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NSG 3100 Exam 2-with 100% verified solutions- -2024.docx, Exams of Nursing

NSG 3100 Exam 2-with 100% verified solutions- -2024.docx

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2023/2024

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NSG 3100 Exam 2-with 100% verified solutions-

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Which of the following is a cause of bradypnea? Increased activity narcotic analgesics Test anxiety Decreased oxygen saturation narcotic analgesics A damp/damp dressing is an example of what type of wound debridement? Autolytic Surgical Mechanical Enzymatic Mechanical What statement describes a stage 2 pressure ulcer? Damage extends to the fascia Skin is intact and does not blanch Presents as open or fluid-filled blister, or shallow crater Base is covered with slough and wound bed cannot be seen Presents as open or fluid-filled blister, or shallow crater Which statement describes a stage 1 pressure ulcer? Intact skin is purple or maroon Skin is pink or red and does not blanch Presents as open or fluid-filled blister, or shallow crater

Base is covered with slough and wound bed cannot be seen Skin is pink or red and does not blanch Age-related findings related to vital signs in older adults: Heart rate increases; blood pressure decreases Heart rate increases; blood pressure increases Heart rate decreases; blood pressure increases Heart rate decreases; blood pressure decreases Heart rate decreases; blood pressure increases What is the correct sequence for donning PPE? What is the correct sequence for removing (doffing) PPEs? Medical asepsis refers to all except? Reduces the spread of microorganisms Objects referred to as clean or dirty Gown, goggles, mask, gloves Gown, gloves, goggles, mask Gown, mask, goggles, gloves Goggles, gown, gloves, mask Gown, mask, goggles, gloves Gloves, gown, goggles, mask Gown, gloves, mask, goggles Goggles, gloves, gown, mask Gloves, goggles, gown, mask Gloves, goggles, gown, mask

Eliminates all pathogens Clean technique Eliminates all pathogens Wound exudate that is clear and blood-tinged is called what? Sanguinous Purosanguinous Serosanguinous Purulent Serosanguinous Wound exudate that is thick, creamy yellow or green is called what? Purosanguinous Purulent Serosanguinous Serous Purulent All of the following are contraindications to heat therapy except Active hemorrhage Chronic conditions such as osteoarthritis First 24 hours after traumatic injury Noninflammatory edema Chronic conditions such as osteoarthritis What is dehiscence? Protrusion of a body organ through an incision

Hemorrhaging of the wound Sutured wound ruptures and layers separate Infection of the wound Sutured wound ruptures and layers separate What is not a sign/symptom of wound infection? Swelling Heat Redness Bruising Bruising Using a blood pressure cuff that is too small, will result in the reading being what? Falsely low Falsely high Falsely high The normal range for blood pressure is: systolic 80-110/ diastolic 70- systolic 90-140/diastolic 60- systolic 90-120/diastolic 60- systolic 80-130/diastolic 50- systolic 90-120/diastolic 60-

The range for normal temperature is: 96.8 - 98. 97.6 - 99. 96.8 - 99. 98.6 - 99. 96.8 - 99. A patient with what type of disease should be placed in airborne precautions? Herpes Zoster MRSA Tuberculosis Pneumonia Tuberculosis A pulse oximeter can be placed on all of the following body parts except? Fingers Ear Toes Chest Chest The nurse is aware that which of the following is an accurate statement about the respiratory rate? A- The respiratory rate increases with age. B- Narcotics slow the respiratory rate.

C- Acute pain decreases the respiratory rate. D- The respiratory rate is increased with alkalosis. B- Narcotics slow the respiratory rate. The nurse instructs the UAP that which of the following methods will obtain a falsely low blood pressure reading? A- Using a BP cuff that is too narrow B- Releasing the pressure value too slowly C- Assessing the BP after the patient exercises D- Place the arm above the level of the heart D- Place the arm above the level of the heart The adult patient is seen in the 24-hour medical center for heat exhaustion. The nurse anticipates that treatment will include which of the following? A- Fluid replacement B- Antibiotic therapy C- Hypothermia wraps D- Tepid water baths A- Fluid Replacement Upon entering the room, the nurse observes that the patient appears to be tachypneic. The nurse should: A- Ask if there have been visitors B- Have the patient lie flat C- Take the radial pulse D- Measure the respiratory rate

