NUR 2356 FINAL EXAM 2 LATEST VERSIONS 2024-2025 MULTIDIMENSIONAL CARE 1 FINAL, Exams of Nursing

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MULTIDIMENSIONAL CARE 1 FINAL

NUR 2356 FINAL EXAM 2 LATEST VERSIONS 2024-

MULTIDIMENSIONAL CARE 1 FINAL

1. A client with acquired immune deficiency syndrome (AIDS) has Pneumocystis carinii (PCP). What is the nurse's priority assessment for this client?: Lung sounds
2. How many ml is one teaspoon?: 5
3. The client with rheumatoid arthritis is having her rheumatoid factor (RF) drawn while she is having a flare-up of the disease. Which result is seen in clients with rheumatoid arthritis?: A positive rheumatoid factor
4. A nurse is providing education for a client who has glaucoma which of the following statements should the nurse include in the teaching?: "Without treatment, glaucoma can cause blindness."
5. A nurse is caring for an immobile client. What is the priority assessment in this client?: Assessment of skin turgor
6. A client with a diagnosis of human immunodeficiency virus (HIV) develops pneumonia. What type of infection is this?: An opportunistic infection 7. What level of Maslow hierarchy does shelter belong to: physiological
7. A client states that he has been experiencing oozing from his wound. What is the nurse priority?: Inspect the wound and assess the drainage
8. What is not a potential complication of rheumatoid arthritis?:

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Paresthesia 10. The nurse is planning care for a post-operative client after a total hip arthroplasty. What is the priority nursing intervention?: Perform neurovascular assessment per protocol

11. The nurse is providing medication education for a client with osteoarthritis. What teaching should the nurse include in the education?: You should not take more than 4000mg of acetaminophen a day
12. The mother of a new born baby is concerned that the baby will develop illnesses from being around people from outside of their family. What is the nurse's best response?: "Tell me more about that"
13. The nurse is preparing to administer medication to a client with osteoarthritis. what is the goal of medication therapy?: Reduce pain and inflammation
14. The nurse has documented the following wound assessment: "Shallow open, reddened ulcer with no slough on the anterior region of the right heel?" What stage is the wound?: Stage 2 15.. By providing measures to prevent skin breakdown, how does the nurse break the chain of infection: Maintaining the integrity of a portal of entry
15. What is not an appropriate nursing intervention for psoriasis?: apply rubbing alcohol to plaques
16. How many milligrams is 3000 mcg: 3 mg

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18. A client has sustained an open fracture. How can the nurse best prevent osteomyelitis in this client?: Use proper hand hygiene and strict infection control
19. Where will the nurse collect the most reliable source of pain assessment?: From the client 20.. Which of the following would be the most appropriate goal for an elderly client with a nursing diagnosis of risk for injury after hip surgery?: Client will remain free from falls throughout their hospital stay
20. Dry skin (xerosis) can lead to itching (pruritis). What statement by the client indicates a need for further teaching about preventing dry skin?: "I will shower every day in hot water"
21. What client is susceptible host most at risk for infection?: A client with leukemia
22. A nurse is caring for a client who has methicillin resistant staphylococcus aureus (MRSA) in an abdominal wound. The nurse prepares to enter the room to check the client's pulse. What personal protective equipment (PPE) should the nurse don?: Gown
23. What nursing interventions decrease the risk of pressure injuries?: Keep head of bed (HOB) at or less than 30 degrees Padding hard surfaces Place pillows between bony surfaces

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25. The nurse is most concerned about which of these findings in a client with systematic lupus erythematosus?: The client has a butterfly rush
26. A client with lupus may experience Raynaud's phenomenon. What should the nurse include when providing client education about this?: "In order to avoid flare ups of Raynaud's, ensure you wear gloves in winter"
27. The nurse is teaching a client with debilitating rheumatoid arthritis about home safety. Which statement should the nurse include: "There are many adaptive devices such as grab bars, reaching tools, grasping devices, and adaptive silverware available that may help you."
28. A client does not understand why vision loss due to glaucoma is irreversible. What is the nurse's best explanation?: Once the tissue has necrosed from high-pressure, it does not regenerate
29. Which of the following nonpharmacological methods can be used to manage the chronic pain of a client with rheumatoid arthritis?: Adequate rest Heat for 20-30 minutes Hot showers
30. A client is admitted for treatment of a wound. What is true about wound healing and nutrition?: Wound healing is negatively impacted by poor nutrition.

