NUR 2571 / NUR2571 Exam 3 (Latest 2021 / 2022): Professional Nursing II / PN 2 - Rasmussen, Exams of Nursing

Download NUR 2571 / NUR2571 Exam 3 (Latest 2021 / 2022): Professional Nursing II / PN 2 - Rasmussen and more Exams Nursing in PDF only on Docsity! NUR2571 Exam 3 Professional Nursing II / PN 2 Know what the left temporal lobe of brain affects as far as the senses 1. 1. Anurse prepares to teach a client who has experienced damage to the left temporal lobe of the brain. Which action should the nurse take when providing education about newly prescribed medications to this client? a. Help the client identify each medication by its color. b. Provide written materials with large print size. c. Sit on the clients right side and speak into the right ear. d. Allow the client to use a white board to ask questions. ANS: C The temporal lobe contains the auditory center for sound interpretation. The clients hearing will be impaired in the left ear. The nurse should sit on the clients right side and speak into the right ear. The other interventions do not address the clients left temporal lobe damage. Know what hypoactive deep tendon reflexes affect 2. A nurse plans care for a client who has a hypoactive response to a test of deep tendon reflexes. Which intervention should the nurse include in this clients plan of care? a. Check bath water temperature with a thermometer. b. Provide the client with assistance when ambulating. c. Place elastic support hose on the clients legs. d. Assess the clients feet for wounds each shift. ANS: B Hypoactive deep tendon reflexes and loss of vibration sense can impair balance and coordination, predisposing the client to falls. The nurse should plan to provide the client with ambulation assistance to prevent injury. The other interventions do not address the clients problem. Know what things can interfere with MRI scans 10. A nurse obtains a focused health history for a client who is scheduled for magnetic resonance imaging (MRI). Which condition should alert the nurse to contact the provider and cancel the procedure? a. Creatine phosphokinase (CPK) of 100 IU/L b. Atrioventricular graft c. Blood urea nitrogen (BUN) of 50 mg/dL d. Internal insulin pump ANS: D Metal devices such as internal pumps, pacemakers, and prostheses interfere with the accuracy of the image and can become displaced by the magnetic force generated by an MRI procedure. An atrioventricular graft does not contain any metal. CPK and BUN levels have no impact on an MRI procedure. 14. After teaching a client who is scheduled for magnetic resonance imaging NIU Viv ae ON a Xe) g a) (¢)\ Ven Oe) en aa (MRI), the nurse assesses the clients understanding. Which client statement indicates a correct understanding of the teaching? a. | must increase my fluids because of the dye used for the MRI. b. My urine will be radioactive so | should not share a bathroom. c. | can return to my usual activities immediately after the MRI. d. My gag reflex will be tested before | can eat or drink anything. ANS: C No postprocedure restrictions are imposed after MRI. The client can return to normal activities after the test is complete. There are no dyes or radioactive materials used for the MRI; therefore, increased fluids are not needed and the clients urine would not be radioactive. The procedure does not impact the clients gag reflex. Know what a single-photon emission computed tomography (SPECT) scan is and if there is any care required afterwards 20. A nurse cares for a client who is recovering from a single-photon emission computed tomography (SPECT) with a radiopharmaceutical agent. Which statement should the nurse include when discussing the plan of care with this client? a. You may return to your previous activity level immediately. b. You are radioactive and must use a private bathroom. c. Frequent assessments of the injection site will be completed. d. We will be monitoring your renal functions closely. ANS: A The client may return to his or her previous activity level immediately. Radioisotopes will be eliminated in the urine after SPECT, but no monitoring or special precautions are required. The injection site will not need to be assessed after the procedure is complete. Know what imitrex is and any side effects associated with it 3. A nurse obtains a health history on a client prior to administering prescribed sumatriptan succinate (Imitrex) for migraine headaches. Which condition should alert the nurse to hold the medication and contact the health care provider? a. Bronchial asthma b. Prinzmetals angina c. Diabetes mellitus d. Chronic kidney disease ANS: B Sumatriptan succinate effectively reduces pain and other associated symptoms of migraine headache by binding to serotonin receptors and triggering cranial vasoconstriction. Vasoconstrictive effects are not confined to the cranium and can cause coronary vasospasm in clients with Prinzmetals angina. The other conditions would not affect the clients treatment. What is bacterial meningitis and how is it contracted? 