Nursing Assessment: Identifying Effective Teaching and Correct Answers, Exams of Health sciences

Download Nursing Assessment: Identifying Effective Teaching and Correct Answers and more Exams Health sciences in PDF only on Docsity! NURS3260 N3260 Evolve Fundamentals Practice Exam 2 ANSWERS BEST EXAM SOLUTION SATISFACTION GUARANTEED SUCCESS,[LATEST UPDATE GRADED A+.] Evolve Practice Test – Fundamentals ANSWERS 1. The nurse is instructing a client with high cholesterol about diet and life style modification. What comment from the client indicates that the teaching has been effective? A) If I exercise at least two times weekly for one hour, I will lower my cholesterol. B) I need to avoid eating proteins, including red meat. C) I will limit my intake of beef to 4 ounces per week. D) My blood level of low density lipoproteins needs to increase. Correct answer(s): C 2.A client with acute hemorrhagic anemia is to receive four units of packed RBCs (red blood cells) as rapidly as possible. Which intervention is most important for the nurse to implement? A) Obtain the pre-transfusion hemoglobin level. B) Prime the tubing and prepare a blood pump set-up. C) Monitor vital signs q15 minutes for the first hour. D) Ensure the accuracy of the blood type match. NURS3260 N3260 Evolve Fundamentals Practice Exam 2 ANSWERS BEST EXAM SOLUTION SATISFACTION GUARANTEED SUCCESS,[LATEST UPDATE GRADED A+.] Correct answer(s): D 3.The nurse observes an unlicensed assistive personnel (UAP) taking a client's blood pressure with a cuff that is too small, but the blood pressure reading obtained is within the client's usual range. What action is most important for the nurse to implement? A) Tell the UAP to use a larger cuff at the next scheduled assessment. B) Reassess the client's blood pressure using a larger cuff. C) Have the unit educator review this procedure with the UAPs. D) Teach the UAP the correct technique for assessing blood pressure. Correct answer(s): B 4.The nurse prepares a 1,000 ml IV of 5% dextrose and water to be infused over 8 hours. The infusion set delivers 10 drops per milliliter. The nurse should regulate the IV to administer approximately how many drops per minute? A) 80 B) 8 C) 21 D) 25 Correct answer(s): C 5.A client is to receive 10 mEq of KCl diluted in 250 ml of normal saline over 4 NURS3260 N3260 Evolve Fundamentals Practice Exam 2 ANSWERS BEST EXAM SOLUTION SATISFACTION GUARANTEED SUCCESS,[LATEST UPDATE GRADED A+.] A) Apply a condom catheter. B) Apply a skin protectant. C) Encourage increased fluid intake. D) Assess for bladder distention. Correct answer(s): D 10. A young mother of three children complains of increased anxiety during her annual physical exam. What information should the nurse obtain first? A) Sexual activity patterns. B) Nutritional history. C) Leisure activities. D) Financial stressors. Correct answer(s): B 11.Examination of a client complaining of itching on his right arm reveals a rash made up of multiple flat areas of redness ranging from pinpoint to 0.5 cm in diameter. How should the nurse record this finding? A) Multiple vesicular areas surrounded by redness, ranging in size from 1 mm to 0.5 NURS3260 N3260 Evolve Fundamentals Practice Exam 2 ANSWERS BEST EXAM SOLUTION SATISFACTION GUARANTEED SUCCESS,[LATEST UPDATE GRADED A+.] cm. B) Localized red rash comprised of flat areas, pinpoint to 0.5 cm in diameter. C) Several areas of red, papular lesions from pinpoint to 0.5 cm in size. D) Localized petechial areas, ranging in size from pinpoint to 0.5 cm in diameter. Correct answer(s): B 12. At the time of the first dressing change, the client refuses to look at her mastectomy incision. The nurse tells the client that the incision is healing well, but the client refuses to talk about it. What would be an appropriate response to this client's silence? A) It is normal to feel angry and depressed, but the sooner you deal with this surgery, the better you will feel. B) Looking at your incision can be frightening, but facing this fear is a necessary part of your recovery. C) It is OK if you don't want to talk about your surgery. I will be available when you are ready. D) I will ask a woman who has had a mastectomy to come by and share her experiences with NURS3260 N3260 Evolve Fundamentals Practice Exam 2 ANSWERS BEST EXAM SOLUTION SATISFACTION GUARANTEED SUCCESS,[LATEST UPDATE GRADED A+.] you. Correct answer(s): C 13. A client is receiving a cephalosporin antibiotic IV and complains