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31. A client is in skeletal traction. With the nurse's assessment. It is noted that the pins appear red, swollen, and there is purulent drainage. What action does the nurse take first?: Collect a culture of the purulent fluid.
32. When providing a routine bed bath, what action does the nurse complete first?: Cleanse the client's face
33. What is a symptom of the expected disease pattern of rheumatoid arthritis?: Bilateral joint pain
34. What can the nurse teach a client with acquired immunodeficiency syndrome (AIDS) to reduce the risk of infection: Avoid raw fruits and vegetables Avoid cleaning your toothbrush with bleach Wash your hands thoroughly
35. A nurse is providing oral hygiene for an unconscious client. What is the priority nursing intervention?: Position the client on one side with the head turned towards you
36. What medication class can decrease tissue inflammation but delay bone healing?: Nonsteroidal ant-inflammatory drugs (NSAIDs)
37. The nurse will be using Braden scale with each admit to the long term care center. Which of these will be utilized in a Braden Scale Assessment?: Friction and shear Nutrition Sensory perception

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38. What are some of the expected outcomes when medications are given for rheumatoid arthritis?: Increased quality of life Decreased pain Increased range of motion Reduced inflammation
39. A client who is sitting in high fowler's position is at risk for what type of injury as the skin layers shift in opposite directions?: Shearing injury 40. What is not appropriate client education on preventing the spread of methicillin resistant staphylococcus aureus (MARSA).: Use a bath sponge to cleanse the skin
40. An area of erythema on the child's skin is being assessed by the nurse. The nurse presses down on the area and the area becomes white. What term does the nurse document for finding?: Blanching
41. A nurse is caring for 25 - year old male quadriplegic client. Which of the following treatments would the nurse perform to decrease the risk of joint contracture and promote joint mobility?: Provide passive range of motion (ROM)
42. What are the risk factors for osteoarthritis?: Older age Sports injuries Obesity Female gender
43. A client is post-operative day 1 and reports a sudden increase in bloodtinged liquid draining from his incision after feeling a popping

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sensation. What is the nurse's next action?: Assess the wound for signs of dehiscence 45. Which of the following statements by a client with human immunodeficiency virus (HIV) requires further teaching?: "I can still have unprotected intercourse with my partner since he doesn't have HIV" "I can spread this through contact with surfaces, so I need to wear gloves in public"

"Because I have HIV, that meant that I'm an AIDS patient"

46. What is the likely reason that a client with acquired immunodeficiency syndrome (AIDS) would succumb to pneumonia while a healthy person exposed to the same infection did not?: The client with AIDS is a susceptible host.
47. The client states "Why am I getting protein supplements while I'm healing from a bed sore?" What is the best response by the nurse?: "Protein has amino acids that promote wound healing."
48. Which of the following clients should be placed in isolation for airborne precautions: A client that recently traveled and developed a fever with cough 49. A homeless client arrives in the emergency room. The client verbalizes an inability to bathe for at least one month. What is the nurse's priority?: inspect the client's skin
49. A client is diagnosed with narcolepsy. What is the nurse's priority intervention?: Inform the client that driving would be dangerous

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51. A nurse providing teaching to an older adult client who has osteoarthritis that is affecting the knees. What statement by the client indicates a correct understanding of the teaching?: "I can use either heat or ice to help relieve the discomfort."
52. The nurse is caring for a client who develops compartment syndrome from a severely fractured arm. The client asks the nurse how this can happen. What is the best response by the nurse?: "Bleeding and swelling cause increased pressure in an area that cannot expand"
53. A postoperative client with a suture abdominal incision felt a sharp abdominal pain after having a bowel movement. Upon inspection, the nurse notices bowel protruding from the incision site. What does the nurse tell the physician about the event?: The client's incisional site has eviscerated.
54. What statement by the client indicates a correct understanding of the timing of progression of human immunodeficiency virus (HIV) to acquired immunodeficiency syndrome (AIDS)?: "If I am re-exposed to HIV, the progression to AIDS may be faster."
55. A nurse caring for a client who is post-operative following an open reduction internal fixation (ORIF) of a femur fracture. What is included in the evaluation of the neurovascular status of the clients affected extremity?: sensation temperature color