D- Measure the respiratory rate The patient is experiencing pain and asks for medication, which has been ordered by the provider. The nurse first assesses the vital signs and finds the blood pressure to be 144/82 mmHg, Pulse 88/min., and respirations 24/min. The nurse should: A- Give the medication as ordered B- Check again that the patient has pain C- Withhold the medication D- Wait 20 min. and check the vital signs again before giving the medication A- Give the medication as ordered The patient gets out of bed to go to the bathroom and tells the nurse that he "feels dizzy." What is the first action the nurse should take? A- Go for help B- Take blood pressure C- Help the patient to sit down D- Have the patient take deep breaths C- Help the patient to sit down A patient asks the nurse about whether her blood pressure is too high. The nurse informs the patient that the blood pressure associated with stage 2 hypertension is: A- 120/ B- 130/ C- 140/ D- 160/ D- 160/

A primary concern for a patient w/ orthostatic hypotension is: A- Risk for falls B- Fluid overload C- Oxygen demand D- Mental confusion A- Risk for falls A 79-year-old resident in a long-term care facility is known to "wander at night" and has fallen in the past. Which of the following is the most appropriate nursing intervention? A- The patient should be checked frequently during the night B- An abdominal restraint should be placed on the patient during sleeping hours C- A radio should be left playing at the bedside to assist in reality orientation D- The patient should be placed in a room away from the activity of the nurses' station A- The patient should be checked frequently during the night The visiting nurse completes an assessment of the ambulatory patient in the home and determines the nursing diagnosis Risk for injury associated with decreased vision. On the basis of this assessment, the patient will benefit the most from: A- Installing fluorescent lighting throughout the home B- Becoming oriented to the position of the furniture and stairways C- Maintaining complete bed rest in a hospital bed w/ side rails D- Applying physical restraints B- Becoming oriented to the position of the furniture and stairways

When applying a wrist restraint, the nurse knows that: A- The padded side is away from the skin B- It should be removed at least once every shift C- The straps should be secured w/ a knot D- Two fingers' width should fit between the skin and the restraint D- Two fingers' width should fit between the skin and the restraint A patient has a 6-inch laceration on his right forearm. An infection develops at the site. Which of the following is a sign of a local inflammatory response observed by the nurse? A- Blanching of the skin B- Edema at the site C- Decrease in temperature D- Bruising at the site B- Edema at the site The nurse employs surgical aseptic technique when: A- Disposing syringes in a puncture-proof container B- Placing soiled linens in a moisture-resistant bag C- Washing hands before changing a dressing D- Inserting an intravenous catheter D- Inserting an intravenous catheter

A patient with active tuberculosis is admitted to the medical center. The nurse recognizes that admission of this patient to the unit will require the implementation by the staff of: A- Droplet precautions B- Airborne precautions C- Contact precautions D- Protective precautions B- Airborne precautions A patient requires a sterile dressing change for a mid-abdominal surgical incision. An appropriate intervention for the nurse to implement in maintaining sterile asepsis is to: A- Put sterile gloves on before opening sterile packages B- Place the cap of the sterile solution well within the sterile field C- Place sterile items on the edge of the sterile drape D- Discard packages that may have been in contact w/ the area below waist level D- Discard packages that may have been in contact w/ the area below waist level The unit manager observes the new staff nurse perform the following actions for a patient with isolation precautions. Which of the following actions should the unit manager address and correct with the new nurse? A- Keeping a thermometer, stethoscope and BP cuff in the patient's room. B- Documenting the precautions required in the patient's record C- Using a particulate respirator mask for the patient who has tuberculosis D- Coming out of the room in the PPE to quickly get another dressing D- Coming out of the room in the PPE to quickly get another dressing

Pressure injuries form primarily as a result of: A- Nitrogen buildup in the underlying tissues B- Prolonged illness or disease C- Tissue ischemia D- Poor hygiene C- Tissue ischemia The nurse prepares to irrigate the patient's wound. The primary reason for this procedure is to: A- Create scar formation B- Remove debris from the wound C- Improve circulation from the wound D- Decrease irritation from wound drainage B- Remove debris from the wound On inspection of the patient's wound, the nurse notes that it appears infected and has a large amount of exudate. An appropriate dressing for the nurse to select on the basis of the wound assessment is: A- Foam B- Hydrogel C- Hydrocolloid D- Transparent film A- Foam The nurse is concerned that the patient's midsternal wound is at risk for dehiscence. Which of the following is the best intervention to prevent this complication?

A- Administering antibiotics to prevent infection B- Using appropriate sterile technique when changing the dressing C- Keeping sterile towels and extra dressing supplies near the patient's bed D- Having the patient splint the incision site when coughing D- Having the patient splint the incision site when coughing After an injury, the patient has thick, yellow drainage coming from the wound. The nurse describes this drainage as: A- Milky B- Serous C- Purulent D- Serosanguinous C- Purulent The nurse has applied a pulse oximeter to the finger of a patient who is hypothermic. The pulse oximeter does not provide a good reading. What action by the nurse is best? A- Move the oximeter probe to another finger B- Remove any fingernail polish present on the fingernail C- Assess the fingers for good circulation D- Document that the reading cannot be obtained C- Assess the fingers for good circulation A nurse performs orthostatic blood pressure readings on a patient w/ the following results: lying 148/76 mmHg, standing 110/60 mmHg. Which action by the nurse is best?

