The nurse is caring for a client who is to receive IV daunorubicin, a chemotherapeutic agent. The nurse starts the infusion and checks the insertion site as per protocol. During the most recent check, the nurse observes that the IV has infiltrated so the nurse stops the infusion. What is the nurse'...
NURS-258 2024-2025 FINAL EXAM
WITH 100% CORRECT ANSWERS.
A gerontologic nurse is teaching students about the high incidence and prevalence
of dehydration in older adults. Which factors contribute to this phenomenon? Select
all that apply. - ANSWER Decreased kidney mass, Decreased renal blood flow,
Decreased excretion of potassium
A client has questioned the nurse's administration of intravenous (IV) normal saline,
asking, "Wouldn't sterile water be a more appropriate choice than saltwater?" Under
what circumstances would the nurse administer electrolyte-free water intravenously?
- ANSWER Never, because it rapidly enters red blood cells, causing them to rupture
The nurse in the medical intensive care unit is caring for a client who is in
respiratory acidosis due to inadequate ventilation. Which diagnosis could the client
have that could cause inadequate ventilation? - ANSWER Guillain- Barre syndrome
The nurse is caring for a client who is to receive IV daunorubicin, a
chemotherapeutic agent. The nurse starts the infusion and checks the insertion site
as per protocol. During the most recent check, the nurse observes that the IV has
infiltrated so the nurse stops the infusion. What is the nurse's priority concern with
this infiltration? - ANSWER Extravasation of the medication
A client with hypertension has been prescribed hydrochlorothiazide. What nursing
action will best reduce the client's risk for electrolyte disturbances? - ANSWER
Ensure the client has sufficient potassium intake
A client comes into the emergency department (ED) by ambulance with a hip
fracture after slipping and falling while at home. The client is alert and oriented but
anxious and reports thirst. The client's pupils are equal and reactive to light and
accommodation, and the heart rate is elevated. An indwelling urinary catheter is
inserted, and 40 mL of urine is present. What is the nurse's most likely explanation
for the client's urinary output? - ANSWER The client is having a sympathetic
reaction, which has stimulated the renin-angiotensin-aldosterone system, which
results in diminished urine output.
The nurse is performing an admission assessment on a 79-year-old client newly
admitted for end-stage liver disease. What principle should guide the nurse's
assessment of the client's skin turgor? - ANSWER Inelastic skin turgor is a normal
part of aging.
The nurse is assuming the care of an adult client who has been experiencing
severe and intractable pain. When reviewing the client's medication administration
record, the nurse notes the presence of gabapentin. The nurse is justified in
suspecting which phenomenon in the etiology of the client's pain? - ANSWER
Neuropathy
A recent nursing graduate is aware of the differences between nursing actions that
are independent and nursing actions that are interdependent. A nurse performs an
interdependent nursing intervention when performing which of the following actions?
- ANSWER Administering an IV bolus of normal saline to a patient with hypotension
,NURS-258 2024-2025 FINAL EXAM
WITH 100% CORRECT ANSWERS.
The public health nurse is presenting a health promotion class to a group of new
mothers. How should the nurse best define health? - ANSWER
The nurse is preparing a wellness program for seniors at a community center.
Which concept of wellness should the nurse utilize when planning the program? -
ANSWER
A nurse on a medical-surgical unit has asked to represent the unit on the hospital's
quality committee. When describing quality improvement programs to nursing
colleagues and members of other health disciplines, what characteristic should the
nurse cite? - ANSWER
The nurse is admitting a client to the medical unit after the client has been
transferred from the emergency department. What is the nurse's priority action at this
time? - ANSWER
The nurse navigator is coordinating the transition from the hospital to a
rehabilitation facility of a client who had a total hip replacement. Which activity would
be an example of the nurse navigator role for this client? - ANSWER
The community health nurse is preparing to conduct a home visit on a client without
an active infection. When performing the home visit, how should the nurse best
implement the principles of infection control?A nurse who has an advanced degree
in primary care for a pediatric population is employed in a health clinic. In what role is
this nurse functioning? - ANSWER
A nurse is collaborating with a team of community nurses to identify the vision and
mission for community care. What is the central focus of nursing? - ANSWER
A community-based case manager is sending a community nurse to perform an
initial home assessment of a newly referred client. To ensure safety, the case
manager must make the nurse aware of which of the following? - ANSWER
The community-health nurse has received a referral for a new client who resides in
a high-crime area. What is the most important request that the nurse should make of
the agency to ensure safety? - ANSWER
The nurse is performing initial visits to two new clients of the local home health care
service. These clients live within two blocks of each other and both homes are in a
high-crime area. What action best protects the nurse's personal safety? - ANSWER
The nurse is planning discharge for a client receiving Medicare. The Medicare
program facilitates what aspect of home health care for the client - ANSWER
The home care nurse is assessing a client's use of crutches in the home. Which of
the following actions by the client indicates that the client is using the crutches
effectively? - ANSWER
, NURS-258 2024-2025 FINAL EXAM
WITH 100% CORRECT ANSWERS.
A nurse has been working with a client whose poorly controlled type 1 diabetes has
led to numerous health problems. Over the past several years the client has had
several admissions to the hospital medical unit, and the nurse has often carried out
health promotion interventions. Who is ultimately responsible for maintaining and
promoting this client's health? - ANSWER
A 20-year-old client newly diagnosed with type 1 diabetes needs to learn how to
self-administer insulin. When planning the appropriate educational interventions and
considering variables that will affect the client's learning, the nurse should prioritize
what factor? - ANSWER
The nurse is preparing discharge teaching for an adult client diagnosed with urinary
retention secondary to multiple sclerosis. The nurse will teach the client to self-
catheterize at home upon discharge. What teaching method is most likely to be
effective for this client? - ANSWER
The nurse is caring for a client with chronic obstructive pulmonary disease (COPD)
who has just received a new diagnosis of diabetes. Which client behavior
demonstrates to the nurse the client's emotional readiness to learn? - ANSWER
A public health nurse is planning educational interventions that are based on
Becker's Health Belief Model. When identifying the variables that affect local
residents' health promotion behaviors, what question should the nurse seek to
answer? - ANSWER
How should the nurse best define health? - ANSWER
A nurse has planned a teaching-learning interaction that is aimed at middle-school-
aged students. To foster successful health education, the nurse's planning should
prioritize what component? - ANSWER
Middle-aged adults are part of an age group that is known to be interested in health
and health promotion, and the nurse is planning health promotion activities
accordingly. To what suggestions do members of this age group usually respond
with enthusiasm? Select all that apply. - ANSWER
A nurse who provides care at the campus medical clinic of a large university puts
much effort into health promotion. What purpose of health promotion should guide
the nurse's efforts? - ANSWER
A client will be receiving outpatient intravenous antibiotic therapy for the treatment
of endocarditis. The nurse is preparing health education to promote the client's
adherence to the course of treatment. What cultural consideration should the nurse
use when developing a teaching plan for the client? - ANSWER
A nurse is performing the admission assessment of a client who will be treated for
pancreatitis on the medical unit. During the nursing assessment, the nurse asks the
client questions related to the client's spirituality. The primary rationale for this aspect
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