NUR 131 FINAL EXAM Questions and Answers Latest Updates 2024 graded A+., Exams of Nursing

Download NUR 131 FINAL EXAM Questions and Answers Latest Updates 2024 graded A+. and more Exams Nursing in PDF only on Docsity! NUR 131 FINAL EXAM Questions and Answers Latest Updates 2024 graded A+ a) does not follow the tenets of a specific faith correct answers The nurses notes on the admission form that the patient has indication "no religious preference." What does this indicate to the nurse about the patient? a) does not follow the tenets of a specific faith b) is in denial about his religious beliefs c) doesn't believe in God or a "higher power" d) will not want to pray or visit with the chaplain d) hold her hand, sit with her, & listen correct answers Your pt is a 17 year old who lost her right leg in a MVA. After her parents leave, she asks you, "Why did God let this happen to me? I have always followed his commandments." Which action best depicts the "caring" aspect of SENC? a) "Let me call your parents back to support you." b) I think the chaplain can provide the support you need." c) cry with the pt as you hug her d) hold her hand, sit with her, & listen d) perceived correct answers The student nurse has earned A's in all of her prerequisite courses. For the first exam in a nursing course, she earns a D and now feels that she may not be smart enough to become a nurse. What type of "loss" is the student experiencing? a) actual b) external c) physical d) perceived d) "Tell me how you are feeling right now" correct answers Your 55 year old pt was just informed that she has metastatic pancreatic cancer and has 4 months to live. After the provider leaves, she says to you, "I don't want my family to know. But they have to know. Please don't tell them. Please tell me what to do, help me." What is your best response? a) "I know this is difficult for you. Take time to thin about it." b) "You should get a second opinion before you alarm your family." c) "Let me hold your hand to make you feel better." d) "Tell me how you are feeling right now." a) "You sound very upset. Tell me more about your dad." correct answers The pt is dying of cancer and can no longer swallow. The son states to the nurse, "You MUST give dad some water, he always drank a lot of water." The nurse's best response is a) "You sound very upset. Tell me more about your dad." b) "Your father is dying from cancer and water will not stop this process." c) "Research shows that withholding oral fluids decreases edema." d) "I will call the provider & get a prescription to insert a NG tube for the water." d) this is an example of distress & could affect the pt's health status correct answers The hospitalized pt states, "I need to know when I'm going to be discharged. I'm so upset & worried that I'm missing work." The nurse knows: a) this is an example of "eustress" & no intervention is necessary b) this is an example of psychological stress & the pt should be placed on antidepressants c) this is an example of developmental stress & the pt should talk to someone his own age d) this is an example of distress & could affect the pt's health status a) true Tenormin is a beta-blocker (or otherwise a anti-hypertensive medication) correct answers A pt who is taking atenolol (Tenormin) may not exhibit a rise in blood pressure & pulse during the alarm stage of the general adaptation syndrome a) true b) false c) the occurrence of stress in pts is unpredictable correct answers The nurse should assess every pt to determine if stress reduction interventions should be part of the plan of care. The rationale for this action is that: a) there are more persons experiencing mental illness now than in the past b) life is so much more stressful than it has ever been c) the occurrence of stress in pts is unpredictable d) pts often develop maladaptive coping strategies c) close the blinds, dim the lights, and ask the pt what other measures would help him rest correct answers Mr. Arbor complains to the nurse that he is feeling anxious. He states, "I'm just so tired of all these tests they are doing, and it's so noisy here at night." Mr. Arbor's pulse is 110 bpm and his blood pressure is 140/70 mmHg. Nursing actions should include which of the following? a) turn on the TV to provide distraction b) ask the pt if he would like to discuss his anxiety further c) close the blinds, dim the lights, and ask the pt what other measures would help him rest d) call the physician and obtain an order for an anti-anxiety medication for PRN use b) 4 correct answers How many stages of death are there? a) 2 b) 4 c) 6 d) 8 a) arterial arterial wounds are most often on the foot, in between/on tips of the toes, & around the lateral malleolus (outer ankle) venous wounds usually develop on the inner leg correct answers What type of wound typically develops on the foot, toes, & outer ankle? a) arterial b) venous b) venous arterial wounds are round & deep with a "punched out" shape, and comes in many sizes *note: arterial wounds may appear shallow in the early