NUR 601 questions and 100% correct answers with rationale, Exams of Nursing

Download NUR 601 questions and 100% correct answers with rationale and more Exams Nursing in PDF only on Docsity! NUR 601 questions and 100% correct answers with rationale A client is being discharged home after a routine hip replacement surgery. The nurse is instructing the client on how to prevent postoperative complications. What statements by the client would indicate the need for further teaching? Select all that apply. “I should continue with my physical therapy and walking.” “Avoiding pain medication will prevent constipation.” “I should empty my bladder when I feel the urge.” “I should drink plenty of liquids like iced tea or coffee.” “Limiting fiber is necessary to avoid diarrhea.” Rationale: Constipation is common after surgery due to pain medication, decreased movement, and anesthesia. Fiber intake should be encouraged as it promotes the prevention of stool retention. Although pain medication can cause constipation, it should not be avoided in the post-operative period. Drinking plenty of fluids is encouraged for both bowel and bladder maintenance, but the client should choose non-caffeinated options. Physical therapy, walking, and exercise will help prevent constipation. Emptying the bladder when the urge is present can help prevent urinary tract infections. Test taking strategy: Note the strategic words need for further teaching. These words indicate a negative event query and the need to select the incorrect client statements. Think about the measures needed for bowel and bladder control to answer correctly. Review: bowel and bladder maintenance. Level of Cognitive Ability: Evaluating Client Need: Physiological Integrity Integrated Process: Teaching and Learning Content Area: Fundamentals of Care: Perioperative Care Test Yourself Quiz Question 1 1 / 1 pts NUR 601 questions and 100% correct answers with rationale Question 2 1 / 1 pts Giddens Concepts: Client Education, Health Promotion HESI Concepts: Health Promotion, Teaching and Learning/Patient Education References: Giddens, J. (2013). Concepts for nursing practice. (p. 143). St. Louis, MO: Mosby. Lewis, S., Dirksen, S., Heitkemper, M., & Bucher, L. (2014). Medical-surgical nursing: Assessment and management of clinical problems (9th ed., pp. 969, 1089-1090). St. Louis: Mosby. The nurse is caring for a Vietnamese client diagnosed with tuberculosis. The client speaks limited English. What should the nurse do to ensure the client and family receives the most accurate information? Select all that apply. Encourage family members to obtain a tuberculosis skin test. Provide culturally sensitive education. Provide written instructions in English for the client to reference. Urge all family and close contact community members to seek and complete treatment to enhance compliance. Encourage the client and family to wash all dishes by hand to prevent the spread of infection. Rationale: As always, the nurse must provide culturally sensitive education. Because tuberculosis is highly contagious, all family members and close community members should have a tuberculosis skin test, seek treatment, and remain compliant. A full course of 6-9 months of treatment is needed to prevent re-infection. Instructions written in English are not helpful for the client with limited English skills. Washing dishes by hand is not the best way to prevent infection; rather a dishwasher should be used if available. NUR 601 questions and 100% correct answers with rationale Question 5 1 / 1 pts Race The nurse in a pediatric unit is planning the staff assignments for children with developmental delays. When planning the assignment, the nurse decides to assign those children who have social or emotional delays amongst different nurses. Which children should be assigned to different nurses? Select all that apply. An infant with fetal alcohol syndrome A child with autism A child with generalized anxiety disorder A child with expressive language disorder A child with attention deficit disorder Rationale: A developmental delay is defined as not meeting the expected developmental level. Social and emotional developmental delays include those affecting personality, emotion, or behaviors. Two examples are autism, and generalized anxiety disorder. Attention deficit disorder and fetal alcohol syndrome are classified as cognitive developmental delays, and expressive language disorder is a communication developmental delay. Test Taking Strategy: Focus on the subject, planning assignments and children with social and emotional developmental delays. Use knowledge of the different types of developmental delays to eliminate those options. Review: developmental delays Level of Cognitive Ability: Creating Client Need: Safe and Effective Care Environment Integrated Process: Nursing Process/Planning Content Area: Developmental Stages: Infancy to Adolescence NUR 601 questions and 100% correct answers with rationale Question 6 1 / 1 pts Priority Concepts: Care Coordination, Development HESI Concepts: Care Coordination, Development References: Giddens, J. (2013). Concepts for nursing practice. (p. 4, 8-9). St. Louis, MO: Mosby. Hockenberry, M, & Wilson, D. (2015). Wong’s nursing care of infants and children (10th ed. pp. 147-148). St Louis: Mosby. McKinney, E., James, S., Murray, S., Nelson, K. & Ashwill, J. (2013). Maternal-child nursing (4th ed., pp. 1492-1493). St. Louis: Elsevier. The nurse is caring for a client admitted to the hospital for shortness of breath and edema in both lower extremities. The client is prescribed furosemide 40mg by the intravenous route once daily. What information in the chart would warrant the nurse to verify continuing the prescription with the health care provider (HCP)? Refer to chart. History and Physical Laboratory Findings Medications Expiratory rales on auscultation Blood pressure 145/94 mmHg Lisinopril 20mg orally daily Peripheral Vascular Disease (PVD) Serum Potassium 3.5 mEq/L (3.5 mmol/L) Atorvastatin 10mg orally at bedtime Expiratory rales Atorvastatin prescription Peripheral vascular disease Potassium level of 3.5 mEq/L (3.5 mmol/L) Rationale: Furosemide is a potassium-losing diuretic. The serum potassium level of 3.5mEq/L (3.5 mmol/L) is on the lower limit of normal, and the nurse should anticipate that the potassium level would drop with the administration of furosemide. Therefore, the nurse should verify continuing the prescription if this potassium level was noted. Expiratory rales are an expected finding with fluid overload and furosemide would be an appropriate treatment. Atorvastatin and peripheral vascular disease are not impacted by NUR 601 questions and 100% correct answers with rationale Question 7 1 / 1 pts the administration of furosemide. Test-Taking Strategy: Focus on the subject, the need to verify continuing the prescription. Note the data in the question and that the client is receiving furosemide. Recall that furosemide is a potassium-losing diuretic. Think about the side and adverse effects of this medication to answer correctly. Review: furosemide Level of Cognitive Ability: Synthesizing Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process: Analysis Content Area: Fundamentals of Care: Fluids & Electrolytes Priority Concepts: Collaboration, Safety HESI Concepts: Collaboration/Managing Care, Safety Reference: Rosenjack Burchum, Rosenthal (2016), pp. 456-457. A nurse employed at a nursing home is caring for a client who has recently been transferred from the hospital to the nursing home. The client is confused and is acting out. The nurse suspects the client is suffering from relocation stress. The nurse should include which helpful actions in the plan of care? Select all that apply. Ensure the client is an active part of decision making regarding their care. Establish a trusting relationship with the client as soon as possible. Encourage friends and family to visit frequently. Allow the client to move around the halls as desired to decrease the confusion and acting-out. Change rooms frequently to prevent the client from becoming bored. NUR 601 questions and 100% correct answers with rationale Question 10 1 / 1 pts “Neglect is parental failure to meet a child’s basic needs.” “A sign of neglect are bruises on the child’s body.” “Neglect occurs when a parent does not seek medical attention for a sick child.” Rationale: Neglect has serious consequences for children. Basically, there are 5 types of child neglect: physical neglect; psychological or emotional neglect; medical neglect; mental health neglect; and educational neglect. One sign of physical neglect is bruising on the child’s body. Neglect is the parental failure to meet a child’s basic needs such as: food, shelter, comfort, love, and medical attention. Consequences of neglect include: learning problems, low self-esteem, developmental delays, passivity and juvenile delinquency. Children who are neglected often show signs of aggression before the age of 2. Test-Taking Strategy: Focus on the strategic word “effective”. Determine which statements indicate that the teaching has been effective, by determining which statements are true. Note the age of the child in option 2. This will assist in eliminating this option. Review: Signs of