NUR 204 EXAM 2 Practice Test Questions With Solved Solutions.
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Course
NUR 204
Institution
NUR 204
What indications are there for applying restraints as last resort? - Answer harm self or others
A nurse is caring for a 25-year-old client who is quadriplegic. Which treatment would be a priority to decrease the risk of joint contracture and promote joint mobility?
A. Active ROM
B. Pass...
NUR 204 EXAM 2 Practice Test
Questions With Solved Solutions.
What indications are there for applying restraints as last resort? - Answer harm self or others
A nurse is caring for a 25-year-old client who is quadriplegic. Which treatment would be a priority to
decrease the risk of joint contracture and promote joint mobility?
A. Active ROM
B. Passive ROM
C. Turning every 2 hours
D. Applying a trochanter roll - Answer B. Passive ROM
Area where they are unable to move (all 4 extremities), do PROM in arms, shoulders, elbows, wrists, and
fingers, hips, knees, ankles, toes. Quadriplegic does NOT mean they are unable to do some movements
A client is admitted to the hospital with COPD. He is receiving supplemental oxygen via nasal cannula.
Which position will best assist his breathing?
A. Fowler's
B. Sims'
C. Lateral
D. Supine
E. Prone - Answer A. Fowler's
Will help breathing the best
High, Semi, and Low Fowler's do exist
,A teenage client was hospitalized 3 weeks ago after MVA in which he crushed his pelvis. He remains on
bedrest. His parents tell the nurse, " Our son is just staring off into space and won't talk to us. He doesn't
want to listen to his music or watch television. That is so unlike him." What is the nurse's best response?
A. "I will inform the doctor and see whether we can get your son started on an antidepressant
medication."
B. "He is at a critical time in his life; teens are often moody, and being in the hospital with an injury will
only make that worse."
C. "Your son had a major injury, and his immobility might be causing him to feel isolated and depressed."
D. "He is bored because he has been in the hospital for 3 weeks; I'll try to find something new for him to
do." - Answer C. "Your son had a major injury, and his immobility might be causing him to feel isolated
and depressed."
A = incorrect, RN is making dx that patient is depressed
B = making assumption "moody"
C= MIGHT, major injury = takes adjustment
D = dont' want to make assumption
An older client suffered left-sided paralysis from a stroke. Which are the best actions for this client?
Select all that apply.
A. Monitor for constipation
B. Encourage an even gait when walking in place
C. Assess the extremities for swelling and muscle atrophy
D. Encourage taking deep breaths frequently to hyper-inflate the lungs.
E. Encourage the client to hold onto the wall while ambulating - Answer A. Monitor for constipation
*not moving around which assists peristalsis
C. Assess the extremities for swelling and muscle atrophy
*not moving, use it or lose it
D. Encourage taking deep breaths frequently to hyper-inflate the lungs.
**prevents pneumonia, keeps air circulating through lungs
,B = unrealistic expectation, gait is uneven after stroke
E = need more of an assistive device than just wall, which will run out, is there a handrail? not enough
info
A client is being transferred from the bed to a stretch for surgery using a transfer board. What should be
the nurse's first action?
A. Lower the stretched below the level of the bed.
B. Explain the procedure to the client.
C. Place the client in the prone position.
D. Place the bed in the lowest position. - Answer B. Explain the procedure to the client.
**Always explain procedure first for anything
A = want transfer to be LEVEL
C = Never put patient face down
D = bad for RN ergonomics
What are the stages of wound healing? - Answer 1. inflammatory
2. proliferative
3. maturation/remodeling
What is the inflammatory stage of wound healing? - Answer begins with injury, lasts 3-6 days
control bleeding (vasoconstriction, blood vessel retraction, fibrin accumulation, clot formation)
deliver O2, WBC, and nutrients
macrophages, phagocytosis
What is the proliferative stage of wound healing? - Answer lasts the next 3-24 days
replace lost tissue w/ connective or granulated tissue and collagen
, contract wound's edges to reduce area that requires healing
resurfacing of new epithelial cells
What is the maturation or remodeling stage of wound healing? - Answer occurs on/about day 21
strengthening of collagen scar and restoration of more normal appearance
can take > 1 year to complete depending on original wound extent
What are the phases of healing process? - Answer 1. primary intention
2. secondary intention
3. tertiary intention
What occurs during primary intention? - Answer -little/no tissue loss
-edges approximated (eg w/in surgical incision)
-heals rapidly
-low risk of infection
-no/minimal scarring
eg = closed surgical incision w/ staples, sutures, or liquid glue to seal laceration
What occurs during secondary intention? - Answer -loss of tissue
What occurs during tertiary intention? - Answer -widely separated
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