stages venous wounds are often large & shallow correct answers What type of wound is large and shallow? a) arterial b) venous a) arterial arterial wounds have well-defined edges venous wounds have irregular edges that may slope correct answers What type of wounds have well-defined edges? a) arterial b) venous b) venous the skin around arterial wounds is pale with non-granulating tissue the skin around venous wounds is a ruddy red color with granulating tissue correct answers What type of wound is a ruddy red color with granulating tissue? a) arterial b) venous a) arterial arterial wounds are often yellow, brown, or black in color venous wounds may have discoloration with yellow slough & a foul odor correct answers What type of wound is often yellow, brown, or black in color? a) arterial b) venous b) venous the skin around arterial wounds is thin, smooth, taut, cool to the touch, & dry the skin around venous wounds is shiny, scaly, & warm to the touch correct answers What type of wound causes the surrounding skin to be shiny, scaly, & warm to the touch? a) arterial b) venous a) arterial arterial wounds are often dry with very minimal drainage venous wounds have lots of exudate, making them appear "wet" correct answers What type of wound is often dry with minimal drainage? a) arterial b) venous True Tunneling is common with venous wounds correct answers True/False: Tunneling is common with venous wounds a) arterial arterial wounds are described as very painful venous wounds are described as dull & aching correct answers What type of wound is described as very painful? a) arterial b) venous C) provide adequate lighting & keep room free from clutter correct answers When caring for an older adult patient with a visual impairment, which is the best nursing intervention? A) ensure glasses on the bedside table B) keep 3 bedside rails up C) provide adequate lighting & keep room free from clutter D) encourage patient to ambulate independently B) explore the patients feelings about wearing dentures correct answers During an assessment of an older pt you notice they haven't been wearing their dentures. What is the best nursing action? A) nothing, it's normal for older adults B) explore the pts feelings about wearing dentures C) offer to clean the dentures after meals D) encourage the pt to use dentures when eating A, B, C, & D correct answers SATA: When assessing a wound, what data are you looking for? A) location B) condition of surrounding tissue C) depth of wound D) type of exudate B) contact precautions correct answers A pt with a wound is placed in isolation. Which type of isolation is most appropriate? A) universal precautions B) contact precautions C) airborne precautions D) neutropenic precautions C) gown correct answers SATA: What type of equipment or precaution is needed for a patient on contact isolation precautions? A) N95 mask B) sterile gloves C) gown D) keep fresh flowers out of room B) asking family members what they would like to do to care for their loved one correct answers In caring for a dying pt, what is an appropriate nursing intervention to increase family involvement? A) insisting that all bedside care be done by the family B) asking family members what they would like to do to care for their loved one C) expecting the family to be able to perform the pts daily needs D) refusing all assistance from the family to decrease stress D) test the bath water temperature to prevent burns correct answers The nurse is caring for a pt with decreased sensation in the lower extremities. Which precaution does the nurse advise? A) auscultation of bilateral breath sounds B) percussion of anterior & posterior chest wall C) palpation of the chest bilaterally for tactile fremitus D) inspection for anterior & posterior chest expansion C) arterial blood gas (ABG) sampling correct answers Which diagnostic test/exam would best measure a pt's level of hypoxemia? A) chest x-ray B) pulse ox reading C) arterial blood gas (ABG) sampling D) peak expiratory flow rate C) develop an effective pain management plan correct answers It is most important for the nurse to understand the various ways in which pain is classified so that he or she can A) document the pt's pain using accurate terms B) be clear in communication with the physician C) development an effective pain management plan D) educate the pt thoroughly A) soft gurgles, irregular clicks correct answers Which of the following describes normal bowel sounds? A) soft gurgles, irregular clicks B) fewer than 5 seconds per min C) continuous sounds D) excessively loud gurgling C) soapsuds works by distending the colon & irritating the walls of the colon, which further increases peristalsis correct answers Which type of enema works by distending the colon & by irritating the walls of the colon, which further increases peristalsis? A) tap water B) normal saline C) soapsuds D) hypertonic sodium phosphate D) specific gravity normal specific gravity is 1.005 to 1.03 correct answers What is the result of comparing the weight of a