolytes The nurse is caring for a male client who has a diagnosis of heart failure. Today's laboratory results show a serum potassium of 3.2 mEq/L. For what complications should the nurse be aware, related to the potassium level? - ansCardiac dysrhythmias The nurse is performing a nutritional assessment of an obese patient who visits a weight control clinic. What information should the nurse take into consideration when planning a weight reduction plan for this patient? - ansPsychological reasons for overeating should be explored, such as eating as a release for boredom. The nurse is preparing to perform handwashing. Arrange the following steps in the correct order. - ansTurn on the faucet and adjust force and temperature of the water. Wet the hand and wrist areas. Apply soap product. Wash the palms and back of the hands for at least 15 seconds. Pat hands dry with a paper towel. Turn the faucet off with a paper towel. The nurse is providing care for a client who is ordered nothing by mouth (NPO). What is an important nursing intervention? - ansProvide frequent mouth care The nurse is setting up a sterile field to perform a catheterization when the patient touches the end of the sterile field. What would be the nurse's next appropriate action? - ansDiscard the sterile field and the supplies and start over. The nurse performs hand hygiene using soap and water before and after providing patient care. Which nursing action is performed correctly according to the procedure? - ansThe nurse washes at least one inch above the area of contamination if present.

The nurse reviews the laboratory test results of a client and notes that the client's potassium level is elevated. Which of the following would the nurse expect to find when assessing the client's gastrointestinal system? - ansDiarrhea The nurse should begin the process of removing a patient's nasogastric (NG) tube by doing which of the following? - ansConfirming the physician's order to remove the tube The nurse's morning assessment of a client who has a history of heart failure reveals the presence of 2+ pitting edema in the client's ankles and feet bilaterally. This assessment finding is suggestive of what? - ansFluid volume excess The nurses on a busy surgical ward use hand hygiene when caring for postsurgical patients. Which action represents the appropriate use of hand hygiene? - ansThe nurse keeps fingernails less than ¼ inch long. The oncoming nurse is assigned to the following patients. Which patient should the nurse assess first? - ansA newly admitted 88-year-old with a two-day history of vomiting and loose stools The physician has asked the nurse to prepare a list of laboratory tests needed to assess an obese client's daily fat intake. Which of the following tests would the nurse include on the list? - ansCholesterol level test What are the recommended cleansing agents for hand hygiene in any setting when the risk of infection is high? - ansAntimicrobial products What is the lab test commonly used in the assessment and treatment of acid-base balance? - ansArterial blood gas What is the route of administration for TPN? - ansIntravenous What nursing diagnosis would be a priority for a client who has a large wound from colon surgery, is obese, and is taking corticosteroid medications? - ansRisk for Infection When caring for a client with a suspected systemic infection, the nurse should evaluate for which of the following assessment findings? - ans• Lethargy

  • Enlarged lymph nodes
  • Increased respirations When feeding a client, the nurse arranges for finger foods to be prepared for the client. The nurse is caring for what type of client? - ansVisually impaired client When patients are pulled up in bed rather than lifted, they are at increased risk for the development of a decubitus ulcer. What is the name given to the factor responsible for this risk? - ansshearing force

Which of the following statements about glove use and hand hygiene is true? - ansArtificial fingernails should not be worn by staff involved in direct client care. Which of the following statements accurately describes a developmental consideration when assessing skin integrity of patients? - ansAn infant's skin and mucous membranes are injured easily and are subject to infection. Which of the following statements best explains the rationale for bringing an extra pair of sterile gloves into an adult patient's room before preparing for a sterile procedure? - ansIf the first pair is contaminated and needs to be replaced, the nurse does not need to leave the room for a new pair. Which of the following types of feeding tubes would be most appropriate for a patient requiring enteral feeding for a long period of time? - ansGastrostomy tube While setting up a sterile field, a small of amount of water splashes onto the sterile drape. Which action by the nurse would be most appropriate? - ansDiscard the sterile field to start over. You are applying a saline-moistened dressing to a client's wound. The client asks, "Wouldn't it be better to let my wound dry out so a scab can form?" Which of the following responses is most appropriate? - ans"Wounds heal better when a moist wound bed is maintained." You are donning a pair of sterile gloves. You correctly don the first glove, but inadvertently insert the thumb and index finger into the thumb hole of the second glove. The glove remains intact. Which of the following actions is most appropriate? - ansContinue to don the glove, then use the other gloved hand to carefully insert the finger into the proper hole. You have completed an intervention with a patient. There is no visible soiling on your hands. Which of the following techniques is recommended by the Centers for Disease Control (CDC) for hand hygiene? - ansDecontaminate hands using an alcohol-based hand rub.