A- Reassesses the blood pressures in 1 hour B- Reassure the patient that these findings are normal C- Document the findings and continue to monitor D- Instruct the patient not to get up w/o help D- Instruct the patient not to get up w/o help A nurse observes a student taking an adult patient's tympanic temperature. What action by the student requires the nurse to intervene? A- Student pulls the pinna of the patient's ear down and back B- Student washes hands prior to patient contact C- Student explains the procedure to the patient D- Student pulls the pinna of the patient's ear up and back A- Student pulls the pinna of the patient's ear down and back The nurse receives a hand-off report on four patients. Which patient finding should the nurse assess first? A- Pulse oximetry 96% B- Pulse 42 BPM C- Blood pressure 102/62 mmHg D- Respiratory rate 18 breaths/min B- Pulse 42 BPM Which patient assessment result would require the nurse to assess that patient further? A- A 65 y/o man w/ a respiratory rate of 10 B- A 50 y/o man w/ a BP of 112/60 upon awakening in the morning

C- A 40 y/o woman w/ a radial pulse of 68 D- a 12 y/o w/ a pulse of 92 after ambulating in the hallway A- A 65 y/o man w/ a respiratory rate of 10 The nurse is caring for a woman who had a right-sided mastectomy 2 years ago. What action by the nurse is most appropriate? A- Place a sign above the bed: "no BP on the right arm" B- Place a sign above the bed "BP in legs only" C- No specific action is needed for this situation D- Place a sign above the bed: "no continuous BP on the right arm" A- Place a sign above the bed: "no BP on the right arm" A nurse is caring for a patient who has orthopnea. (Discomfort when breathing while lying down flat; common in people with some types of heart or lung conditions.) What action by the nurse is most appropriate? A- Medicate the patient for pain as needed B- Monitor the length of time the patient doesn't breathe C- Keep the head of the bed elevated D- Encourage deep breathing and coughing C- Keep the head of the bed elevated The nursing faculty member is observing a student taking a patient's carotid pulse. What action by the student requires intervention by the faculty? A- Counts pulse for 30 seconds and multiplies by two. B- Compares pulses in both carotid arteries at the same time. C- Assesses pulse on one side and then assesses the other side.

D- Performs hand hygiene prior to patient contact. B- Compares pulses in both carotid arteries at the same time. A nurse assesses a patient's radial pulse rate to be 110 beats/min and regular. What action by the nurse is best? A- Assess the patient for causes of tachycardia B- Take an apical heart rate and compare the two C- Notify the patient's health care provider D- Document the findings in the patient's chart A- Assess the patient for causes of tachycardia The nurse is caring for a patient on contact precautions. Which action will be most appropriate to prevent the spread of disease? A- Place the patient in a room w/negative airflow B- Wear a gown, gloves, face mask, and goggles for interactions w/ the patient C- Transport the patient safely and quickly when going to the radiology department D- Use a dedicated BP cuff that stays in the room and is used for that patient only D- Use a dedicated BP cuff that stays in the room and is used for that patient only The nurse is caring for a group of medical-surgical patients. Which patient is most at risk for developing an infection? A- A patient who is in observation for chest pain B- A patient who has been admitted w/ dehydration C- A patient who is recovering from a right total hip surgery D- A patient who has been admitted for stabilization of heart problems C- A patient who is recovering from a right total hip surgery

The nurse is caring for a patient w/ an incision. Which actions will best indicate an understanding of medical and surgical asepsis for a sterile dressing change? A- Donning clean goggles, gown, and gloves to dress the wound B- Donning sterile gown and gloves to remove the wound dressing C- Utilizing clean gloves to remove the dressing and sterile supplies for the new dressing D- Utilizing clean gloves to remove the dressing and clean supplies for the new dressing C- Utilizing clean gloves to remove the dressing and sterile supplies for the new dressing The nurse is caring for a school-aged child who has injured the right leg after a bicycle accident. Which signs and symptoms will the nurse assess for to determine if the child is experiencing a localized inflammatory response? A- Malaise, anorexia, enlarged lymph nodes, and increased white blood cells B- Chest pain, shortness of breath, and nausea and vomiting C- Dizziness and disorientation to time, date, and place D- Edema, redness, tenderness, and loss of function D- Edema, redness, tenderness, and loss of function The nurse is changing linens for a postoperative patient and feels a prick in the left hand. A contaminated needle is noted in the linens. For which condition is the nurse most at risk? A- Diphtheria B- Hepatitis B C- Clostridium Difficile