of pain and irritation at the infusion site. The nurse observes erythema, swelling, and a red streak along the vessel above the IV access site. Which action should the nurse take at this time? A) Administer the medication more rapidly using the same IV site. B) Initiate an alternate site for the IV infusion of the medication. C) Notify the healthcare provider before administering the next dose. D) Give the client a PRN dose of aspirin while the medication infuses. Correct answer(s): B 14.In developing a plan of care for a client with dementia, the nurse should remember that confusion in the elderly A) is to be expected, and progresses with age. B) often follows relocation to new surroundings. C) is a result of irreversible brain pathology. D) can be prevented with adequate sleep. NURS3260 N3260 Evolve Fundamentals Practice Exam 2 ANSWERS BEST EXAM SOLUTION SATISFACTION GUARANTEED SUCCESS,[LATEST UPDATE GRADED A+.] C) It is safe to use a walker to get out of bed, but you need assistance when walking. D) Take pain medication 30 minutes after your physical therapy sessions. Correct answer(s): B 18.A client with chronic renal failure selects a scrambled egg for his breakfast. What action should the nurse take? A) Commend the client for selecting a high biologic value protein. B) Remind the client that protein in the diet should be avoided. C) Suggest that the client also select orange juice, to promote absorption. D) Encourage the client to attend classes on dietary management of CRF. Correct answer(s): A 19.The healthcare provider prescribes morphine sulfate 4mg IM STAT. Morphine comes in 8 mg per ml. How many ml should the nurse administer? A) 0.5 ml. B) 1 ml. NURS3260 N3260 Evolve Fundamentals Practice Exam 2 ANSWERS BEST EXAM SOLUTION SATISFACTION GUARANTEED SUCCESS,[LATEST UPDATE GRADED A+.] C) 1.5 ml. D) 2 ml. Correct answer(s): A 20. The nurse assigns a UAP to obtain vital signs from a very anxious client. What instructions should the nurse give the UAP? A) Remain calm with the client and record abnormal results in the chart. B) Notify the medication nurse immediately if the pulse or blood pressure is low. C) Report the results of the vital signs to the nurse. D) Reassure the client that the vital signs are normal. Correct answer(s): C 21. An African-American grandmother tells the nurse that her 4-year-old grandson is suffering with "miseries." Based on this statement, which focused assessment should the nurse conduct? A) Inquire about the source and type of pain. B) Examine the nose for congestion and discharge. C) Take vital signs for temperature elevation. NURS3260 N3260 Evolve Fundamentals Practice Exam 2 ANSWERS BEST EXAM SOLUTION SATISFACTION GUARANTEED SUCCESS,[LATEST UPDATE GRADED A+.] D) Explore the abdominal area for distension. Correct answer(s): A 22.While instructing a male client's wife in the performance of passive range-of-motion exercises to his contracted shoulder, the nurse observes that she is holding his arm above and below the elbow. What nursing action should the nurse implement? A) Acknowledge that she is supporting the arm correctly. B) Encourage her to keep the joint covered to maintain warmth. C) Reinforce the need to grip directly under the joint for better support. D) Instruct her to grip directly over the joint for better motion. Correct answer(s): A 23. Heparin 20,000 units in 500 ml D5W at 50 ml/hour has been infusing for 5½ hours. How much heparin has the client received? A) 11,000 units. B) 13,000 units. C) 15,000 units. D) 17,000 units. NURS3260 N3260 Evolve Fundamentals Practice Exam 2 ANSWERS BEST EXAM SOLUTION SATISFACTION GUARANTEED SUCCESS,[LATEST UPDATE GRADED A+.] C) Alcohol use in any form is not allowed. D) A vegetarian diet must be followed. Correct answer(s): B 28. When assessing a client with wrist restraints, the nurse observes that the fingers on the right hand are blue. What action should the nurse implement first? A) Loosen the right wrist restraint. B) Apply a pulse oximeter to the right hand. C) Compare hand color bilaterally. D) Palpate the right radial pulse. Correct answer(s): A 29. The nurse notices that the Hispanic parents of a toddler who returns from surgery offer the child only the broth that comes on the clear liquid tray. Other liquids, including gelatin, popsicles, and juices, remain untouched. What explanation is most appropriate for this behavior? A) The belief is held that the "evil eye" enters the child if anything