child abuse. Level of Cognitive Ability: Evaluating Client Needs: Psychosocial Integrity Integrated Process: Teaching and Learning Content Area: Leadership/Management Giddens Concepts: Health Care Law, Interpersonal Violence HESI Concepts: Health Policy/Systems – Health Care Law, Violence References: Giddens, J. (2013). Concepts for nursing practice. (1st ed., p. 353). St. Louis: Mosby. Hockenberry, M, & Wilson, D. (2015). Wong’s nursing care of infants and children (10th ed. p. 562). St Louis: Mosby. The nurse is obtaining the medical history from an older client with a black eye and bruising to the head. The nurse suspects that the client has been abused, and that there may be a history of abuse. Which statement by the client indicates the need for further questioning by a social worker? Select all that apply. “I got into a car accident yesterday and the airbag deployed.” NUR 601 questions and 100% correct answers with rationale “Sometimes my grandson becomes angry with me when I can’t give him money.” “Well, I don’t remember anything that would have caused the injuries.” “I tripped over a rug and now I have a black eye.” “Perhaps I somehow did this to myself.” Rationale: There are certain elements in the medical history that raise concern for physical abuse. Perpetrators may provide a history of events that are incomplete or inconsistent with injuries seen. Many individuals who experience interpersonal violence are unable or afraid to provide an accurate account of events. Often individuals will provide a history of trauma that is inconsistent with the physical examination. It is unlikely that these injuries were self-inflicted or the result of tripping over a rug. Having no recollection of how an injury occurred should be an alert to the nurse, as well as statements that another person caused the injury. The nurse should immediately report this to a health care provider and the social worker so that proper intervention and follow-up can be arranged. A car accident with air bag deployment could reasonably cause the injuries to the client. The nurse should continue on with assessment, treatment and arrange follow-up care for the client. Test-Taking Strategy: Focus on the subject, “abuse to an older client”. Determine which statements made by the client would indicate that abuse may be occurring. Abuse individuals often make statements that do not correlate with injuries. Eliminate option 3, because air bag deployment could have caused the client’s injuries. Review: Signs of abuse in the older client. Level of Cognitive Ability: Analyzing Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Assessment Content Area: Leadership/Management Giddens Concepts: Clinical Judgment, Interpersonal Violence HESI Concepts: Health Policy/Systems – Health Care Law, Violence References: Giddens, J. (2013). Concepts for nursing practice. (1st ed., p. 354.). St. Louis: Mosby. NUR 601 questions and 100% correct answers with rationale Question 11 1 / 1 pts Hockenberry, M, & Wilson, D. (2015). Wong’s nursing care of infants and children (10th ed. pp. 565-566). St Louis: Mosby. The nurse is meeting with an older client who was brought into the health care facility for evaluation. According to the family member, the client has lost a large amount of weight recently and does not eat much. Which actions would be the most important for the nurse to take? Select all that apply. Assess the client's eyesight. Assess the client for mental status changes. Determine the fit of the client's dentures. Obtain a list of the client's medications. Question the client about urinary habits. Rationale: Older adults in the community or in any health care setting are most at risk for poor nutrition. The nurse should review the medical history to determine the possibility of increased metabolic needs or nutritional losses, chronic disease, trauma, recent surgery of the gastrointestinal tract, drug and alcohol abuse, and recent significant weight loss. Each of these conditions can contribute to malnutrition. As part of a thorough assessment, the nurse should assess the client's eyesight. Clients with poor vision are often not able to drive to obtain groceries or cook for themselves. The nurse should also obtain a list of the client's medications, both prescription and over- the-counter. Certain medications can alter the taste perception and decrease the desire to eat. It is also important for the nurse to determine the fit of the client's dentures. Poor fitting dentures can lead to painful sores, which lead to a decrease in food intake. The nurse should also include an assessment of the client's mental status, observing for behavoir that may be abnormal for the client. Utilizing the family member's knowledge of the client's typical behavior will be important in the treatment of this client. While the client's urinary status is important to assess, it is not the most important action for the NUR 601 questions and 100% correct answers with rationale Question 14 1 / 1 pts "My heart and lungs are mildly affected by obesity". "Physical inactivity is one of the causes of obesity". Rationale: Obesity refers to an excess amount of body fat when compared with lean body mass. After receiving education from the nurse, the client should be able to state that complications and risks of obesity such as type II diabetes and peripheral artery disease and other cardiovascular and respiratory system complications such as obstructive sleep apnea. It is also important that the nurse discuss the causes of obesity, which include physical inactivity. Encouraging the client to exercise 20 minutes per day can decrease the risk of obesity and life threatening illnesses. Test-Taking Strategy: Focus on the strategic words, “need for further teaching.” Think about the physiological effects of obesity to assist in answering correctly. Eliminate statements that show that the teaching has been effective, such as options 1, 2, and 3. These options demonstrate that the client has an adequate understanding of the consequences of obesity. Options 4 and 5 are incorrect, showing the client would benefit from further education from the nurse. Review: Obesity. Level of Cognitive Ability: Evaluating Client Needs: Physiological Integrity Integrated Process: Nursing Process/Evaluation Content Area: Nutrition Giddens Concepts: Client Education, Nutrition, HESI Concepts: Health, Wellness, and Illness: Nutrition/ Teaching and Learning:Patient Education Reference: Ignatavicius, D & Workman, M. (2013). Medical-surgical nursing: Patient- centered collaborative care. (7th ed., p. 1350). Philadelphia: Saunders. The nurse is attending a teaching sessionatt on communicating with the ill child. Which statement by the nurse indicates that the teaching has been effective? Select all that apply. "Children are often reluctant to ask questions, when they fear the answers". "I will strive to maintain honesty and trust with each child". "Providing as much information as possible will help ease the child's fears". NUR 601 questions and 100% correct answers with rationale Question 15 1 / 1 pts "To prevent misunderstandings, I should ask the child to explain what is known". "Complete honesty may cause problems for some family and staff members". Rationale: Communication is the most important factor in establishing a good relationship with the child and family. The nurse caring for the ill child should strive to make the child feel comfortable, as well as decrease any fears that the child may have. After listening to the lecture on communication with the ill child, the nurse should understand the need to strive to maintain honesty and trust with each child. Lack of honesty and trust can hinder care and leave the child feeling frightened. The nurse should also understand that children often are reluctant to ask questions when they fear the answers. The nurse should keep the child informed, while clarifying any questions the child has. Clarifying questions can help the nurse avoid providing more information than the child wants or can handle emotionally. Providing too much information may be overwhelming and frightening to the child. It may also inhibit future questions and interaction with the nurse. It is important for the nurse to consider that not everyone agrees with complete honesty; at times, parents may directly ask the nurse to withhold information from the child. It is important that the nurse maintain honesty, using terms that the parents agree upon. One of the most important aspects of communicating with a child is to have the child explain what is already known to them about their illness. The nurse can then answer questions accordingly without overwhelming the child with information. Test-Taking Strategy: Focus on the strategic word, “effective.” Think about the developmental process and the effects illness can cause Determine which statements show that the nurse has an understanding of the topic, communication with the ill child. Eliminate option 3, because this statement indicates that more education is needed. Review: Communication techniques. Level of Cognitive Ability: Evaluating Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Evaluation Content Area: Child Health Giddens Concepts: Caregiving, Communication.. HESI