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56. A client is experiencing numbness and tingling distal to a new arm cast with no increase in pain. The nurse assesses that the client's fingers are pale and cool. What action does the nurse take next?: Raise the arm above the level of the heart
57. A nurse is obtaining a client's oral temperature. The client informs the nurse that he has just had some ice chips. What is the most appropriate action by the nurse?: Wait 30 minutes to take an oral temperature
58. A client has an abdominal incision. The surgical wound was closed with 10 sutures. This surgical wound is healing by what process?: Primary intention
59. A client has a new diagnosis of human immunodeficiency virus HIV. The client is distraught and does not know what to do. What intervention by the nurse is best?: Assess the client's support system
60. A nurse is assessing a client's vital signs. The oxygen is 85%. What intervention should the nurse perform first?: Raise the head of the bed
61. Which practice is recommended to prevent human immune deficiency virus (HIV) transmission by health care workers?: Using standard precaution
62. A client with systemic sclerosis (scleroderma) has been in bed for two weeks due to fatigue and abdominal pain. Today, the client can into the clinic complaining of her leg being hot, red. and painful. What does the nurse suspect?: Deep vein thrombosis

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63. A nurse is teaching a client who has a new prescription for ibuprofen to treat rheumatoid arthritis. The nurse should teach the client to monitor for what effect of this medication?: constipation
64. What is the nurse's priority action for a client with compromised immunity?: Wash hands before entering the client's room
65. A nurse is teaching a client about adequate nutrition and hydration for the client with acquired immunodeficiency syndrome (AIDS). What is important to teach the client?: Drink at least 2 to 3 L of fluids per day Lower your caloric intake Eat high-calorie foods
66. The nurse is preparing communication for a provider. The client is experiencing acute pain greater than the severity of the fracture. Distal to the injury, he is experiencing a "pins and needles" sensation. The pulse is weak and thready but is bounding on all unaffected extremities. What emergent condition does the nurse suspects?: Compartment syndrome
67. How many ml I is two tablespoons?: 30 mL
68. Which organization publishers the National Patient Goals?: The Joint commission
69. The nurse is caring for four clients. What client should the nurse see first?: A client on Methotrexate with a fever

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70. The nurses notice a new area of skin breakdown near the site of a dressing. This wound is an example of which phase of the nursing process?: assessment 71. A client has cellulitis on his left arm. What statement by the client indicated a correct understanding of symptom management?: "I can use warm, moist towel" 72.. The client complains of fatigue and joint pain and reports that they are unable to walk due to pain in the knees. What is the most appropriate statement by the nurse?: "Please tell me more about when your pain started."
71. A provider has ordered a wound culture for a client with a non-healing wound. What is the nurse's first action?: Put on non-sterile gloves
72. The quality and risk nurse in the local hospital is performing a hospital survey on sentinel events. Which statement would the nurse use best?: An unexpected event involving death or serious physical or psychological injury 75. The nurse is caring for a client with rheumatoid arthritis one day after shoulder injury. What would prompt the nurse to call the provider immediately?: The client has paresthesia in her fingers and intense increasing pain her shoulder
73. The nurse is performing a psychosocial assessment on a client with severe rheumatoid arthritis. What would be the most appropriate statement by the nurse?: "How does this impact your role in your family"

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77. A nurse is admitting a client who has tuberculosis. What transmissionbased precautions should the nurse initiate?: Airborne
78. What is an infectious disease that can be transmitted directly from one person to another?: a communicable disease
79. A nurse is teaching a client who has fibromyalgia bout strategies that might help reduce her symptoms. What should the nurse include in the client education?: Establish a regular sleep pattern
80. The nurse is caring for four clients. Which of these clients will the nurse see first?: A client with sudden and increasing pain in his fractured arm
81. A client has acquired immunodeficiency syndrome (AIDS). Which of these statements' findings indicate possible infection?: Temperature: 101. degrees Fahrenheit Purulent drainage
82. The nurse assesses a deep wound. The area is covered by black necrotic tissue. What term would nurse use when documenting this wound?: Eschar
83. What are the causes of pressure ulcers?: Ischemia Immobility Poor nutrition Moisture