cold is ingested. B) After surgery the child probably has refused all foods except broth. NURS3260 N3260 Evolve Fundamentals Practice Exam 2 ANSWERS BEST EXAM SOLUTION SATISFACTION GUARANTEED SUCCESS,[LATEST UPDATE GRADED A+.] C) Eating broth strengthens the child's innate energy called "chi." D) Hot remedies restore balance after surgery, which is considered a "cold" condition. Correct answer(s): D 30. During a physical assessment, a female client begins to cry. Which action is best for the nurse to take? A) Request another nurse to complete the physical assessment. B) Ask the client to stop crying and tell the nurse what is wrong. C) Acknowledge the client's distress and tell her it is all right to cry. D) Leave the room so that the client can be alone to cry in private. Correct answer(s): C 31. The UAPs working on a chronic neuro unit ask the nurse to help them determine the safest way to transfer an elderly client with left-sided weakness from the bed to the chair. What method describes the correct transfer procedure for this client? A) Place the chair at a right angle to the bed on the client's left side before moving. B) Assist the client to a standing position, then place the right hand on the armrest. NURS3260 N3260 Evolve Fundamentals Practice Exam 2 ANSWERS BEST EXAM SOLUTION SATISFACTION GUARANTEED SUCCESS,[LATEST UPDATE GRADED A+.] C) Have the client place the left foot next to the chair and pivot to the left before sitting. D) Move the chair parallel to the right side of the bed, and stand the client on the right foot. Correct answer(s): D 32.Three days following surgery, a male client observes his colostomy for the first time. He becomes quite upset and tells the nurse that it is much bigger than he expected. What is the best response by the nurse? A) Reassure the client that he will become accustomed to the stoma appearance in time. B) Instruct the client that the stoma will become smaller when the initial swelling diminishes. C) Offer to contact a member of the local ostomy support group to help him with his concerns. D) Encourage the client to handle the stoma equipment to gain confidence with the procedure. Correct answer(s): B 33. An elderly client with a fractured left hip is on strict bedrest. Which nursing measure is essential to the client's nursing care? A) Massage any reddened areas for at least five minutes. B) Encourage active range of motion exercises on extremities. NURS3260 N3260 Evolve Fundamentals Practice Exam 2 ANSWERS BEST EXAM SOLUTION SATISFACTION GUARANTEED SUCCESS,[LATEST UPDATE GRADED A+.] section. The tubing has been changed to a 20 gtt/ml administration set. The nurse plans to set the flow rate at how many gtt/min? A) 42 gtt/min. B) 83 gtt/min. C) 125 gtt/min. D) 250 gtt/min. NURS3260 N3260 Evolve Fundamentals Practice Exam 2 ANSWERS BEST EXAM SOLUTION SATISFACTION GUARANTEED SUCCESS,[LATEST UPDATE GRADED A+.] Correct answer(s): B 38. The healthcare provider prescribes furosemide (Lasix) 15 mg IV stat. On hand is Lasix 20 mg/2 ml. How many milliliters should the nurse administer? A) 1 ml. B) 1.5 ml. C) 1.75 ml. D) 2 ml. Correct answer(s): B 39. The nurse observes that a male client has removed the covering from an ice pack applied to his knee. What action should the nurse take first? A) Observe the appearance of the skin under the ice pack. B) Instruct the client regarding the need for the covering. C) Reapply the covering after filling with fresh ice. D) Ask the client how long the ice was applied to the skin. Correct answer(s): A 40. NURS3260 N3260 Evolve Fundamentals Practice Exam 2 ANSWERS BEST EXAM SOLUTION SATISFACTION GUARANTEED SUCCESS,[LATEST UPDATE GRADED A+.] The nurse is assessing the nutritional status of several clients. Which client has the greatest nutritional need for additional intake of protein? A) A college-age track runner with a sprained ankle. B) A lactating woman nursing her 3-day-old infant. C) A school-aged child with Type 2 diabetes. D) An elderly man being treated for a peptic ulcer. Correct answer(s): B 41. The healthcare provider prescribes the diuretic metolazone (Zaroxolyn) 7.5 mg PO. Zaroxolyn is available in 5 mg tablets. How much should the nurse plan to administer? A) ½ tablet. B) 1 tablet. C) 1½ tablets. D) 2 tablets. Correct answer(s): C NURS3260 N3260 Evolve Fundamentals Practice Exam 2 ANSWERS BEST EXAM SOLUTION SATISFACTION GUARANTEED SUCCESS,[LATEST UPDATE GRADED A+.] A) Record the coughing incident. No further