Concepts: Communication, Developmental Reference: Hockenberry, M, & Wilson, D. (2015). Wong’s nursing care of infants and children (10th ed. pp. 92-94). St Louis: Mosby. A client is being assessed for post-partum depression. Which actions by the client would indicate a need for follow-up by the nurse? Select all that apply. NUR 601 questions and 100% correct answers with rationale Stating that that the infant latched on properly during a feeding. Not responding to the infant’s cries. Crying after talking with spouse on the phone. Making statements about being fat and unattractive now. Stating that family was not supportive of the pregnancy. Rationale: The weeks following the birth are a time of vulnerability to psychiatric disorders, such as depression for many women, causing significant distress for the mother, disrupting family life, and, if prolonged, negatively affecting the child's emotional and social development. Mood and anxiety disorders are particularly likely to recur or worsen during these weeks. Such conditions can interfere with attachment to the newborn and family integration, and some may threaten the safety and well-being of the mother, the newborn, and other children. It is important that the nurse frequently assess the client for post-partum depression. Ignoring the infant’s cries should alert the nurse that further assessment is needed. Crying after talking with a spouse of the phone could indicate a problem at home. Statements of non-supportive family members need to be addressed by the nurse, for the safety and well-being of the client and infant. The nurse should also address the client’s statements about body image, educating the client about what is normal and what is not normal in the post-partum period. Stating that the infant latched on during a feeding is a positive action and would not indicate the need for further assessment. Test-Taking Strategy: Focus on the strategic words, “need for follow-up.” Determine which actions by the client indicate that the client could be experiencing post-partum depression. Eliminate option 5, because this statement is positive and does not indicate that the client is experiencing post-partum depression. Review: Post-partum depression. Level of Cognitive Ability: Analyzing Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Assessment Content Area: Maternity Giddens Concepts: Clinical Judgment, Mood and Affect NUR 601 questions and 100% correct answers with rationale Question 18 1 / 1 pts option 5 because it isolates the client from others and could lead to post-partum depression. Review: Prevention of post-partum depression. Level of Cognitive Ability: Applying Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Implementation Content Area: Maternity. Giddens Concepts: Client Education, Health Promotion HESI Concepts: Health, Wellness, and Illness – Health Promotion, Teaching and Learning/Patient Education Reference: Lowdermilk, D., Perry, S., Cashion, K., & Alden, K. (2016). Maternity & Women’s Health Care (11th ed., p. 748). St. Louis: Elsevier. The nurse is preparing to discharge a child who was treated in the emergency department. Which should the nurse consider when planning medication discharge instructions for the client's parents? Select all that apply. Assist the child’s parents in obtaining the medication at an affordable cost. Ensure that the child's family is able to read the written discharge instructions. Provide the child's parents with a simple dosing schedule. Create a medication schedule that fits the parent’s lifestyle. Refer the family to the pharmacist with questions about medication side effects. Rationale: Medicating infants and children is an important nursing responsibility. The nurse plays a key role in administering medications, supporting the child and family during the experience, and teaching the child and parents about pharmacologic aspects of the child's care. The nurse should not only coordinate the child's care, but also the discharge process. It is important that the nurse create a medication schedule that fits the family’s lifestyle and provide the family with a simple dosing chart. This helps to NUR 601 questions and 100% correct answers with rationale Question 19 1 / 1 pts ensure that the childreceives proper medication dosing and prevents medication errors. The nurse should consider cost of prescribed medications and providing the family with resources as needed. During the discharge process, the nurse should verify that the family can read the written discharge instructions and answer any questions about the prescribed medications, including side effects. Test-Taking Strategy: Focus on the subject, “discharge planning“ and “medication instructions.” The discharge process is often complex, the nurse should take actions to simplify this as much as possible. Eliminate options 5, because the nurse should review medications and side effects with the family during the discharge. Although the pharmacist is an excellent resource, it is the nurse’s responsibility to teach about the medication. Review: Discharge teaching. Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Child Health Giddens Concepts: Care Coordination, Client Education HESI Concepts: Collaboration/Managing Care – Care Coordination, Teaching and Learning/Patient Education Reference: Hockenberry, M, & Wilson, D. (2015). Wong’s nursing care of infants and children (10th ed. pp. 932-933). St Louis: Mosby. The nurse is preparing to administer blood to a client. Which actions by the nurse are the most appropriate before administration of the blood? Select all that apply. Obtain and assess vital signs. Check the health care provider’s prescriptions with another nurse. Assess laboratory values. Evaluate the client’s venous access. NUR 601 questions and 100% correct answers with rationale Question 20 1 / 1 pts Identify the client by room number and bed. Rationale: Preparation of the client for transfusion therapy is critical, and institutional blood product administration procedures must be carefully followed. Before administering any blood product, review the agency's policies and procedures. The nurse should take care to ensure that the client is adequately prepared to receive the blood. This is accomplished by assessing the client’s laboratory values, in order to determine the client’s need for intervention. The nurse should be aware of the health care facilities policies and procedures regarding blood administration. The nurse should also obtain and assess the client’s vital signs, prior to blood administration. This is completed so that the nurse can detect any change from the client’s baseline during the administration. The client’s venous access should be assessed prior to the blood administration, ensuring that at least a 20 gauge IV is in place and patent. Checking the health care provider’s prescription with another nurse is a crucial step that must be completed. The nurse should not simply identify the client by room number and bed. The nurse must follow the policies and procedures set by the health care facility for safe blood administration. Test-Taking Strategy: Focus on the strategic words, “most appropriate.” Determine which actions should be completed by the nurse prior to blood administration. Eliminate option 4, because this step is unsafe and could lead to client harm. The nurse should identify the client using appropriate and safe identifier guidelines. The nurse should take steps to provide for client safety during blood administration. Review: Blood Administration. Level of Cognitive Ability: Analyzing Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Analysis Content Area: Blood Administration Giddens Concepts: Clinical Judgment, Safety HESI Concepts: Clinical Decision-Making/Clinical Judgment, Safety Reference: Ignatavicius, D., & Workman, M. (2016). Medical-surgical nursing: Patient- centered collaborative care. (8th ed., p. 822). St. Louis: Saunders. The nurse is evaluating a medication prescription written by the health care provider. Which pieces of information should the nurse verify has been included in the prescription? Select all that apply. The generic medication name NUR 601 questions and 100% correct answers with rationale The nurse is providing discharge instructions to a client with rheumatoid arthritis who is taking leflunomide. Which instructions should the nurse give to the client? Select all that apply. “It is ok to drink alcohol.” “It has been shown that leflunomide can cause birth defects.” “Leflunomide is a potent medication that is generally tolerated.” “You may lose your hair.” “Diarrhea is a common side effect.” Rationale: Medication therapy and nonpharmacologic interventions are used to manage systemic inflammation and joint pain. The expected outcome is that the disease goes into remission and its progression slows. When creating and providing discharge instructions, it is important that the nurse include accurate information. The nurse should educate that the client that hair loss and diarrhea are possible. Women of child-bearing age should remain strict with birth control, as the medication can cause birth defects. The client should be educated that while leflunomide is a potent medication, it is generally well tolerated. Test-Taking