substance with the weight of an equal amount of water? A) turbidity B) hematuria C) pH D) specific gravity B) straight a straight cath is a single tube with holes at the end; it is made of red rubber, clear plastic, or silicone correct answers If you are caring for a pt who is unable to fully empty his or her bladder, and you have found residual urine in the bladder using a bladder scan, you could expect to receive orders to insert which type of catheter? A) indwelling B) straight C) three-way D) condom false correct answers True/false: The nurse knows the lab result that is the best indicator of a pt's nutritional status is the serum albumin D) introduce a small amount of fluid into the tube before feeding correct answers You receive an order to begin enteral tube feedings. The first step is to: A) place the pt in a prone position B) irrigate the tube with normal saline C) check to see that the tube is properly placed D) introduce a small amount of fluid into the tube before feeding a) verify tube placement before feeding correct answers The nurse is concerned about pulmonary aspiration when providing her pt with tube feedings. The nurse should: A) verify tube placement before feeding B) lower the head of the bed to a supine position C) add blue food coloring to the enteral formula D) run the formula over 12 hours to decrease volume A, C, D correct answers A pt was recently admitted to the hospital. What indications, if observed, may suggest that the pt has dysphagia? (Select all that apply) A) persistent drooling B) drowsiness C) change in voice after swallowing D) wet, gurgly voice E) loss of appetite C, D, E, F correct answers In the change of shift report, you are told that a pt requires "minimal assistant with meals." What would you expect to do for the pt at mealtime? (Select all that apply.) A) place the meal tray in the room, leave the room, & return in 30mins to remove the tray B) feed the pt C) open packages & cartons D) assist the pt to an upright position E) ask the pt if he or she wants you to cut up the food or butter the bread F) document the pt's intake a) maceration Maceration is the softening of the skin from prolonged moisture, which is typically seen with incontinent pts correct answers A pt that has urinary incontinence is susceptible to what type of skin issue? a) maceration b) dry skin c) abrasions d) pressure injuries d) ensure proper placement of the needle correct answers When the nurse administers some intramuscular injections, the nurse aspirates. What is the rationale for the nurse aspirating? a) to draw blood b) in case the muscle isn't large enough to hold the medication c) reduce discomfort of the injection d) ensure proper placement of the needle a) respiratory rate correct answers In caring for a pt that is febrile, it would be important for the nurse to monitor for: a) respiratory rate b) pulse c) pulse ox d) circulation b) family practice correct answers When completing a patient assessment, which variable is classified as "external" ? a) self-esteem b) family practice c) self concept d) perception of functioning D) S4 A) right 2nd intercostal space correct answers Where can you hear the aortic valve? A) right 2nd intercostal space B) left 2nd intercostal space C) left 3rd intercostal space D) lower left, 4th intercostal space at the sternal boarder E) left 5th intercostal space, medial to midclavicular line B) left 2nd intercostal space correct answers Where can you hear the pulmonary valve? A) right 2nd intercostal space B) left 2nd intercostal space C) left 3rd intercostal space D) lower left, 4th intercostal space at the sternal boarder E) left 5th intercostal space, medial to midclavicular line C) left 3rd intercostal space correct answers Where can you hear erb's point? A) right 2nd intercostal space B) left 2nd intercostal space C) left 3rd intercostal space D) lower left, 4th intercostal space at the sternal boarder E) left 5th intercostal space, medial to midclavicular line D) lower left, 4th intercostal space at the sternal boarder correct answers Where can you heart the tricuspid valve? A) right 2nd intercostal space B) left 2nd intercostal space C) left 3rd intercostal space D) lower left, 4th intercostal space at the sternal boarder E) left 5th intercostal space, medial to midclavicular line E) left 5th intercostal space, medial to midclavicular line correct answers Where can you heart the mitral valve? A) right 2nd intercostal space B) left 2nd intercostal space C) left 3rd intercostal space D) lower left, 4th intercostal space at the sternal boarder E) left 5th intercostal space, medial to midclavicular line A & B cold, rhinosinusitis, pharyngitis, influenza correct answers Which infections are considered upper respiratory infections? (Select all that apply.) A) cold B) pharyngitis C) RSV D) acute bronchitis C & D resp syncytial virus (RSV), acute bronchitis, TB correct answers Which infections are considered lower respiratory infections? (Select all that apply.) A) cold B) pharyngitis C) RSV D) acute bronchitis