D- Methicillin-resistant Staphylococcus aureus B- Hepatitis B The surgical mask the nurse is wearing becomes moist. Which action will the nurse take? A- Apply a new mask B- Reapply the mask after it air-dries C- Change the mask when relieved by the next shift D- Do not change the mask if the nurse is comfortable A- Apply a new mask The nurse is admitting a patient with an infectious disease process. Which question will be most appropriate for a nurse to ask about the patient's susceptibility to this infectious process? A- "Do you have a spouse?" B- "Do you have a chronic disease?" C- "Do you have any children living in the home?" D- "Do you have any religious beliefs that will influence your care?" B- "Do you have a chronic disease?" The nurse is caring for a group of patients. Which patient will the nurse see first? A- A patient w/ Clostridium Difficile in droplet precautions B- A patient w/ tuberculosis in airborne precautions C- A patient w/ MRSA infection in contact precautions D- A patient w/ pneumonia in droplet precautions A- A patient w/ Clostridium Difficile in droplet precautions

The nurse is caring for a patient who needs a protective environment. The nurse has provided the care needed and is now leaving the room. In which order will the nurse remove the personal protective equipment (PPE), beginning with the first step? 1) Remove eyewear/face shield and goggles. 2) Perform hand hygiene, leave room, and close door. 3) Remove gloves. 4) Untie gown, allow gown to fall from shoulders, and do not touch outside of gown. 5) Remove mask by strings, do not touch outside of mask. 6) Dispose of all contaminated supplies and equipment in designated receptacles. A- 3,1,4,5,6, B- 1,4,5,3,6, C- 1,4,5,3,2, D- 3,1,4,5,2, D- 3,1,4,5,2, The nurse is caring for a postoperative patient. Which finding will alert the nurse to a potential wound dehiscence? A- Protrusion of visceral organs through a wound opening B- Chronic drainage of fluid through the incision site C- Report by patient that something has given way D- Drainage that is odorous and purulent C- Report by patient that something has given way The nurse is caring for a patient who has experienced a laparoscopic appendectomy. For which type of healing will the nurse focus the care plan? A- Partial-thickness repair B- Secondary intention C- Tertiary intention

D- Primary intention D- Primary intention A nurse is caring for a patient with a wound. Which assessment data will be most important for the nurse to gather with regard to wound healing? A- Muscular strength B- Hemoglobin/Hematocrit C- Sensation D- Sleep B- Hemoglobin/Hematocrit The nurse is cleansing a wound site. As the nurse administers the procedure, which intervention should be included? A- Allow the solution to flow from the most contaminated to the least contaminated B- Scrub vigorously when applying a noncytotoxic solution to the skin C- Cleanse in a direction from the least contaminated area D- Utilize clean gauze and clean gloves to cleanse a site C- Cleanse in a direction from the least contaminated area The nurse is caring for a patient who is immobile. The nurse wants to decrease the formation of pressure ulcers. Which action will the nurse take first? A- Offer frequent liquids B- Turn the patient every 2 hours C- Determine the patient's risk factors D- Encourage increased quantities of carbohydrates and fats C- Determine the patient's risk factors

The nurse is caring for a patient with a pressure ulcer on the left hip. The ulcer is black. Which next step will the nurse anticipate? A- Monitor the wound B- Document the wound C- Debride the wound D- Manage drainage from the wound C- Debride the wound The nurse is caring for a patient on the medical-surgical unit with a wound that has a drain and a dressing that needs changing. Which action should the nurse take first? A- Provide analgesic medications as ordered B- Avoid accidentally removing the drain C- Don sterile gloves D- Gather supplies A- Provide analgesic medications as ordered Blood pressure cuff (bladder cuff) too narrow falsely high Blood pressure cuff (bladder cuff) too wide falsely low

Arm unsupported during BP reading falsely high Insufficient rest before the BP assessment falsely high Repeating BP assessment too quickly Erroneously high systolic or low diastolic readings Cuff wrapped too loosely or unevenly false high reading Deflating cuff too quickly falsely low systolic and high diastolic readings Deflating cuff too slowly false high diastolic reading Failure to use the same arm consistently inconsistent measurements

Arm above level of the heart false low Assessing immediately after a meal or while client smokes or has pain Falsely high Failure to identify auscultatory gap falsely low systolic pressure and erroneously low diastolic pressure