Strategy: Focus on the subject, “discharge instructions for the client receiving leflunomide.” Use general medication guidelines to assist in answering correctly. Remember alcohol should not be consumed if the client is taking medications. Review: Discharge instructions for leflunomide. Level of Cognitive Ability: Creating Client Needs: Physiological Integrity Integrated Process: Teaching and Learning Content Area: Pharmacology Giddens Concepts: Client Education, Safety HESI Concepts: Teaching and Learning/Patient Education, Safety NUR 601 questions and 100% correct answers with rationale Question 23 1 / 1 pts Reference: Ignatavicius, D., & Workman, M. (2016). Medical-surgical nursing: Patient- centered collaborative care. (8th ed., pp. 308, 310). St. Louis: Saunders. The nurse is caring for a client who has been admitted to the intensive care unit with acute pulmonary edema. After assessing the client, the nurse administers furosemide as prescribed. Which actions by the nurse are the most important after administering the medication? Select all that apply. Document the client’s meal intake Measure urine output Assess the client for pitting edema Obtain and monitor vital signs Assess lung sounds Rationale: The client with pulmonary edema usually needs aggressive treatment and continuous cardiac monitoring. The nurse should be prepared to assess the client and manage the pulmonary edema efficiently. The most important interventions for the nurse to take after administration of the medication include: assessing the client lung sounds and vital signs and measuring the urine output. These interventions will assist in evaluating client status and response to treatment and alert the nurse to any deterioration in the client’s health. Documenting the client’s meal intake and assessing for pedal edema are not the most important actions to take after administering the medication. Test-Taking Strategy: Focus on the strategic words, “most important.” Recall that furosemide is a diuretic and think about its expected effects in the treatment of pulmonary edema. Review: furosemide and pulmonary edema Level of Cognitive Ability: Synthesizing NUR 601 questions and 100% correct answers with rationale Question 24 0.67 / 1 pts Question 25 1 / 1 pts Client Needs: Physiological Integrity. Integrated Process: Nursing Process/Implementation Content Area: Pharmacology Giddens Concepts: Gas Exchange, Perfusion HESI Concepts: Oxygenation/Gas Exchange, Perfusion Reference: Ignatavicius, D., & Workman, M. (2016). Medical-surgical nursing: Patient- centered collaborative care. (8th ed., pp. 689, 715). St. Louis: Saunders. The nurse preceptor is orienting a new nurse on an acute medical-surgical unit and educating the nurse on peripherally inserted central catheters (PICCs). Which statement by the new nurse indicates an understanding of a PICC? Select all that apply. “PICCs are the most appropriate for client’s who require short-term antibiotics.” “PICCs with a lumen size of 14 Fr or larger can be used for blood sampling.” “PICCs can accommodate infusions of all types of therapy.” “The tip of the PICC line sits in the superior vena cava.” “Insertion of the PICC line occurs in the operating room.” The nurse is assigned to care for a client who needs an intravenous (IV) catheter inserted and will receive an IV infusion of a vesicant medication. When creating a plan of care for the client, which interventions should the nurse include in the plan? Select all that apply. NUR 601 questions and 100% correct answers with rationale Question 27 1 / 1 pts Giddens Concepts: Clinical Judgment, Safety HESI Concepts: Clinical Decision-Making/Clinical Judgment, Safety Reference: Lilley, L., Rainforth Collins, S., Harrington, S., & Snyder J. (2014). Pharmacology and the nursing process (7th ed., pp. 487-488). St. Louis: Mosby. The nurse is caring for a client with a latex allergy. Upon entering the client’s room, the nurse should plan to take which action as the priority? Perform a physical assessment Ask if the client needs pain medication Remove the banana from the client’s breakfast tray Perform a skin assessment Rationale: A sensitivity or allergy to certain substances alerts the nurse to other possible cross allergies. The nurse should be aware of this and prevent allergic reactions whenever possible. The nurse should know that the client with an allergy to latex, may also be allergic to bananas. The priority action that the nurse should plan to take when entering the client’s room, is to remove the banana from the client’s breakfast tray. The other actions can be completed once the risk of allergic reaction has been removed. Test-Taking Strategy: Focus on the strategic word, “first” and focus on the data in the question, that the client has a latex allergy. It is necessary to know cross-sensitivities to answer correctly. Eliminate options 1, 2, and 3, because these actions can safely wait until the banana has been removed from the client’s breakfast tray. Also note that options 1 and 2 are comparable or alike and can be eliminated. Review: latex allergy Level of Cognitive Ability: Synthesizing Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Leadership/Management: Prioritizing Giddens Concepts: Clinical Judgment, Safety HESI Concepts: Clinical Decision-Making/Clinical Judgment, Safety NUR 601 questions and 100% correct answers with rationale Question 28 1 / 1 pts Reference: Ignatavicius, D., & Workman, M. (2016). Medical-surgical nursing: Patient- centered collaborative care. (8th ed., pp. 402-403). St. Louis: Saunders. The nurse has been assigned to care for an older client with a hip fracture who had surgical repair. After receiving report, the nurse learns that the health care provider has prescribed meperidine for pain management. Which action should the nurse take first? Verify the dosage of meperidine Clarify the medication prescription with the health care provider. Assess the client’s pain score before administration. Prepare the medication Rationale: After fracture treatment, the client often has pain for a prolonged time during the healing process. The health care provider commonly prescribes opioid and non- opioid analgesics, anti-inflammatory drugs, and muscle relaxants. The nurse should immediately recognize that meperidine is contraindicated for the older client because it has toxic metabolites that can cause seizures and other complications. The first step the nurse should take is to clarify the prescription with the health care provider. The other steps should not be done. Test-Taking Strategy: Focus on the strategic word, “first” and focus on the data in the question and that the client is an older client. Determine which step the nurse should take first when receiving the medication order. Eliminate options, 1, 2, and 3, because this medication should not be given to an older client. Review: contraindications for meperidine Level of Cognitive Ability: Synthesizing Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Leadership/Management: Prioritizing Giddens Concepts: Clinical Judgment, Safety HESI Concepts: Clinical Decision-Making/Clinical Judgment, Safety Reference: Ignatavicius, D., & Workman, M. (2016). Medical-surgical nursing: Patient- centered collaborative care. (8th ed., p. 42). St. Louis: Saunders. NUR 601 questions and 100% correct answers with rationale The nurse is caring for a client recovering from an abdominal aortic aneurysm (AAA) endovascular stent graft. What priority actions should the nurse include in the plan of care? Select all that apply. Administer analgesics as needed Monitor urinary output Assess for pedal pulses Encourage use of an abdominal pillow when coughing or deep breathing Keep the head of the bed elevated to at least 60 degrees Rationale: A priority nursing action after an AAA repair with a graft is to ensure patency of the graft. In order to do this, the nurse would monitor vital signs, pedal pulses, urinary output, and extremity color at least hourly. Pain medication is administered as needed and as prescribed and administered regularly for better pain management. The head of the bed is maintained at 45 degrees or less to prevent flexion of the graft. The client should be instructed to use an abdominal pillow when coughing or deep breathing to prevent incision splitting. Test-Taking Strategy: Focus on the strategic word ‘priority’ to select correct options to be included in the care plan. Focus on the data in the question and the surgical procedure. Not that the client had a graft stent and think about the impact of vascular patency to answer correctly. Review: care following an Abdominal Aortic Aneurysm with graft Level of Cognitive Ability: Creating Client Needs: Physiological Integrity Integrated Process: Nursing Process: Planning Content Area: Adult Health: Cardiovascular Question 29 1 / 1 pts NUR 601 questions and 100% correct answers with rationale Question 32 1 / 1 pts Content Area: Fundamentals of Care: Cultural Awareness Giddens Concepts: Caregiving, Culture HESI Concepts: Caregiving, Cultural/Spiritual Reference: Giger, J. (2013). Transcultural nursing: Assessment & interventions (6th ed., p. 317). St Louis: Mosby. The nurse is caring for a client in the emergency department who is being treated for