A) infant Infants gather their formation of self-concept by learning that their physical self is separate from those people and objects around them "me, not me" correct answers Forming self-concept for a/an _____________ involves learning that the physical self is different from the environment A) infant B) child C) child and/or adult D) adult B) child Children internalize others' attitudes about them, primarily from their parents and peers "Who do they say I am?" correct answers Forming self-concept for a/an ___________ involves internalizing others' attitudes about the self A) infant B) child C) child and/or adult D) adult C) child and adult Both children and adults internalize societal standards "How do I compare to others?" correct answers Forming self-concept for a/an ___________ involves internalizing standards of society A) infant B) child C) child and/or adult D) adult D) adult Adults rely on self-actualization & self-adjustment to acknowledge their self-concept "This is who I am & will continue to be" correct answers Forming self-concept for a/an ___________ involves self-actualizing and self-adjustment A) infant B) child C) child and/or adult D) adult A) inspection correct answers This examination tool is the first of four A) inspection B) palpation C) percussion D) auscultation B) palpation correct answers This examination tool is the second of four A) inspection B) palpation C) percussion D) auscultation C) percussion correct answers This examination tool is the third of four A) inspection B) palpation C) percussion D) auscultation D) auscultation correct answers This examination tool is the last of four d) malnourishment e) immobility b & c correct answers SATA: Which are extrinsic factors for developing pressure ulcers? a) immobility b) friction c) shearing d) malnourishment e) immobility stage 1 intact skin with non-blanchable redness correct answers What stage is the shown pressure injury? stage 2 characterized by partial-thickness loss correct answers What stage is the shown pressure injury? stage 3 pressure injury full-thickness tissue loss with visible fat correct answers What stage is the shown pressure injury? stage 4 pressure injury full-thickness tissue loss with exposed bone, muscle, or tendon correct answers What stage is the shown pressure injury? a) normal variant correct answers What type of lesions consist of milia, nevi, skin tags, & striae? a) normal variant b) primary c) secondary b) primary correct answers What type of lesions result from disease or local irritation? a) normal variant b) primary c) secondary d) tertiary c) secondary correct answers What type of lesions develop from a primary lesion? a) normal variant b) primary c) secondary d) teritary b) 15% correct answers Deep tissue (pressure) injuries affect what percentage of hospitalized patients? a) 10% b) 15% c) 20% d) 35% b & c hemoglobin & hematocrit correct answers SATA: What is an H&H lab? a) histamine b) hemoglobin c) hematocrit d) homocysteine a & d monosaccharides: corn syrup, honey, milk, table sugar, molasses, cane sugar, beets, fruits dietary fiber, bread, & legumes are polysaccharides correct answers SATA: Which foods are monosaccharides? a) corn syrup b) dietary fiber c) bread d) beets e) legumes b, c, e polysaccharides: dietary fiber, vegetables, bread, cereal, pasta, grains, legumes corn syrup & beets are monosaccharides correct answers SATA: Which foods are polysaccharides? a) corn syrup b) dietary fiber c) bread d) beets e) legumes a & c blood plasma & visceral tissue correct answers SATA: Where is protein located in the body? a) blood plasma b) liver c) visceral tissue d) subcutaneous tissue d) 90% correct answers What percentage of lipids (fats) are located in the subcutaneous tissue? a) 50% b) 65% c) 85% d) 90% c) 60-70% correct answers What percentage of your body weight is made of water? a) 40-50% b) 50-60% c) 60-70% d) 70-80% d) vitamin D correct answers Which vitamin is the body able to make itself? a) vitamin A b) vitamin B c) vitamin C d) vitamin D c) 3 correct answers How many stages are there in general adaptation syndrome (GAS)? a) 1 b) 2 c) 3 d) 4 A & D fat-soluble vitamins: A, D, E, & K vitamins B & C are water-soluble correct answers SATA: Which of the following vitamins are fat-soluble? a) vitamin A b) vitamin B c) vitamin C very deep pitting, indentation lasts a long time, leg is very swollen 8+ mm depth correct answers What is the level of edema shown in this photo? d) pulmonary artery *is the ONLY artery that brings deoxygenated blood to the lungs "Goes to the lungs, picks up his best friend oxygen, and brings it back to the heart." correct answers Which artery brings deoxygenated blood to the lungs? a) carotid artery b) vertebral artery c) subclavian artery d) pulmonary artery a, c, & d upper airway: nasal passages, mouth, pharynx the trachea is part of the lower airway correct answers SATA: Which of the following structures are part of the upper airway? a) nasal passages b) trachea c) mouth d) pharynx b & c lower airway: trachea, bronchi, bronchioles the nasal passages & pharynx are part of the upper airway correct answers SATA: Which of the following structures are part of the lower airway? a) nasal passages b) bronchi c) bronchioles d) pharynx a) apprehension early hypoxia: apprehension, restlessness, inability to concentrate, decreased LOC, dizziness, behavioral changes cyanosis is a symptom of late hypoxia correct answers Which of the following symptoms are part of early hypoxia? a) apprehension b) cyanosis c) bruxism d) urticaria a) women of child-bearing age you should also assess vulnerable adults (elderly, disabled, etc.) and children correct answers Who should you assess for abuse when they come in with an injury? a) women of child-bearing age b) middle-aged women c) middle-aged men d) young men c) every 4-8 hours for a stable patient vitals are taken every 15-60 mins correct answers How often should vital signs be taken on a stable patient? a) every 15-60 mins b) every 1-4 hours c) every 4-8 hours d) every 8-12 hours c) small intestine 5 organs for excretion: kidneys, liver, bowel, lungs, exocrine glands correct answers Which of these organs is NOT used for excretion? a) kidneys b) liver c) small intestine d) lungs a) true the lungs excrete anesthetic gases & alcohol correct answers Drugs can be excreted through the lungs a) true b) false c) vastus lateralis correct answers Which muscle is the preferred IM injection site for infants? a) deltoid b) ventrogluteal c) vastus lateralis d) dorsogluteal b) 20 seconds correct answers What is the required length for hand washing? a) 15 seconds b) 20 seconds c) 25 seconds d) 30 seconds d & e "you know it is quite normal to feel anger toward your husband at this time" "tell me more about how you are feeling" correct answers SATA: A nurse is consoling the partner of a client who just expired after a long battle with liver cancer. The partner is displaying grief and states, "I hate him for leaving me." Which of the following statements by the nurse successfully facilitate mourning for the grieving partner? A. "Would you like me to contact the chaplain to come speak with you?" B. "You will feel better soon. You have been expecting this for a while now." C. "Let's talk about your children and how they are going to react." D. "You know it is quite normal to feel anger toward your husband at this time." E. "Tell me more about how you are feeling." A. Plan is developed for nursing care. correct answers Once a nurse assesses a client's condition and identifies appropriate nursing diagnoses, a: A. Plan is developed for nursing care. B. Physical assessment begins C. Implementation begins. D. Review of the assessment is conducted with other team members. A. Referred pain correct answers Which term would the nurse use to document pain at one site that is perceived in other site? patient? A.Inspection B.Auscultation C.Palpation D.Percussion D. Client will take pain medication every 4 hours around the clock. correct answers The nurse writes an expected outcome statement in measurable terms. An example is: A. Client will have less pain. B. Client will be pain free. C. Client will report pain acuity less than 4 on a scale of 0-10. D. Client will take pain medication every 4 hours around the clock. d. Pneumonia correct answers Which problem would increase a patient's calorie requirements? a. Nausea b. Obesity c. Dysphagia d. Pneumonia b. Sitting correct answers Which position should a patient be in while using an incentive spirometer? a. Semi-fowlers. b. Sitting c. Side lying. d. Supine. d. Heart rate 120 bpm correct answers Which vital sign finding is abnormal? a. Pulse Ox. 95-100% b. Blood Pressure 120/80 c. Temperature 96.8-100.2 F d. Heart rate 120 bpm e. 12-20 respirations. C. Long-term goal correct answers The following statement appears on the nursing care plan for a client at risk for infection: The client will remain free from infection throughout hospitalization. This statement is an example of a (an): A. Nursing Diagnosis B. Independent Intervention C. Long-term goal D. Expected outcome d & e displaying sympathy & being insistent while collecting data correct answers SATA: Which of the communication skills of the nurse listed are non therapeutic? a. Utilizing both verbal and non verbal techniques b. Interviewing skills c. Remaining non judgmental d. Displaying sympathy. e. Being insistent while collecting data. D. Pain intensity reported as a 3 or less during hospital stay. correct answers After determining a nursing diagnosis of acute pain, the nurse develops the following appropriate client-centered goal: A. Encourage client to implement guided imagery when pain begins. B. Determine effect of pain intensity on client function. C. Administer analgesic 30 minutes before physical therapy treatment. D. Pain intensity reported as a 3 or less during hospital stay. b, c, & e diaphoresis, hypertension, tachycardia correct answers Identify the human responses that are objective. a. c/o Pain. b. Diaphoresis. c. Hypertension. d. Nausea. e. Tachycardia