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84. A client has suffered from femur fracture. What is the nurse's priority assessment?: pedal pulses
85. A client on bedrest complains of pain and burning in the right calf area. What is the nurse's next action?: Compare the circumference to the left calf
86. A nurse assesses an area of skin over bony prominence. What findings would be most concerning: Redness
87. The 65-year-old male client who is complaining of blurred vision reports he thinks his glasses need to be cleaned all the time, and he denies any type of eye pain. Which eye disorder should the nurse suspect the client has?: Cataracts
88. A wound has a blood-tinged liquid that is dripping from the surgical site. How does the nurse document this finding?: Serosanguineous
89. A client arrives speaking only Spanish. What is the priority intervention?- : Request a medical interpreter
90. The client had surgery one day ago. What assessment is not likely related to the pain?: blood pressure of 175/90mm Hg
91. A nurse is caring for a client who has a cute osteomyelitis. Which of the following intervention is the nurse's priority?: Administer antibiotic to the client 92. A client is diagnosed with systematic sclerosis (Scleroderma). What symptoms is the first to occur?: Joint pain

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93. Most adults with immunodeficiency virus will exhibit which of the following laboratory values: Lower-than-normal number of CD4+ T-cells and higher than normal CD8 Tcells.
94. The client with rheumatoid arthritis complains of intensely dry eyes. What does the nurse suspect?: Sjogren's syndrome
95. Which statement is a nonverbal sign of pain: Increase in hear rate Decreased attention span grimacing increased agitation
96. Which of the following lab tests may be used for diagnosing connective tissue disease?: Rheumatoid Factor (RF) C-reactive protein (CRP) Anti-nuclear antibody (ANA) Erythrocyte sedimentation rate (ESR)
97. A client has been suffering from arthritis for many years and is experiencing an exacerbation. The client states he has a lot of stress from his position as an administrative assistant, and his job is not getting better. What is the most appropriate response from the nurse?: "You are stating that this job is not getting better. Tell me more about that."
98. A man has been admitted to the hospital unit with a medical diagnosis of chronic obstructive pulmonary disease (COPD). He is receiving

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supplemental oxygen of 2 L/Min via a nasal canula. Which positioning technique will best assist him with his breathing?: Fowler's position

99. A nurse is reviewing factors that increase the risk of urinary tract infections (UTIs) with a client who has recurrent UTIs. Which of the following factors should the nurse include?: Frequent sexual intercourse Location of the urethra closer to the anus Frequent catheterization
100. A nurse is teaching a group of newly licensed nurses on complementary and alternative therapies they can incorporate into their practice without the need for specialized licensing or certification. Which of the following should the nurse encourage them to use?: Guided imagery Meditation Music therapy
101. A nurse is reviewing complementary and alternative therapies with a group of newly licensed nurses. Which of the following interventions are mind-body therapies?: Art therapy Yoga Biofeedback
102. Accepting pauses or silences that may extend for some time without interjecting a verbal response is considered which of the following?: Therapeutic communication

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103. The American Nurse Association exists to advance the nursing profession by: Fostering high standards of nursing practice Advocating on health care issues affecting nurses and the public Promoting a safe and ethical work environment
104. component of the nursing process: Promote professionalism provide a framework for use of skills promote use of critical thinking
105. A client states that they will schedule massages as well as take their prescribed medication for pain control. What is this an example of: Complementary therapy
106. A nurse is telling a new mother from Africa that she shouldn't carry her baby in a sling created from a large rectangular cloth. The African woman tells the nurse that everyone in Mozambique carries babies this way. The nurse believes bassinets are safer for infants, what is this scenario an example of?: Cultural Imposition
107. What factors may interfere with sleep?: Medications

A stressful job A large meal right before bedtime Anxiety

108. When a labor and delivery nurse tells a coworker that an asian client probably did not want any pain medication because Asian women typically are stoic, "the nurse expresses a belief known as what?: Stereotype