major burns and smoke exposure. What information in the medical chart would warrant the nurse to call the Rapid Response Team immediately? Refer to chart. Medical History Assessment Findings Laboratory Values Asthma Hoarse voice Sodium 131 mEq/L (131 mmol/L) Diabetes mellitus Blood pressure 98/62 mmHg Blood glucose 68 mg/dL (3.7 mmol/L) Blood glucose of 68 mg/dL (3.7 mmol/L) Blood pressure of 98/62 mmHg Hoarse voice Asthma Rationale: Clients with major burns are at risk for respiratory compromise. A hoarse voice is an impending sign that the client may soon lose his airway due to obstruction or swelling. This would indicate the need to immediately activate the rapid response team as intubation is required. A history of asthma may impact respiratory status, however, the presence of asthma alone does not warrant a call to the rapid response team. The client’s blood glucose reading is low, and should be treated, however, this can be done by the RN assigned to the client and does not warrant a rapid response team. Hypovolemia is associated with burns and would explain the low blood pressure reading. Test-Taking Strategy: Note the strategic word ‘immediately’. Use the ABC – airway, breathing, and circulation to assess airway first. In this case, a hoarse voice would NUR 601 questions and 100% correct answers with rationale Question 33 1 / 1 pts indicate a problem with the airway. Review: Burn care Level of Cognitive Ability: Synthesizing Client Needs: Physiological Integrity Integrated Process: Nursing Process: Analyzing Content Area: Critical Care: Emergency Situations/Management Giddens Concepts: Clinical Judgment, HESI Concepts: Clinical Decision-Making/Clinical Judgment, Tissue Integrity Reference: Ignatavicius, D., & Workman, M. (2013). Medical-surgical nursing: Patient- centered collaborative care. (7th ed., p. 522). St. Louis: Saunders. The nurse is caring for a client with joint pain and is educating the client on pharmacological management of pain with acetaminophen. What statements made by the client would indicate a need for further teaching? Select all that apply. “I should report any skin itching or yellowing of the skin to my healthcare provider.” “I should avoid eating grapefruit while taking this medication.” “This medication is safe to take with my warfarin.” “To prevent a stomach ache, I should take this medication with food.” “I should not take this medication more often than 3 times per day.” Rationale: Acetaminophen works by blocking pain receptors. Grapefruit does not impact the ability of this medication and can be taken together. Dosing can occur every 4 to 6 hours as long as a daily maximum of 4000 mg is not exceeded. Gastrointestinal side effects are not common with this medication, and therefore, can be taken on an empty stomach. Acetaminophen does not inhibit platelet aggregation and can safely be taken with blood thinners. Side effects such as liver toxicity, which include skin itching or yellowing of the skin should be reported immediately to the healthcare provider. NUR 601 questions and 100% correct answers with rationale Question 34 1 / 1 pts Test-Taking Strategy: Focus on the strategic words “need for further teaching.” These words indicate a negative event query and the need to select the incorrect client statements. Focus on the medication name and think about its properties to assist in answering. Review: Pain management and acetaminophen Level of Cognitive Ability: Evaluating Client Needs: Physiological Integrity Integrated Process: Teaching and Learning Content Area: Fundamental of Care: Pain Giddens Concepts: Client Education, Pain HESI Concepts: Pain, Teaching and Learning/Patient Education Reference: Ignatavicius, D., & Workman, M. (2013). Medical-surgical nursing: Patient- centered collaborative care. (7th ed., p. 51). St. Louis: Saunders. Rosenjack Burchum, Rosenthal (2016) p. 868. The nurse is providing discharge education to a client that was admitted for treatment with Addison’s crisis and is reviewing the medication hydrocortisone. What statements made by the client would indicate teaching was effective. Select all that apply. “If I notice any swelling or fluid retention, I should notify my healthcare provider.” “Weight gain is common and I should expect it.” “ I should take this medication twice a day.” “If I forget a dose, I should take two pills the next time.” “I may notice my cheeks become fat and rounded but this is okay.” Rationale: Hydrocortisone is used in the treatment of Addison’s disease. Adverse effects such as weight gain, moon face, and fluid retention are not expected and may NUR 601 questions and 100% correct answers with rationale A client is being treated on the medical surgical unit for a deep vein thrombosis (DVT). The client will be discharged home on oral anticoagulants. What information in the client’s medical record would warrant the need for teaching? Refer to chart. History and Physical Laboratory Findings Medications Iron-deficient anemia Sodium 142 mEq/L (142 mmol/L) Lisinopril 10 mg orally daily 10 pack year history of smoking Positive D-Dimer Vitamin D 400 IU daily Vitamin D 400 IU daily Sodium result 10 pack year history of smoking D-Dimer result Rationale: A deep vein thrombosis (DVT) is the most common type of venous thromboembolism (VTE). DVTs occur most often in the legs, but can also occur in the upper arms. Smoking increases the risk of DVT formation, and clients should educated on the importance of quitting. The sodium result is within normal limits. The positive d- dimer result is expected, as it is a marker for DVT’s. Vitamin D supplementation does not impact DVTs or anticoagulation therapy. Test Taking Strategy: Focus on the subject, deep vein thrombosis and anti-coagulation therapy. Note the strategic words “need for teaching.” Think about the pathophysiology associated with DVT and the risk factors. Recall the implications of a DVT and treatment considerations to correctly answer this question. Review: Deep Vein Thrombosis Level of Cognitive Ability: Analyzing Client Needs: Health Promotion and Maintenance Integrated Process: Teaching and Learning Content Area: Adult Health: Cardiovascular Giddens Concepts: Clinical Judgment, Perfusion HESI Concepts: Clinical Decision-Making/Clinical Judgment, Perfusion Reference: Lewis, S., Dirksen, S., Heitkemper, M., & Bucher, L. (2014). Medical- Question 36 1 / 1 pts NUR 601 questions and 100% correct answers with rationale Question 37 1 / 1 pts surgical nursing: Assessment and management of clinical problems (9th ed., p. 848). St. Louis: Mosby. The nurse is caring for an older client who is being treated for malnutrition. Which actions by the nurse would be the most appropriate when providing for this client’s care and comfort? Select all that apply. Educate the client on how to choose healthy foods. Evaluate the fit of the client’s dentures. Ask if the client lives alone. Recommend that the client choose over-the-counter medications for ailments. Determine if the client qualifies for any food services. Rationale: The minimum nutritional requirements of the human body remain consistent from youth through old age, with a few exceptions. Older adults need an increased dietary intake of calcium, vitamin D, vitamin C, and vitamin A because aging changes disrupt the ability to store, use, and absorb these substances. A sedentary lifestyle and reduced metabolic rate require a reduction in total caloric intake to maintain an ideal body weight. Malnutrition or nutrition-related problems can occur in older adults when these needs are not met. When caring for the malnourished client, the nurse should evaluate the client’s living situation. Older clients, who live alone, are more likely to become malnourished. The nurse should also evaluate the fit and comfort of dentures. The client is less likely to eat if dentures are poor fitting. It should not be assumed that the client understand what foods are considered healthy and which are not. The nurse should be prepared to determine the client’s level of knowledge and educate as necessary. Food services, such as meals on wheels, provide food to the older client NUR 601 questions and 100% correct answers with rationale Question 38 1 / 1 pts who may not be able to obtain food on their own. The nurse should assess the client to determine if this assistance would be an option. Over-the-counter medications can cause changes in taste, placing the client at a greater risk for a decreased appetite. The client should speak with the health-care provider before beginning any over-the-counter medication. Test-Taking Strategy: Focus on the strategic words, “most appropriate.” Note the subject, the actions by the nurse that would assist in providing for the client’s care and comfort. Eliminate option 5, because this action could potentially place the client at a greater risk for malnutrition. Review: Malnutrition in the older client. Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Fundamentals of Care: Nutrition Giddens Concepts: Health Promotion, Nutrition HESI Concepts: Health, Wellness, and Illness, Nutrition Reference: Ignatavicius, D & Workman, M. (2013). Medical-surgical nursing: Patient- centered collaborative care. (7th ed., p. 17). Philadelphia: Saunders. The nurse is planning care for a client who is confused. The nurse should include which actions in the client’s care plan? Select all that apply. Apply restraints as needed if the client becomes agitated Play soft, calming music Toilet the client every 2 to 3 hours Evaluate the client for signs of pain Allow a pet visit NUR 601 questions and 100% correct answers with rationale Question 41 0.75 / 1 pts Cleanse the area with a topical antiseptic. Apply a non-sterile dressing to the site. Contact a surgeon immediately. Rationale: Brown recluse spider venom causes cell damage. The bite may be described as painless or stinging to sharp and painful. Some victims are unaware that they were bitten until intense local aching and pruritus develop over minutes to hours. The central bite site may appear as a bleb or vesicle surrounded by edema and erythema, which may expand over the course of hours as the toxin spreads to surrounding tissues. The nurse should take immediate action to prevent further damage to the bitten area. Applying ice to the site helps decrease the enzyme activity of the venom and assists in decreasing swelling of the tissue. Cleansing the area with a topical antiseptic and applying a sterile dressing can help decrease the risk of infection, and prevent a current infection from worsening. The nurse should also assess the date of the client’s last tetanus shot, and prepare to administer the vaccine if necessary. It is not necessary to contact a surgeon immediately. If necrosis is present then a surgeon may be needed for debridement. Test-Taking Strategy: Focus on the subject, care to a client who is a victim of a bite from a brown recluse spider. Focusing in the data in the question will assist in eliminating option 2 because there is no indication that a surgeon is needed. Eliminate option 3, because a non- sterile dressing could lead to infection or worsen infection. Review: Brown recluse spider bites Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Adult Health: Integumentary Giddens Concepts: Clinical Judgment, Tissue Integrity HESI Concepts: Clinical Decision-Making/Clinical Judgment, Tissue Integrity Reference: Ignatavicius, D & Workman, M. (2013). Medical-surgical nursing: Patient- centered collaborative care. (7th ed., p. 144). Philadelphia: Saunders. The nurse is educating a client on how to prevent altitude sickness. Which statements indicate that the teaching has been effective? Select all that apply. NUR 601 questions and 100% correct answers with rationale Question 42 1 / 1 pts “I will refrain from consuming alcohol when I am at a high altitude.” “I will plan a quick ascent when changing to a higher altitude.” Correct Answer “I will drink plenty of water.” “I will wear sunscreen and high quality goggles.” “I will pay attention to the manifestations of altitude-related illnesses.” The nurse is educating a child’s parents on using the behavior modification technique of discipline. Which statement should the nurse make to the parents? “Corporal punishment should not be used to encourage good behaviors.” “All behaviors should be acknowledged.” “Negative behaviors are recorded where the child can see them.” “Rewards are given at the end of the training period only.” NUR 601 questions and 100% correct answers with rationale Question 43 1 / 1 pts Rationale: The behavior modification technique of discipline rewards positive behavior and ignores negative behavior. This technique requires parents to choose selected behaviors, preferably only one at a time, that they desire to stop. They choose others that they want to encourage. The basic technique is useful for any age from toddlerhood through adolescence. Corporal punishment can lead to child abuse if the disciplinarian loses control. It can also lead to false accusation of child abuse by either the child or other adults. Because of the high cost and low benefit of this form of punishment, parents should avoid its use. When educating the paents, the nurse should provide accurate information such as: ignoring negative behaviors, giving rewards throughout and at the end of the training period and recording negative behaviors out of the client’s view. Test-Taking Strategy: Focus on the subject, statement the nurse should make about behavior modification. Think about the components of behavior modification technique and read each option carefully to assist in answering correctly. Also note the closed-ended words “all” in option 1 and “only” in option 2. Review: Behavior modification Level of Cognitive Ability: Applying Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Implementation Content Area: Pediatrics Giddens Concepts: Client Education, Communication HESI Concepts: Communication, Teaching and Learning/Patient Education Reference: Hockenberry, M, & Wilson, D. (2015). Wong’s nursing care of infants and children (10th ed. pp. 24-26). St Louis: Mosby. The nurse is caring for a client who has been diagnosed with bladder cancer. Which action should the nurse take as a priority when planning psychosocial care for this client? Question the client about insurance coverage Ask the client if there is a history of cancer in the family Assess the client’s ability to cope with the diagnosis NUR 601 questions and 100% correct answers with rationale Question 46 1 / 1 pts “Relocating to a nursing home causes stress.” “A history of anxiety can be a source of stress in the older person.” The nurse is caring for a client with bipolar disorder. When creating a care plan for this individual, which should the nurse include? Select all that apply. The client will state the importance of taking medications as prescribed. The client will ask the nurse to refill the prescriptions each month. The client will understand what bipolar disorder is. The client will perform activities of daily living (ADLs) independently. The client will be able to manage the symptoms of bipolar disorder. Rationale: Mood and affect is a psychosocial concept that underlies all other concepts in the significant impact it has on health outcomes. While caring for the bipolar client, it is important that the nurse create a plan of care, in order for the client to have the best outcome. The nurse should ensure that the client understands important concepts such as: what bipolar disorder is, how to manage the symptoms and the importance of taking medications as they are prescribed. The nurse should also assess the client’s ability to realistically solve problems of daily living, such as obtaining more medications. The NUR 601 questions and 100% correct answers with rationale Question 47 0.5 / 1 pts client should be able to call the pharmacy to refill medications, instead of relying on the nurse. Test-Taking Strategy: Focus on the subject, “a plan of care for a client with bipolar disorder.” Think about the psychopathology of bipolar disorder and what needs the client may have. Eliminate option 2, because this would encourage the client to rely on the nurse instead of being independent. Review: Bipolar disorder. Level of Cognitive Ability: Creating Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Planning Content Area: Mental Health Giddens Concepts: Care Coordination, Client Education. HESI Concepts: Care Coordination, Teaching and Learning/Patient Education References: Giddens, J. (2013). Concepts for Nursing Practice. (1st ed., p. 299). St. Louis: Mosby. Varcarolis, E. (2013). Essentials of Psychiatric Mental Health Nursing: A communication approach to evidence-based care. (revised reprint)) (2nd ed. pp. 289-230). St. Louis: Saunders. The nurse is creating a plan of care for a client that will undergo a total joint replacement. What should the nurse include in the client’s plan of care? Select all that apply. Correct Answer Include the client’s family in discussions about the surgery Complete a physical assessment before the surgery Allow time for the surgeon to address questions after the surgery Teach interventions to reduce client anxiety NUR 601 questions and 100% correct answers with rationale Question 48 1 / 1 pts Educate the client on what to expect after surgery The nurse is caring for a client with a blood pressure of 80/54 mmHg. Which actions should the nurse take because of the risk of hypovolemic shock? Select all that apply. Anticipate administering blood products Anticipate administering Ringer’s lactate solution Insert a large-bore intravenous (IV) line Perform assessments and monitor the client closely Keep intravenous fluids to be administered cold Rationale: Hypovolemic shock occurs when there is a decrease in the circulating blood volume in the body. When treating a client in hypovolemic shock, the nurse should insert a large-bore IV line, administer Ringer’s lactate or 0.9 % normal saline solutions, perform assessments and monitor the client closely, and anticipate administering blood products. These treatments will restore circulating blood volume to the client. Intravenous fluids should be warmed prior to administration to the client. Test-Taking Strategy: Focus on the subject, “treating hypovolemic shock.” Recall the pathophysiology associated with hypovolemic shock to assist in answering correctly. Eliminate option 3, because intravenous fluids should be warmed prior to administration. Review: Hypovolemic shock. Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Critical Care: Emergency Situations/Management NUR 601 questions and 100% correct answers with rationale The nurse is caring for a client with cancer who has a sealed implant of a radioactive source. Which actions should the nurse take to promote safety for staff and visitors? Select all that apply. Limit each visitor to 1 hour per day Keep the client’s door closed Wear a lead apron while providing care Assign the client to a semi-private room Remove dressings and linens from the room as they are soiled Rationale: Solid or sealed radiation sources are implanted within or near the tumor. These sources can be temporary or permanent. Most implants emit continuous, low- energy radiation to tumor tissues. Safety for staff and visitors should be a priority for the nurse and are focused on preventing exposure to the radiation. Therefore, ways to promote safety include wearing a lead apron while providing care. The nurse should always keep the lead facing the client, never turning away from the client. The door to the client’s room should be kept closed. Visitors should be limited to one-half hour a day, and should remain 6 feet (1.8 meters) from the source of radiation. The client should be assigned to a private room with a private bathroom, and not in a semi-private room. All dressings and linens should be kept in the room until the source of radiation has been removed. Test-Taking Strategy: Focus on the subject, “promoting safety for staff and visitors from a client with a sealed implant of a radioactive source.” Recall that implants emit continuous, low-energy radiation to tumor tissues and that exposure to others is a concern. Then read each option and determine if the action will protect staff and visitors. Review: Radioactive implants. Level of Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Fundamentals of Care: Safety Giddens Concepts: Caregiving, Safety NUR 601 questions and 100% correct answers with rationale Question 52 0.5 / 1 pts Question 53 1 / 1 pts HESI Concepts: Caregiving, Safety Reference: Ignatavicius, D & Workman, M. (2013). Medical-surgical nursing: Patient- centered collaborative care. (7th ed., p. 413). Philadelphia: Saunders. The nurse provides information to a unlicensed assistive personnel (UAP) about caring for a client with neutropenia. Which statements by the UAP indicate that teaching has been effective? Select all that apply. “Any sores or skin irritations should be reported right away.” “The client needs mouth care at least every 12 hours.” Correct Answer “The client may not have a high fever if infection occurs.” “I should practice good hand washing.” “I need to take precautions to protect myself from the client’s illness.” The nurse is caring for a client who expresses an interest in alternative therapies to reduce the risk of illness and disease. What noninvasive activities should the nurse recommend to the client? Select all that apply. Yoga NUR 601 questions and 100% correct answers with rationale Question 54 1 / 1 pts Meditation Acupuncture Biofeedback Herbal therapy Rationale: Integrative health care encompasses complementary and alternative therapies in combination with conventional Western modalities of treatment. Many popular alternative healing modalities offer human-centered care based on philosophies that recognize the value of the client’s input and honor the individual’s cultural beliefs, values, and desires. When caring for this client, the nurse should recommend noninvasive activities such as yoga, meditation, and the use of biofeedback. Acupuncture and herbal therapies are invasive modalities. Test-Taking Strategy: Focus on the subject, “noninvasive activities.” This will direct you to the correct options. Review: invasive and noninvasive alternative therapies Level of Cognitive Ability: Applying Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Implementation Content Area: Fundamentals of Care: Culture Giddens Concepts: Client Education, Health Promotion HESI Concepts: Health Promotion, Teaching and Learning/Patient Education Reference: Lewis, S., Dirksen, S., Heitkemper, M., & Bucher, L. (2014). Medical- surgical nursing: Assessment and management of clinical problems (9th ed., p. 86). St. Louis: Mosby. The nurse is educating a new registered nurse (RN) about the Healthy People 2020 goals. Which statements by the RN indicate that teaching has been effective? Select all that apply. NUR 601 questions and 100% correct answers with rationale Question 56 1 / 1 pts Reference: Lowdermilk, D., Perry, S., Cashion, K., & Alden, K. (2016). Maternity & Women’s Health Care (11th ed., pp. 310-311, 330). St. Louis: Elsevier. When conducting the preoperative interview with the client, the client reports an allergy to shellfish. Which agent is most likely to cause an allergic reaction in this client? Medical tape Intravenous (IV) fluids Providone-Iodine Latex Rationale: The client's readiness for surgery is critical to the outcome. Preoperative care focuses on preparing the client for the surgery and client safety. Preoperative interviews are conducted in order to gather client information before the surgery. This allows time for interventions and special considerations to be made. The nurse should anticipate this client to have an allergic reaction to providone-iodine, also known as betadine. It is important that the nurse report the allergy to shellfish to the surgeon right away so that another method of skin cleansing can be chosen. Latex, IV fluids, and medical-tape are not considered cross allergens for shellfish. Test-Taking Strategy: Note the strategic words, most likely. Focus on the subject, “a client with a shellfish allergy.” Determine what could cause an allergic reaction in the client. Eliminate options 1, 2, and 4 because these options are not shown to cause reactions in a client with a shellfish allergy. Also think about the association between shellfish and iodine. Review: Allergy to shellfish Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process/Assessment Content Area: Fundamentals of Care: Safety Giddens Concepts: Clinical Judgment, Safety HESI Concepts: Clinical Decision-Making/Clinical Judgment, Safety Reference: Ignatavicius, D & Workman, M. (2013). Medical-surgical nursing: Patient- centered collaborative care. (7th ed., pp. 241, 245). Philadelphia: Saunders. NUR 601 questions and 100% correct answers with rationale Which actions should the nurse take to adequately prepare a client for a thoracentesis? Select all that apply. Inform the client that it is common to feel pressure from the needle insertion Tell the client to expect a stinging sensation from the anesthetic Teach the client to take slow, deep breaths during the procedure Explain the procedure to the client Instruct the client not to move during the procedure Rationale: Thoracentesis is the aspiration of pleural fluid or air from the pleural space. It can be used for diagnosis or treatment. In preparing the client for a thoracentesis, the nurse should thoroughly explain the procedure to the client, allowing time for the client to ask questions. The nurse should also instruct the client not to move during the procedure, and therefore the client should not cough or take deep breaths, in order to avoid puncture of the lungs or pleura. The client should be informed to expect a stinging sensation and pressure as the needle is inserted. Test-Taking Strategy: Focus on the subject, “preparing a client for a thoracentesis.” Think about the purpose of the procedure and how it is done by the health care provider. Eliminate option 3, because the client should be instructed not to move during the procedure and therefore needs to avoid taking deep breaths during the thoracentesis. Review: thoracentesis. Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Fundamentals of care: Diagnostic tests Giddens Concepts: Care Coordination, Safety Question 57 1 / 1 pts NUR 601 questions and 100% correct answers with rationale Question 58 1 / 1 pts HESI Concepts: Collaboration/Managing Care, Safety Reference: Ignatavicius, D., & Workman, M. (2013). Medical-surgical nursing: Patient- centered collaborative care. (7th ed., pp. 559-560). Philadelphia: Saunders. The nurse is providing discharge teaching to the client who had a thoracentesis about the manifestations of a pneumothorax. Which statements should the nurse make to the client to help the client recognize signs/symptoms of a pneumothorax? Select all that apply. “Presents of a slanted trachea in the neck region need to be reported.” “Discomfort on the unaffected side should be evaluated immediately.” “Frequent coughing should be reported.” “Be sure and report any bluish color to the skin.” “A pneumothorax can cause a feeling of air hunger.” Rationale: The client, who is being discharged following a thoracentesis needs to be instructed about the manifestations of complication including a pneumothorax. Signs and symptoms of a pneumothorax include: cyanosis, often noticed around the lips; pain on the affected side, frequent coughing, a feeling of air hunger, and a slanted trachea. Clients with these signs and symptoms will need to be evaluated right away. Discomfort on the unaffected side is not associated with a thoracentesis or