GN 6501: Nursing of Adults and Older Adults I Spring 2021 – Final Exam Study Guide
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GN 6501
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GN 6501
GN 6501: Nursing of Adults and Older Adults I Spring 2021 – Final Exam Study Guide As a reminder, approximately 75% of the final will cover content on exam #1, 2 and 3 Approximately 25% will be on content in new chapters 1. Review prioritization o Prioritize Hypotheses. Consider all possibilities...
GN 6501: Nursing of Adults and Older Adults I
Spring 2021 – Final Exam Study Guide
As a reminder, approximately 75% of the final will cover content on exam #1, 2 and 3
Approximately 25% will be on content in new chapters
1. Review prioritization
o Prioritize Hypotheses. Consider all possibilities and determine their urgency and risk for the patient. What will happen?
Which possible outcomes present the greatest concern?
o Patient and staff safety is the major priority for professional nurses
o Prioritize patients by ABCs --> 1) airway, 2) breathing, 3) circulation. Prioritization begins with determining
immediate threats to life as part of the initial assessment and is based on the ABC pneumonic focusing on the airway as
priority, moving to breathing, and circulation.
A client is scheduled to have a tracheostomy placed in an hour. What action by the nurse is the
priority?
a. Administer prescribed anxiolytic medication.
b. Ensure informed consent is on the chart.
c. Reinforce any teaching done previously.
d. Start the preoperative antibiotic infusion.
ANS: B
Since this is an operative procedure, the client must sign an informed consent, which must be on
the chart. Giving anxiolytics and antibiotics and reinforcing teaching may also be required but do
not take priority.
A nurse assesses a clients respiratory status. Which information is of highest priority for the
nurse to obtain?
a. Average daily fluid intake
b. Neck circumference
c. Height and weight
d. Occupation and hobbies
ANS: D
Many respiratory problems occur as a result of chronic exposure to inhalation irritants used in a
clients occupation and hobbies. Although it will be important for the nurse to assess the clients
fluid intake, height, and weight, these will not be as important as determining his occupation and
hobbies. Determining the clients neck circumference will not be an important part of a
respiratory assessment.
A client is admitted with a suspected cervical spinal cord injury. What is the nurse’s priority action for this client?
A. Assess cardiac sounds.
B. Manage the client’s airway.
C. Check oxygen saturation level.
D. Perform a neurologic assessment.
Answer: B
Which precaution is a priority for the nurse to teach a client prescribed the gene therapy combination of ivacaftor/tezacaftor
in order to prevent harm from this therapy?
A. Examine your skin and the whites of your eyes daily for a yellow appearance.
B. Apply ice to the injection site for 30 minutes after each dose to keep bleeding to a minimum
C. Wait at least 15 minutes after using other inhaled drugs before inhaling this drug combination .
D. Go to your primary health care provider immediately if you develop a fever or other signs of infection.
Answer: A
A postoperative client has just been admitted to the postanesthesia care unit (PACU). What assessment by the PACU nurse
takes priority?
a. Airway
,Which precaution is a priority for the nurse to teach a client prescribed the gene therapy combination of ivacaftor/tezacaftor
in order to prevent harm from this therapy?
A. Examine your skin and the whites of your eyes daily for a yellow appearance.
B. Apply ice to the injection site for 30 minutes after each dose to keep bleeding to a minimum
C. Wait at least 15 minutes after using other inhaled drugs before inhaling this drug combination .
D. Go to your primary health care provider immediately if you develop a fever or other signs of infection.
Answer: A
A postoperative client has just been admitted to the postanesthesia care unit (PACU). What assessment by the PACU nurse
takes priority?
a. Airway
b. Bleeding
c. Breathing
d. Cardiac rhythm
ANS: A
Assessing the airway always takes priority, followed by breathing and circulation. Bleeding is part of the
circulation assessment, as is cardiac rhythm.
2. Review what you can delegate to others and what a RN must do
o only delegate something that is within that person’s scope of practice
o you must supervise the person and make sure the task is carried out
o initial assessment and vitals must be carried out by bedside nurse
o example of delegation tasks – ADLs ambulate, turning and positioning, vitals on a stable pt, I&O
measurements, feeding a stable patient
o UAP/CNAs cannot assess patients, give meds, assist w/ feeding on a pt with special diet rules/issues such as
dysphagia, cannot educate
o Nurses cannot delegate TAPE
§ Teaching
§ Assessment
§ Planning
§ Evaluation
5. A nurse and unlicensed assistive personnel (UAP) are helping a client during a hysterosalpingogram. Which
action by the nurse is best delegated to the UAP?
a. Witnessing of the consent form
b. Assisting the client into a lithotomy position
c. Asking about allergies to iodine or shellfish
d. Assessing for pelvic or shoulder pain after the study
ANS: B
The UAP would be able to position the client for the procedure. Only the nurse has the
3. A client is diagnosed with a fibrocystic breast condition while in the hospital and is experiencing breast
discomfort. What comfort measure would the nurse delegate to the unlicensed assistive personnel (UAP)?
a. Aid in the draining of the cysts by needle aspiration.
b. Teach the client to wear a supportive bra to bed.
c. Administer diuretics to decrease breast swelling.
d. Obtain a cold pack to temporarily relieve the pain.
