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RNSG 1430| RN CONCEPT BASED ASSESSMENT LEVEL 1 NEWEST 2024 ACTUAL EXAM
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RNSG 1430| RN CONCEPT BASED ASSESSMENT LEVEL 1 NEWEST 2024 ACTUAL EXAM
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TEST BANK For Medical-Surgical Nursing 10th Edition Concepts for Interprofessional Collaborative Care, by Donna D. Ignatavicius, 2024/2025 All chapters 1 – 69
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surgery-Chapter 16 Quiz
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MEDICAL SURGICAL NURSING CONCEPTS FOR CLINICAL JUDGEMENT AND COLLABORATIVE CARE 11TH EDITION FULL TEST BANK | ALL CHAPTERS.
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RNSG 1430| RN CONCEPT BASED ASSESSMENT LEVEL 1NEWEST 2024 ACTUAL EXAM 100 QUESTIONS AND
CORRECT DETAILED ANSWERS WITH RATIONALES
(VERIFIED ANSWERS) |ALREADY GRADED A+
A nurse is caring for a client who is 2 days postoperative following an above-the-
knee amputation. The client states he is experiencing a dull, burning pain in the leg
that was amputated. Which of the following actions should the nurse take to treat
the client's neuropathic pain? - ANSWER: Administer a beta-blocking medication to
the client.
(The nurse should administer a beta-blocking medication to the client. This
classification of medication has been shown to relieve the phantom limb pain
manifestations of constant dull and burning type pain.)
A newly licensed nurse asks a charge nurse where to find information about scope of
practice for registered nurses. Which of the following responses should the charge
nurse make? - ANSWER: "The state board of nursing can provide this information"
(each state develops a nurse practice act, which defines scope of practice for nurses
in that state. This practice act is available on the board of nursing website for each
state.)
A nurse is planning care to prevent a catheter-related bloodstream infection for a
client who is receiving IV fluid therapy. Which of the following interventions should
the nurse include in the plan? - ANSWER: Perform hand hygiene before touching the
IV tubing.
(The nurse should perform thorough hand hygiene before touching any part of the
infusion system or the client to reduce the risk of catheter-related blood stream
infections.)
A nurse is creating a plan of care for a client who is non-ambulatory and has bladder
and bowel incontinence. Which of the following interventions should the nurse
include to prevent skin breakdown? - ANSWER: Offer the client a glass of water every
two hour when repositioning.
(The nurse should offer the client a glass of water every two hours on the clients
repositioning schedule. This helps prevent dehydration, which increases the risk of
skin breakdown.)
A nurse is teaching a young adult female client about health screening for breast
cancer. Which of the following statements by the client indicates an understanding
of breast self-examination (BSE)? - ANSWER: "I should expect to feel a firm ridge
along the bottom curve of each breast."
(The nurse should instruct the client at a firm ridge is expected along the bottom
curve of each breast. The client should be able to feel this area during the BSE.
Performing a BSE promotes breast self awareness so that the client knows how her
,breast normally feel. The awareness increases the clients ability to identify changes
that require further evaluation.)
A nurse is caring for an adolescent who is in critical condition following a motor
vehicle crash which he was the passenger. The clients parent shout at the nurse,
asking why her son is dying instead of the driver. Which of the following actions
should the nurse take to provide emotional support to the parent? - ANSWER:
Inform the parent that anger is a natural response when dealing with loss.
(The nurse should identify that the parent is in the anger stage of grief. The nurse
should assist the parent to understand that anger is a natural response to loss and
encourage her to talk about her feelings.)
A nurse is teaching an older adult client about accessing electronic resources for
healthcare information on the internet. Which of the following statements should
the nurse include in the teaching? - ANSWER: "Websites ending in '.gov' are reliable
sites for obtaining health information from government agencies."
(The nurse should teach the client how to select reliable internet websites when
researching health care information. The nurse should identify that websites ending
in '.gov' and '.edu' are considered reliable and credible sources for health
information. Websites ending in '.com' should not be used for researching credible
healthcare information.)
A nurse enters a clients room and finds the client lying on the floor. The client states
that on the way to the bathroom her "knee locked," causing her to fall. Which of the
following actions should the nurse take first? - ANSWER: Check the client for injuries.
(The first action the nurse should take when using the nursing process is to assess
the client. The nurse should first check the client for injuries and measure vital signs
to help determine physiologic stability. The nurse should also inform the provider of
the clients fall and of the assessment findings.)
A nurse is teaching a client who has rheumatoid arthritis about chronic pain
management. Which of the following statements by the client indicates an
understanding of the teaching? - ANSWER: "I should use a warm paraffin dip for my
hands and feet."
(The nurse should instruct the client to dip her hands and feet in warm paraffin to
alleviate pain and stiffness. The client can more easily perform hand and finger
exercises following the treatment.)
A community health nurse is planning prevention strategies for hypertension among
members of her community. The nurse should identify that which of the following
ethnic groups in the community is at greatest risk of developing hypertension? -
ANSWER: African American
(Evidence-based practice indicates that individuals of AA ethnicity have the highest
prevalence of hypertension. Therefore, the nurse should identify community
members of this ethnicity are at greatest risk of developing hypertension.)
, A nurse is preparing to extinguish a small fire in a clients room. Which of the
following actions should the nurse take when using the fire extinguisher? - ANSWER:
Slide the pin on top of the fire extinguisher straight out.
(The nurse should pull the pin on top of the fire extinguisher to allow for use to
extinguish the fire.)
A nurse is preparing to administer intermittent external nutrition via a clients NG
tube. In which order should the nurse take the following actions? - ANSWER: 1.
Assist the client to an upright position.
2. Aspirate 5 mL of gastric contents.
3. Test the pH of gastric aspirate.
4. Measure gastric residual volume.
5. Flush the NG tube with 30 mL of water.
(First, the nurse should assist the client into high Fowler's position or raise the HOB
at least 30 degrees to help prevent aspiration. Then, the nurse should verify the
tubes placement by aspirating 5 mL of gastric contents and then testing the pH.
Then, the nurse should check for gastric residual volume. Excessive GRV is an
indication of delayed gastric emptying, which places the client at risk of aspiration if
additional formula is given. Finally, the nurse should flush the tubing with 30 mL of
water to ensure the tube is clear and patent.)
A nurse is caring for a 47-year-old female client who had urinary incontinence. Which
of the following actions should the nurse take first? - ANSWER: Obtain a specimen
from the client for culture.
(The first action the nurse should take when using the nursing process is assessment.
The nurse should obtain a urine specimen from the client to rule out a UTI. If it is a
determined the client has RBC's and WBC's in the urine, the specimen will require a
culture. If it is determined that the client has a UTI, this will require treatment before
any further assessment of incontinence would be indicated.)
A nurse is talking with a client who has a major depressive disorder. The client states,
"Nobody cares if I'm around or not." Which of the following responses should the
nurse make? - ANSWER: "It sounds as though you're feeling hopeless."
(This statement by the nurse is an example of restraining, which is a therapeutic
response. This technique restates the main idea the client has expressed and allows
the client to clarify any misunderstanding.)
A charge nurse is teaching a group of newly licensed nurses how to prevent errors
during administration of blood transfusions. Which of the following actions should
the nurse include? - ANSWER: Use a new blood administration tubing set for each
blood bag infused.
(The nurse should use a new blood infusion tubing set for each component of blood.
A blood infusion set should not be reused, even for the same client.)
A nurse is caring for a client who has C. diff infection and is incontinent of stool
following a long-term antibiotic therapy. Which of the following actions should the
nurse take? - ANSWER: Wear a gown when providing care for the client.
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