NU211 FUNDAMENTALS FINAL EXAM (updated) QUESTIONS AND ANSWERS GURANTEED A+
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Course
NU211
Institution
NU211
NU211 FUNDAMENTALS FINAL EXAM 2022-
2023(updated) QUESTIONS AND ANSWERS
GURANTEED A+
The nurse is assigned to care for a client who reports nausea, vomiting, and diarrhea.
The client's vital signs are as follows: T 100.6°F, AP 100, RR 20, BP 92/69, O2
saturation 98%. Which nursing actions r...
NU211 FUNDAMENTALS FINAL EXAM 2022 -
2023 (updated ) QUESTIONS AND ANSWERS GURANTEED A+ The nurse is assigned to care for a client who reports nausea, vomiting, and diarrhea. The client's vital signs are as follows: T 100.6°F, AP 100, RR 20, BP 92/69, O2 saturation 98%. Which nursing actions represent the nurse using critical -thinking skills to separate important from unimportant data? Select all that apply A. The nurse asks what the client has eaten in the past 24 hours. B. The nurse administers an antiemetic to the client. C. The nurse asks the client how long the symptoms have been present . D. The nurse assesses the skin turgor of the client. E. The nurse asks the client if he or she is employed. - ANSWER - A,C,D Option 1: When the nurse asks what the client has eaten in the past 24 hours, he or she is determining if food consumption could be the cause of the clinical manifestations. Option 2: Administering an antiemetic is a nursing intervention to alleviate clinical manifestations. However, it does not help the nurse identify important data. Option 3: The nurse asks the client how long the symptoms have been present to obtain relevant information about the manifestations. Option 4: The nurse notices the client is febrile; has had nausea, vomiting, and diarrhea; and has an elevated apical pulse and decreased blood pressure. These are signs o f dehydration. Assessing the skin turgor would indicate if the client is dehydrated, which is an urgent status the nurse can promptly treat. Option 5: Asking a client about employment status would not obtain relevant data to determine the client's health s tatus. This is low -priority demographic information that can be obtained later A nurse has multiple clients assigned at the beginning of a shift on the surgical unit. Which client should be assessed first? 1. Female, posthysterectomy, blood pressure 90 /52 mm Hg 2. Male, postappendectomy, pain medications administered 15 minutes ago 3. Male, posthip arthroplasty, to be up and ambulating 4. Female, postcholecystectomy, being discharged with wound care and diet instruction - ANSWER - 1 Option 1: Blood pressure below what is considered normal in a postoperative client should be assessed immediately. Option 2: This client is low -priority because a nurse just saw him and he has no clinical manifestations of any problem. Option 3: Ambulation is not an urgent need and can be lower priority. Option 4: Discharge is the lowest on priorities of this list of client needs. The nurse is preparing to perform wound care that includes irrigating the wound. Which personal protective equipment should the nurse gat her? Select all that apply. 1. Goggles 2. N-95 mask 3. Client gown 4. Shoe covers 5. Several pairs clean gloves - ANSWER - 1,5 Option 1: If splashing could possibly occur as with irrigating a wound, the nurse should gather goggles. Option 2: The nurse does not need to bring in an N -95 respirator mask as this client does not have an airborne illness. Option 3: The nurse does not use a client gown during dressing changes. Gowns used should be permeable to solution and be disposable. Option 4: The nurse need not wear shoe covers as the wound care procedure should not contaminate the shoes. Option 5: The nurse will be changing gloves during the procedure. Therefore, the nurse needs several pairs of clean gloves. Which piece of personal protective equipment (PPE) should be removed first? 1. Mask 2. Gloves 3. Gowns 4. Shoe covers - ANSWER - 2 Option 1: The mask is not the first piece of PPE to be removed. Option 2: The gloves should be removed first as they are the most contaminated. Leaving the gloves on and removing other PPE first would cause contamination. Option 3: The gown is usually one of the last pieces of PPE to be removed. Option 4: Shoe covers are not the first piece of PPE that is removed. Question 5. The nurse enters the room of a client to perform wound care and administer medications. When should the nurse apply clean gloves? Select all that apply. 1. During medication administration 2. Prior to removing soiled dressings 3. Before applying clean dressings 4. Prior to leaving the client's room 5. After giving the client intravenous medications - ANSWER - ans: 1, 2, 3 Rationales Option 1: The nurse should don gloves when opening packages for administering medications to the client. Option 2: The nurse should put gloves on prior to removing soiled dressings. This decreases the nurse's exposure to infectious drainage. Option 3: The nurse shou ld remove his/her gloves after taking off the soiled dressings and apply new clean gloves prior to placing clean dressings on the wound. Option 4: The nurse should not wear gloves when leaving the client's room. Soiled gloves can transmit infections to oth er clients or staff. Option 5: The nurse wears gloves when administering intravenous medications, but they should be removed prior to leaving the room. Question 6. The nurse is supervising a student nurse during the administration of an insulin injection. Which action made by the student nurse increases the risk for infection? 1. Cleaning the skin prior to the injection 2. Identifying the client prior to giving the insulin 3. Recapping the needle after giving the injection 4. Disposing of the syri nge and needle in the sharps container - ANSWER - ans: 3 Rationales Option 1: The student nurse should prep the site with alcohol prior to administering the injection. This helps decrease the risk for infection. Option 2: The student nurse should identify the client prior to administering the insulin. This step does not place anyone at risk for infection. Option 3:
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