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109. A client begins to fall while the nurse is assisting with ambulation, what is the priority nursing intervention?: Guide the client safely to the floor 110. Which organization publishes the National patient safety Goals: The joint Commission
110. What complication may be a result of decreased mobility: Pressure injuries 112. A client just received a diagnosis of cancer. Which statement by the nurse best demonstrates empathy?: This must be hard news to hear. Tell me more about it
111. Which set of vital signs, taken on an adult, is cause for concern and requires further evaluation?: Temperature 97.F; pulse 54 bpm; respirations 14 breaths/minute; blood pressure 196/114 mmHg
112. A nurse observes an unlicensed assistive personnel (UAP) obtaining vitals from a client with hearing loss. Which of the following actions by the unlicensed assistive personnel causes the nurse to provide further education to improve communication?: UAP is chewing gum while taking
113. A nurse in the transitional care unit is reviewing the client's electronic health record from the hospital before the client arrives at the unit. What phase of the therapeutic relationship are the nurse and client: pre-interaction
114. What is the most reliable source used to measure pain?: The client 117. To decrease a client's risk of injury when ambulating to the bathroom at night,

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which of the following interventions would the nurse implement?: Remove obstacles between the bed and the bathroom

118. A client states, I don't know what to do. My life is a mess. "What is an inappropriate response by the nurse: Don't worry, everything will be fine
119. , What level of Maslow's hierarchy of needs does food belong to?: Physiological
120. What is the primary purpose of an incident report?: device used in identifying opportunities for improvement
121. A client recently arrived at the medical-surgical unit following laparoscopic cholecystectomy. During the nurse assessment, the client complains of pain at the incision site. What type of pain is the client experiencing?: Nociceptive 122. A client has decreased mobility, what nursing intervention would be appropriate to promote mobility: Teach the client to do active range of motion (AROM) Exercises every 2 hours
122. A nurse enters a client's room and states, Hello, I am Roger, and I will be your nurse today. What is your preferred name while we work together today? What phase of the therapeutic relationship does this interaction occur in?: Orientation phase

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124. A client has immigrated from the United States to mexico. Over time the client begins to eat more local foods and learn spanish. What is this an example of?: Assimilation
125. The nurse is teaching a community group about poisoning prevention. Which of the following statements from an attendee would indicate the need for further teaching: I should immediately induce vomiting if I suspect poisoning
126. A nurse is assisting with a transfer from the wheelchair to their bed. Which of the following is not a priority action of the nurse to nurse to ensure client safety?: Place the bed in a high fowler's position
127. Which of the following are the sequential steps to the nursing process?- : Assessment, Analysis, Planning, Implementation, Evaluation
128. For which of the following reasons is the client's culture important to their healthcare?: Culture defines values, dimensions factors, and disparities
129. A client recently migrated from Mexico to the United States and lives in a Spanish speaking community with other relatives. Following a fall at work, the client is taken to the ER and admitted to the hospital for observation. This client is at risk for which of the following?: Cultural shock
130. What is true about side rails?: Split rails are considered restraints even if a client requests them to feel more secure

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131. A client has an area of ecchymosis on their coccyx. What is the best intervention by the nurse to prevent further skin and tissue breakdown?: Reposition the client to relieve pressure
132. Non-pharmacological interventions for pain management include which of the following?: Transcutaneous electrical nerve stimulation (TENS) Cold therapy Acupuncture Deep Breathing
133. What expected physiological changes of the older adult put them at risk of fall?: Reduced muscle strength Sensory losses like vision and hearing Slowing of reflexes
134. The nurse knows which of the following is a "never event": A surgical sponge is left in a client's surgical site
135. What is an example of non-verbal communication by a nurse?: Eye contact
136. The nurse is caring for a 65 year-old client and notes a temperature of

How does the nurse interpret this finding?: Hypothermia

137. A nurse is caring for a patient recently diagnosed with lung cancer. Based on testing, there is no indication that the cancer has spread to

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the other organs. The client is scheduled for surgery to have lobectomy performed. This is classified as, which type of surgical treatment?: Curative