ANS: D
All of the options would be comfort measures for a client with a fibrocystic breast condition. The UAP can
obtain the cold or heat therapy. Only the nurse should aid the health care provider with a needle aspiration,
teach, and administer medications.
5. The nurse is caring for a postoperative client following an anterior colporrhaphy. What action can be
delegated to the unlicensed assistive personnel (UAP)?
a. Reviewing the hematocrit and hemoglobin results
b. Teaching the client to avoid lifting her 4-year-old grandson
c. Assessing the level of pain and any drainage
d. Drawing a shallow hot bath for comfort measures
ANS D
,3. A client is diagnosed with a fibrocystic breast condition while in the hospital and is experiencing breast
discomfort. What comfort measure would the nurse delegate to the unlicensed assistive personnel (UAP)?
a. Aid in the draining of the cysts by needle aspiration.
b. Teach the client to wear a supportive bra to bed.
c. Administer diuretics to decrease breast swelling.
d. Obtain a cold pack to temporarily relieve the pain.
ANS: D
All of the options would be comfort measures for a client with a fibrocystic breast condition. The UAP can
obtain the cold or heat therapy. Only the nurse should aid the health care provider with a needle aspiration,
teach, and administer medications.
5. The nurse is caring for a postoperative client following an anterior colporrhaphy. What action can be
delegated to the unlicensed assistive personnel (UAP)?
a. Reviewing the hematocrit and hemoglobin results
b. Teaching the client to avoid lifting her 4-year-old grandson
c. Assessing the level of pain and any drainage
d. Drawing a shallow hot bath for comfort measures
ANS: D
13. A client has just returned from a total abdominal hysterectomy and needs postoperative nursing care. What
action can the nurse delegate to the unlicensed assistive personnel (UAP)?
a. Assess heart, lung, and bowel sounds.
b. Check the hemoglobin and hematocrit levels.
c. Evaluate the dressing for drainage.
d. Empty the urine from the urinary catheter bag.
ANS: D
6. A nurse and an unlicensed assistive personnel (UAP) are caring for a client with an open radical
prostatectomy. Which comfort measure could the nurse delegate to the UAP?
a. Administering an antispasmodic for bladder spasms
b. Managing pain through patient-controlled analgesia
c. Applying ice to a swollen scrotum and penis
d. Helping the client transfer from the bed to the chair
ANS: D
3. A postoperative client has an epidural infusion of morphine and bupivacaine (Marcaine). What actions does
the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.)
a. Ask the client to point out any areas of numbness or tingling.
b. Determine how many people are needed to ambulate the client.
c. Perform a bladder scan if the client is unable to void after 4 hours.
d. Remind the client to use the incentive spirometer every hour.
e. Take and record the clients vital signs per agency protocol.
ANS: C, D, E
The UAP can assess and record vital signs, perform a bladder scan and report the results to the nurse, and
remind the client to use the spirometer. The nurse is legally responsible for assessments and should ask the
client about areas of numbness or tingling, and assess if the client is able to bear weight and walk.
3. Remember safety always!
· Safety: ability to keep the patient and staff free from harm and minimize errors in care
· Patient harm and medical errors generally occur as a result of:
§ Lack of clear or adequate communication among patient, family, and the interprofessional health care team
§ Lack of attentiveness and patient monitoring
§ Lack of clinical judgement
§ Inadequate measures to prevent health complications
§ Errors in medication administration
§ Errors in interpreting authorized provider prescriptions
§ Lack of professional accountability and patient advocacy
§ Inability to carry out interventions in an appropriate and timely manner
§ Lack of mandatory reporting
· Best safety practices reduce error/harm through established protocols, memory checklists, and systems
such as bar-code medication administration. Working around these systems (often called work-arounds) is not
acceptable and can increase risk of errors
, 4. Review therapeutic communication
a. What is the purpose of therapeutic communication?
i. Allows client to
1. identify and explore problems in relating to others
2. discover healthy ways of meeting emotional needs
3. experience a satisfying interpersonal relationship
b. How is therapeutic communication delivered? How is it used? When it is used?
i. SOLER
1. Sit squarely facing client
2. Open posture
3. Lean forward towards client
4. Establish eye contact
5. Relax
ii. Used during motivational interviewing to promote behavioral change and guide patients to
explore their own motivation for cange and the advantages/disadvantages of their decisions
c. What type of statements would a nurse make that support therapeutic communication?
i. Facilitation, silence, reflection, empathy, clarification, confrontation, interpretation,
explanation, summary
5. Review priorities in patient care, which patient do you see first? Issues with what body system(s) must be
addressed first?
6. For a patient who is in the death and dying stage of life, what is assessed to determine how close a patient is
to passing?
- As death nears, patients often have signs and symptoms of decline in physical function, manifesting
as weakness; increased sleep; anorexia; and changes in cardiovascular function, breathing patterns,
and genitourinary function.
- Loss of consciousness often declines to lethargy, unresponsiveness, or coma.
- Cardiovascular dysfunction leads to decreases in peripheral circulation and poor tissue perfusion
manifesting as cold, mottled, and cyanotic extremities.
- Blood pressure decreases and often is only palpable.
- Heart rate may increase, become irregular, and gradually decrease before stopping.
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