pneumothorax. Test-Taking Strategy: Focus on the subject, signs/symptoms of a pneumothorax. Read each option carefully. Eliminate option 4 because of the words “unaffected side” and reported immediately.” Review: signs/symptoms of a pneumothorax Level of Cognitive Ability: Analyzing NUR 601 questions and 100% correct answers with rationale Question 61 1 / 1 pts Rationale: Victims of heat stroke have a profoundly elevated body temperature (above 104 °F [40°C]) and need to be treated immediately with cooling measures to rapidly lower the body temperature. The nurse would monitor the temperature continuously using a rectal thermometer or other acceptable temperature measuring method. An intravenous line is inserted to administer fluids such as 5% dextrose in the event of hypoglycemia that can occur as a complication. The nurse should not administer antipyretics. Antipyretics can interrupt the change in the hypothalamic set point and are not expected to work on a healthy hypothalamus that has been overloaded, as in the case of heatstroke. In addition, they can be harmful in some situations. Test-Taking Strategy: Focus on the subject, “treating a client with heat stroke.” It is necessary to understand the pathophysiology associated with heat stroke to answer correctly. Remember that antipyretics are not a part of the treatment plan for a client with heat stroke. Review: management of heat stroke Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Critical care: Emergency situations/management Giddens Concepts: Care Collaboration, Thermoregulation HESI Concepts: Collaboration/Managing Care, Thermoregulation Reference: Ignatavicius, D., & Workman, M. (2013). Medical-surgical nursing: Patient- centered collaborative care. (7th ed., pp. 138-139). Philadelphia: Saunders. Which interventions should be included in the care of a client with a chest tube? Select all that apply. Keep the drainage system lower than the level of the client’s chest. Assess the water seal chamber for a continuous, strong bubbling. Change the chest tube each shift. Assess the insertion site for signs of infection. NUR 601 questions and 100% correct answers with rationale Question 62 1 / 1 pts Alert the health care provider (HCP) if drainage in the tube stops in the first 24 hours. Rationale: Caring for a client with a chest tube involves an adequate understanding of chest tubes and interventions needed to ensure sterility and patency. The chest tube site should be assessed for signs of infection and the drainage system should always be kept below the level of the client’s chest to ensure adequate drainage. If drainage stops in the first 24 hours, the HCP should be notified immediately because there could be a blockage in the tube. The chest tube is not changed each shift and the system needs to remain closed and patent. A continuous strong bubbling in the water seal chamber indicates an air leak, requiring further investigation. Test-Taking Strategy: Focus on the subject, chest tube care. Think about the physiological functioning of a chest tube and the purpose of a chest tube to assist in answering correctly. Review: Chest tube care. Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Adult Health: Respiratory Giddens Concepts: Gas Exchange, Safety HESI Concepts: Oxygenation/ Gas Exchange, Safety Reference: Ignatavicius, D., & Workman, M. (2013). Medical-surgical nursing: Patient- centered collaborative care. (7th ed., p. 637). Philadelphia: Saunders. The nurse is providing care to a client with chronic peripheral arterial disease (PAD). Which assessments findings should alert the nurse to the onset of an acute arterial occlusion? Select all that apply. Bounding pulse in the affected extremity below the level of the occlusion Complaints of sudden and severe pain in the affected extremity Client complaints of problems moving the affected extremity NUR 601 questions and 100% correct answers with rationale Question 63 1 / 1 pts Cyanosis of the skin in the affected extremity Skin temperature cool to touch in the affected extremity Rationale: Although chronic peripheral arterial disease (PAD) progresses slowly, the onset of acute arterial occlusions may be sudden and dramatic. Acute arterial occlusion is serious and occurs when blood flow in a leg artery stops suddenly. If blood flow to the toe, foot, or leg is completely blocked, the tissue begins to die and can lead to gangrene. Intervention is needed immediately to restore blood flow. Manifestations of acute arterial occlusion are due to a lack of blood flow and include cyanosis, cool skin temperature, severe pain, problems moving the affected extremity, and a lack of a pulse. There would be no pulse as a result of the occlusion and blocked artery. Test-Taking Strategy: Focus on the subject, “assessment findings of an acute arterial occlusion.” Think about what an acute arterial occlusion is. Noting the word “occlusion” will assist in eliminating option 5 because no pulse would be present. Review: chronic peripheral arterial disease and acute arterial occlusion Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process/Assessment Content Area: Critical care: emergency situations and management Giddens Concepts: Clinical Judgment, Perfusion HESI Concepts: Clinical Decision-Making/Clinical Judgment, Perfusion Reference: Ignatavicius, D., & Workman, M. (2013). Medical-surgical nursing: Patient- centered collaborative care. (7th ed., p. 792). Philadelphia: Saunders. Which manifestations are specifically noted in a client with right-sided heart failure.? Select all that apply. Dependent edema Neck vein distention NUR 601 questions and 100% correct answers with rationale Question 66 1 / 1 pts “I will report new signs and symptoms to my home care nurse when she visits.” “I have my medications and dosages written down for easy review and administration.” “I will wear my oxygen at night as prescribed.” “I will weight myself daily.” Rationale: Health teaching is essential for promoting self-management. Many clients with heart failure are readmitted to hospitals because they do not maintain their prescribed treatment plan, including lifestyle changes. The client should state the importance of daily weights to monitor for increases indicating fluid retention, wearing oxygen at night to prevent hypoxia, keeping follow-up appointments for monitoring status, and having medications and dosages written down and available for review and administration. The client should not wait for the home care nurse to report new signs and symptoms, but should report them immediately to the HCP in charge of care. Waiting could lead to worsening heart failure and complications such as pulmonary edema. Test-Taking Strategy: Note the strategic word, effective. Focus on the subject, heart failure and client self management at home. Think about the pathophysiology associated with heart failure and the complications that can occur to select the correct options. Eliminate option 4 because waiting to report new signs and symptoms could result in worsening heart failure. Review: Heart failure. Level of Cognitive Ability: Evaluating Client Needs: Physiological Integrity Integrated Process: Teaching and Learning Content Area: Adult Health: Cardiovascular Giddens Concepts: Client Education, Infection HESI Concepts: Infection, Teaching and Learning/Patient Education Reference: Ignatavicius, D., & Workman, M. (2013). Medical-surgical nursing: Patient- centered collaborative care. (7th ed., p. 757). Philadelphia: Saunders. NUR 601 questions and 100% correct answers with rationale The client has been diagnosed with valvular disease. Which interventions should the nurse be prepared to discuss with the client? Select all that apply. Monitoring for an irregular heart rhythm Surgical management Placing limits on physical activity Medication management Required dietary changes Rationale: Management of valvular heart disease depends on which valve is affected and the degree of valve impairment. When caring for a client with valvular disease the nurse should be prepared to discuss interventions. These include surgical and medication management, as well as placing limits on physical activity. Monitoring for an irregular heart rhythm is also a common intervention for clients with valvular disease. Required dietary changes is not specific to valvular heart disease although diet changes would be necessary for other cardiac disorders such as coronary artery disease. Test-Taking Strategy: Focus on the subject, interventions for valvular disease. Think about the pathophysiology associated with valvular disease. Eliminate option 2, because of the word “required” and because diet does not typically have an effect on valvular disease. Review: Valvular disease. Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity. Integrated Process: Teaching and Learning Content Area: Adult Health: Cardiovascular Giddens Concepts: Client Education, Infection HESI Concepts: Infection, Teaching and Learning/Patient Education Reference: Ignatavicius, D., & Workman, M. (2013). Medical-surgical nursing: Patient- centered collaborative care. (7th ed., p. 761). Philadelphia: Saunders. NUR 601 questions and 100% correct answers with rationale Previous Next Submission Details: Quiz Score: 63.33 out of 66