138. The patient who has undergone which surgical procedure is most at risk for hypocalcemia?: Thyroidectomy
139. A nurse is providing education to a client and family that is undergoing radiation as a part of his cancer treatment plan for brain tumor. Which of the following are side effects of radiation?: Skin irritation Cerebral edema Alopecia
140. what are the normal values for serum sodium?: 135-145 mEq/L 141. what is the step in which normal cells become damaged? This step is irreversible and leads to concern development.: initiation
141. A nurse is caring for a 90-year-old female admitted for nausea, vomiting, and diarrhea for the best five days. Heart rate is 130 bpm, blood pressure is 96 / 50 mmHg: mucous membrane is dry, and the client has poor skin turgor. Which of the following is an appropriate fluid replacement for this client?: Isotonic 143. The provider wants to administer an isotonic solution to the client. Which of the following concentration is considered an ionic solution?: 0.9% NaCl 144. a client would like to know what it means that her Breast cancer has metastasized. What does this mean?: Cancer cells have moved from their primary sites

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145. A client presented to the emergency department with increased shortness of breath and pitting edema of his lower extremities. The client recently saw his primary doctor, who increased his furosemide. The client has a history of heart failure and diabetes. The client's laboratory findings are as follows: Na 150mEq/L Potassium 2.5 mEq/L. Which of the following electrolyte imbalance is the client exhibiting?: hypernatremia and hypokalemia
146. 4. a nurse is caring for a client who presents with a new onset of seizures, confusion and muscle tremors. Her laboratory results revealed hypomagnesemia. Which of the following would be a cause of hypomagnesemia?: Alcoholism
147. Tumor lysis syndrome is an example of what type of oncological emergency?: Hematologic
148. What serum laboratory value does the nurse expect to see in a client with hypokalemia?: Potassium less than 3.5 mEq/L
149. A nurse should instruct the client to follow which strategies to prevent cancer?: Smoking cessation Avoid alcohol Vaccination Diet low in saturated fats

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150. A nurse is providing client and family education. Which of the following examples would indicate the client's and family's understand of secondary cancer prevention?: Mammogram 151.. An outdoor construction worker with profuse diaphoresis is at risk for which of the following conditions?: hyponatremia
151. A nurse is caring for a client recently diagnosed cancer who is exhibiting signs and symptoms of superior vena cava syndrome. Which of the following is priority medical treatment for their relief of airway obstruction?: High dose radiation
152. A nurse is caring for a client who presented to the emergency department with nagging cough, unusual bleeding, and changes in bowel and bladder habits. Based on these findings, the nurse would anticipate which of the following diagnosis?: Cancer
153. Which of the following are causes of hypovolemia?: blood loss fever vomiting
154. A client undergoing chemotherapy is receiving education about reduction of infection risk. Which action reduces the risk of infection?: Hand hygiene 156. What does the nurse expect when left palmar flexion in response to a blood pressure cuff's inflation is assessed in a client?: Hypoglycemia, and it's called a positive to Trousseau's sign

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157. A nurse is caring for a client with a diagnosis of hypernatremia. Which of the following assessment findings would the nurse expect to see?: Increased thirsty

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158 A nurse should instruct a client with a positive family history of colon cancer to adhere to which of the following recommendation?: Encourage baseline colonoscopy screening

159. A nurse is caring for a client who is undergoing external radiation treatment for liver cancer. What information needs to be provided to the client and the family?: Importance of maintaining external markings for future treatment 160. The nurse knows that which side effect of chemotherapy is the most serious?: Bone marrow suppression
160. Cancer management requires a collaborative approach, including establishing a multidisciplinary team. After diagnosis which is the next priority step?: developing a treatment plan
161. A nurse is caring for a client presently diagnosed with cancer and undergoing chemotherapy. A review of the morning labs refill hyperphosphatemia, hyperkalemia, hyperuricemia. Based on the laboratory findings, which of the following conditions is the patient exhibiting?: Tumor lysis syndrome 163. Which of the following cancers arise from blood cell forming tissue?: leukemias
162. Patients diagnosed with cancer who have exhausted all treatment options are good candidates for:: Palliative care 165.. A nurse is caring for a newly diagnosed leukemia patient who recently completed the initial round of chemotherapy. Which of the following should be included in the patient and family education?: The client is at increased risk of developing mucositis