action is required at this time. B) Stop the feeding, explain to the family why it is being stopped, and notify the healthcare provider. C) After clearing the tube with 30 ml of air, check the pH of fluid withdrawn from the tube. D) Inject 30 ml of air into the tube while auscultating the epigastrium for gurgling. Correct answer(s): C 44. An elderly resident of a long-term care facility is no longer able to perform self-care and is becoming progressively weaker. The resident previously requested that no resuscitative efforts be performed, and the family requests hospice care. What action should the nurse implement first? A) Reaffirm the client's desire for no resuscitative efforts. B) Transfer the client to a hospice inpatient facility. C) Prepare the family for the client's impending death. D) Notify the healthcare provider of the family's request. Correct answer(s): D 45. Which nutritional assessment data should the nurse collect to best reflect total muscle mass in an adolescent? NURS3260 N3260 Evolve Fundamentals Practice Exam 2 ANSWERS BEST EXAM SOLUTION SATISFACTION GUARANTEED SUCCESS,[LATEST UPDATE GRADED A+.] A) Height in inches or centimeters. B) Weight in kilograms or pounds. C) Triceps skin fold thickness. D) Upper arm circumference. Correct answer(s): D 16. The nurse notices that the mother a 9-year-old Vietnamese child always looks at the floor when she talks to the nurse. What action should the nurse take? A) Talk directly to the child instead of the mother. B) Continue asking the mother questions about the child. NURS3260 N3260 Evolve Fundamentals Practice Exam 2 ANSWERS BEST EXAM SOLUTION SATISFACTION GUARANTEED SUCCESS,[LATEST UPDATE GRADED A+.] C) Ask another nurse to interview the mother now. D) Tell the mother politely to look at you when answering. Correct answer(s): B 47. What is the most important reason for starting intravenous infusions in the upper extremities rather than the lower extremities of adults? A) It is more difficult to find a superficial vein in the feet and ankles. B) A decreased flow rate could result in the formation of a thrombosis. C) A cannulated extremity is more difficult to move when the leg or foot is used. D) Veins are located deep in the feet and ankles, resulting in a more painful procedure. Correct answer(s): B 48. Which snack food is best for the nurse to provide a client with myasthenia gravis who is at risk for altered nutritional status? A) Chocolate pudding. NURS3260 N3260 Evolve Fundamentals Practice Exam 2 ANSWERS BEST EXAM SOLUTION SATISFACTION GUARANTEED SUCCESS,[LATEST UPDATE GRADED A+.] C) Obtain a prescription for portable oxygen while ambulating. D) Move the oximetry probe from the finger to the earlobe. Correct answer(s): A 52. A male client being discharged with a prescription for the bronchodilator theophylline tells the nurse that he understands he is to take three doses of the medication each day. Since, at the time of discharge, timed-release capsules are not available, which dosing schedule should the nurse advise the client to follow? A) 9 a.m., 1 p.m., and 5 p.m. B) 8 a.m., 4 p.m., and midnight. C) Before breakfast, before lunch and before dinner. D) With breakfast, with lunch, and with dinner. Correct answer(s): B 53. An obese male client discusses with the nurse his plans to begin a long-term weight loss NURS3260 N3260 Evolve Fundamentals Practice Exam 2 ANSWERS BEST EXAM SOLUTION SATISFACTION GUARANTEED SUCCESS,[LATEST UPDATE GRADED A+.] regimen. In addition to dietary changes, he plans to begin an intensive aerobic exercise program 3 to 4 times a week and to take stress management classes. After praising the client for his decision, which instruction is most important for the nurse to provide? NURS3260 N3260 Evolve Fundamentals Practice Exam 2 ANSWERS BEST EXAM SOLUTION SATISFACTION GUARANTEED SUCCESS,[LATEST UPDATE GRADED A+.] A) Be sure to have a complete physical examination before beginning your planned exercise program. B) Be careful that the exercise program doesn't simply add to your stress level, making you want to eat more. C) Increased exercise helps to reduce stress, so you may not need to spend money on a stress management class. D) Make sure to monitor your weight loss regularly to provide a sense of accomplishment and motivation. Correct answer(s): A 54. When assisting an 82-year-old client to ambulate, it is important for the nurse to realize that the center of gravity for an elderly person is the