Q-bank Test 11 Exam Questions with Correct Answers
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Course
Applied nursing
Institution
Applied Nursing
The nurse provides discharge teaching to a client dx w/a stage 2 pressure injury. The nurse instructs the client to perform prescribed wound care twice daily by cleansing the wound w/wound cleanser, covering the wound w/an abdominal pad, and securing the dressing w/paper tape. The client is to foll...
Q-bank Test 11 Exam Questions with
Correct Answers
The nurse provides discharge teaching to a client dx w/a stage 2 pressure injury. The
nurse instructs the client to perform prescribed wound care twice daily by cleansing the
wound w/wound cleanser, covering the wound w/an abdominal pad, and securing the
dressing w/paper tape. The client is to follow up w/the HCP in three days. Which
nursing action is *most* appropriate to ensure the client can perform the needed wound
care?
1. ask the client, "do you understand the wound care instructions?"
2. tell the client to keep the current dressing in place until the follow-up appointment
3. contact the case manager to ensure the client can obtain needed wound care
supplies
4. request the client stay as an inpt in the hospital unitl until the follow-up appointment -
Answer-3
The nurse prepares a transdermal fentanyl patch for a client w/cancer pain. Which
action does the nurse take when applying the patch on the client? *select all that apply*
1. avoid a skin area that has abrasions
2. select an area of the skin that has no hair
3. apply gloves before preparing the medication
4. cleanse the skin of the previously applied patch
5. discard the previously removed patch in the sharps container
6. remove the previous patch and fold it w/the medication side in - Answer-1, 2, 3, 4, 6
The patch should not be applied to areas w/cuts, burns, or abrasions since the
medication may irritate these areas
The site to apply a transdermal patch should be clean, dry, and free of hair
Gloves should be applied before preparing the medication to prevent accidental
exposure to the medication through the skin
The site of the previous patch should be cleansed to remove any traces of the
medication
The previous patch should be removed and folded w/the medication side in to prevent
accidental exposure to residual medication on the patch
The nurse provides care for clients in the ED. Four clients come in at the same time.
Which client does the nurse see *first*?
1. a 6 month old w/vomiting and diarrhea
2. a 2 year old w/a temperature of 101 F
3. a 20 year old at 8 weeks' gestation reporting vaginal spotting
4. a 32 year old reporting n/v for several hours - Answer-1
This client is at significant risk for dehydration and electrolyte imbalances due to the
small body mass, inability to compensate effectively, and loss from both upper and
lower GI sources
This client is the priority
,The nurse provides care for a client who reports flank pain. The HCP wrties a client
prescription that states, "CT scan to r/o CVA." Which action does the nurse take *first*?
1. assess if the client has metal implants
2. determine if the client has peripheral IV access
3. ask if the client has an allergy to contrast media
4. contact the provider for clarification - Answer-4
The nurse should question the HCP about the prescription
Flank pain does not support a CT scan to r/o CVA
The prescription will likely need to be rewritten
The nurse plans care for a client dx w/dementia. Which nursing intervention is the
*priority*?
1. encourage the family to perform ADLs for the client
2. provide a flexible schedule for the client
3. limit reminiscing by the client
4. assume a face-to-face position when speaking to the client - Answer-4
By speaking face-to-face, the nurse maximizes verbal and nonverbal cues
The nurse should use short, simple words and phrases, and speak slowly to give the
client time to process information
Which information is essential to report when communicating client information at the
change of shift? *select all that apply*
1. the client is newly dx w/T1DM and needs follow-up teaching about insulin
administration
2. the client is seemingly more confused and has been attempting to get out of bed w/o
assistance
3. the attending HCP prescribed lorazepam PRN for restlessness
4. the client has a 20 year hx of smoking
5. the client receives carvedilol, benztropine mesylate, and losartan on a daily basis -
Answer-1, 2, 3
Client teaching needs r/t discharge are important in the continuum of care, and should
be communicated during the change of shift report
A behavior change and/or new symptom is essential to report during the change of shift
All HCP prescriptions that are new are essential to communicate during the change of
shift report
An LPN/LVN works under the supervision of a nurse in the medical unit. Which client
should the nurse delegate to the LPN/LVN?
1. a client w/acute flank pain r/t a dx of acute pyelonephritis
2. a client experiencing urinary incontinence who needs bladder retraining prior to
discharge
3. a client dx w/cystitis who is currently on scheduled oral antibiotic therapy
4. a client w/a new prescription for lithotripsy following a dx of renal calculi - Answer-3
Administering oral antibiotics for a stable client is w/in the scope of practice of an
LPN/LVN
, The nurse manager reviews the unit's emergency response plan for a fire w/the staff.
Which statement by a staff member indicates a need for further education? *select all
that apply*
1. keep the doors to the unit open at all times so staff, clients, and visitors can evacuate
more easily
2. clients in immediate danger should be evacuated first
3. the nurse should extinguish the fire and then activate the fire alarms
4. the nurse should aim the fire extinguisher at the top of the fire
5. critically ill clients should have the doors to their rooms closed until ambulatory clients
have been evacuated - Answer-1, 3, 4
Doors to the unit should be closed; closing doors and windows helps contain the fire
and prevent the spread to other areas of the hospital
The fire alarm should be activated first to alert others of the fire threat
A fire extinguisher is most effective when pointed at the base of the fire
The nurse provides care to a hospitalized client who has just begun receiving low-dose
radiation (LDR) via seed implants for tx of prostate cancer. To ensure safety of the
client's visitors and health care team members, the nurse implements which
intervention?
1. limiting visitors to spending no more than 60 minutes per visit w/the client
2. requiring pregnant staff members to wear a lead apron when providing client care
3. planning the client's care to minimize staff members' exposure to radiation
4. ensuring visitors remain at least 2 feet from the radiation source - Answer-3
To minimize the health care team's exposure to radiation, client care should be planned
to allow the least amount of exposure to the client
The nurse provides care for a postpartum client 4 days after delivery. Which finding
*most* concerns the nurse?
1. the uterine fundus has descended 2 cm
2. the vaginal walls are edematous
3. lacerations are noted to the perineum
4. brown-tinged discharge is noted on the peripad - Answer-1
This is an abnormal finding
The uterine fundus descends by approximately 1 cm, or one fingerbreadth, per day
Subinvolution occurs when process of involution does not occur properly and can lead
to postpartum hemorrhage
By 14th day, the fundus has normally descended into the pelvic cavity and cannot be
palpated abdominally
The descent is documented in relation to the umbilicus
The nurse interacts w/a client who has just accepted a job in an office located on the
36th floor of a building. The client reports experiencing severe anxiety in elevators and
enclosed spaces. Which interventions is *most* important for the nurse to recommend?
1. psychopharmacological intervention
2. group therapy
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