A) Arms. B) Upper torso. C) Head. NURS3260 N3260 Evolve Fundamentals Practice Exam 2 ANSWERS BEST EXAM SOLUTION SATISFACTION GUARANTEED SUCCESS,[LATEST UPDATE GRADED A+.] Correct answer(s): B 59. The nurse is teaching a client with numerous allergies how to avoid allergens. Which instruction should be included in this teaching plan? A) Avoid any types of sprays, powders, and perfumes. B) Wearing a mask while cleaning will not help to avoid allergens. NURS3260 N3260 Evolve Fundamentals Practice Exam 2 ANSWERS BEST EXAM SOLUTION SATISFACTION GUARANTEED SUCCESS,[LATEST UPDATE GRADED A+.] C) Purchase any type of clothing, but be sure it is washed before wearing it. D) Pollen count is related to hay fever, not to allergens. Correct answer(s): A 60. The nurse mixes 50 mg of Nipride in 250 ml of D5W and plans to administer the solution at a rate of 5 mcg/kg/min to a client weighing 182 pounds. Using a drip factor of 60 gtt/ml, how many drops per minute should the client receive? A) 31 gtt/min. B) 62 gtt/min. C) 93 gtt/min. D) 124 gtt/min. Correct answer(s): D 61. The nurse witnesses the signature of a client who has signed an informed consent. Which statement best explains this nursing responsibility? A) The client voluntarily signed the form. NURS3260 N3260 Evolve Fundamentals Practice Exam 2 ANSWERS BEST EXAM SOLUTION SATISFACTION GUARANTEED SUCCESS,[LATEST UPDATE GRADED A+.] B) The client fully understands the procedure. C) The client agrees with the procedure to be done. D) The client authorizes continued treatment. Correct answer(s): A 62. A client who is in hospice care complains of increasing amounts of pain. The healthcare provider prescribes an analgesic every four hours as needed. Which action should the nurse implement? A) Give an around-the-clock schedule for administration of analgesics. B) Administer analgesic medication as needed when the pain is severe. NURS3260 N3260 Evolve Fundamentals Practice Exam 2 ANSWERS BEST EXAM SOLUTION SATISFACTION GUARANTEED SUCCESS,[LATEST UPDATE GRADED A+.] A) Aspirating gastric contents to assure a pH value of 4 or less. B) Hearing air pass in the stomach after injecting air into the tubing. C) Examining a chest x-ray obtained after the tubing was inserted. D) Checking the remaining length of tubing to ensure that the correct length was inserted. Correct answer(s): C 67. When evaluating a client's plan of care, the nurse determines that a desired outcome was not achieved. Which action will the nurse implement first? A) Establish a new nursing diagnosis. B) Note which actions were not implemented. C) Add additional nursing orders to the plan. D) Collaborate with the healthcare provider to make changes. Correct answer(s): B 68. After completing an assessment and determining that a client has a problem, which action should the nurse perform next? A) Determine the etiology of the problem. NURS3260 N3260 Evolve Fundamentals Practice Exam 2 ANSWERS BEST EXAM SOLUTION SATISFACTION GUARANTEED SUCCESS,[LATEST UPDATE GRADED A+.] B) Prioritize nursing care interventions. C) Plan appropriate interventions. D) Collaborate with the client to set goals. Correct answer(s): A 69. The nurse is administering medications through a nasogastric tube (NGT) which is connected to suction. After ensuring correct tube placement, what action should the nurse take next? A) Clamp the tube for 20 minutes. B) Flush the tube with water. C) Administer the medications as prescribed. D) Crush the tablets and dissolve in sterile water. Correct answer(s): B NURS3260 N3260 Evolve Fundamentals Practice Exam 2 ANSWERS BEST EXAM SOLUTION SATISFACTION GUARANTEED SUCCESS,[LATEST UPDATE GRADED A+.] 70. A client who is 5' 5" tall and weighs 200 pounds is scheduled for surgery the next day. What question is most important for the nurse to include during the preoperative assessment? A) What is your daily calorie consumption? B) What vitamin and mineral supplements do you take? C) Do you feel that you are overweight? D) Will a clear liquid diet be okay after surgery? Correct answer(s): B 71. During the initial morning assessment, a male client denies dysuria but reports that his urine appears dark amber. Which intervention should the nurse implement? A) Provide additional coffee on the client's breakfast tray. B) Exchange the client's grape juice for cranberry juice. C) Bring the client additional fruit at mid-morning. D) Encourage additional oral intake of juices and water. Correct answer(s): D 72.