9. Anurse obtains a focused health history for a client who is suspected of having bacterial meningitis. Which question should the nurse ask? NIU Viv ae ON a Xe) g a) (¢)\ Ven Oe) en aa a. This is a sign of fatigue. The client would benefit from a daily nap. b. Engage the client in scheduled activities throughout the day. c. It sounds like this is difficult for you. | will consult the social worker. NIU Viv ae ON a Xe) g a) (¢)\ Ven Oe) en aa (ola d. The provider can prescribe a mild sedative for restlessness. ANS: B Several strategies may be used to cope with restlessness and wandering. One strategy is to engage the client in structured activities. Another is to take the client for frequent walks. Daily naps and a mild sedative will not be as effective in the management of restless behavior. Consulting the social worker does not address the caregivers concern. 17. A nurse prepares to discharge a client with Alzheimers disease. Which statement should the nurse include in the discharge teaching for this clients caregiver? a. Allow the client to rest most of the day. b. Place a padded throw rug at the bedside. c. Install deadbolt locks on all outside doors. d. Provide a high-calorie and high-protein diet. ANS: C How do you treat lower back pain? 1. A nurse promotes the prevention of lower back pain by teaching clients at a community center. Which instruction should the nurse include in this education? a. Participate in an exercise program to strengthen muscles. b. Purchase a mattress that allows you to adjust the firmness. c. Wear flat instead of high-heeled shoes to work each day. d. Keep your weight within 20% of your ideal body weight. ANS: A Exercise can strengthen back muscles, reducing the incidence of low back pain. The other options will not prevent low back pain. 2. A nurse plans care for a client with lower back pain from a work-related injury. Which intervention should the nurse include in this clients plan of care? a. Encourage the client to stretch the back by reaching toward the toes. b. Massage the affected area with ice twice a day. c. Apply a heating pad for 20 minutes at least four times daily. d. Advise the client to avoid warm baths or showers. ANS: C Heat increases blood flow to the affected area and promotes healing of injured nerves. Stretching and ice will not promote healing, and there is no need to avoid warm baths or showers. 4. A nurse assesses clients at a community center. Which client is at greatest risk for lower back pain? a. A 24-year-old female who is 25 weeks pregnant b. A36-year-old male who uses ergonomic techniques c. A 45-year-old male with osteoarthritis d. A53-year-old female who uses a walker ANS: C NIU Viv ae ON a Xe) g a) (¢)\ Ven Oe) en aa Osteoarthritis causes changes to support structures, increasing the clients risk for low back pain. The other clients are not at high risk. What happens with spinal cord injuries at level T5? Clinical manifestations? 7. A nurse assesses a client with a spinal cord injury at level T5. The clients blood pressure is 184/95 mm Hg, and the client presents with a flushed face and blurred vision. Which action should the nurse take first? a. Initiate oxygen via a nasal cannula. b. Place the client in a supine position. c. Palpate the bladder for distention. d. Administer a prescribed beta blocker. ANS: C The client is manifesting symptoms of autonomic dysreflexia. Common causes include bladder distention, tight clothing, increased room temperature, and fecal impaction. If persistent, the client could experience neurologic injury. Precipitating conditions should be eliminated and the physician notified. The other actions would not be appropriate. 7. Anurse assesses a client who experienced a spinal cord injury at the T5 level 12 hours ago. Which manifestations should the nurse correlate with neurogenic shock? (Select all that apply.) a. Heart rate of 34 beats/min b. Blood pressure of 185/65 mm Hg c. Urine output less than 30 mL/hr d. Decreased level of consciousness e. Increased oxygen saturation ANS: A, C, D Neurogenic shock with acute spinal cord injury manifests with decreased oxygen saturation, symptomatic bradycardia, decreased level of consciousness, decreased urine output, and hypotension. What happens in cervical spine injuries? Clinical manifestations? 8. An emergency room nurse initiates care for a client with a cervical spinal cord injury who arrives via emergency medical services. Which action should the nurse take first? a. Assess level of consciousness. b. Obtain vital signs. c. Administer oxygen therapy. d. Evaluate respiratory status. ANS: D The first priority for a client with a spinal cord injury is assessment of respiratory status and airway patency. Clients with cervical spine injuries are particularly Prone to respiratory compromise and may even require intubation. The other assessments should be performed after airway and breathing are assessed What is the purpose of rehabilitation for patients with paraplegia? NIU Viv ae ON a Xe) g a) (¢)\ Ven Oe) en aa b. Low fluid volume c. Inadequate airway d. Potential for skin breakdown ANS: C Airway takes priority. Anxiety is probably present, but a physical diagnosis takes Priority over a psychosocial one. The client has no reason to have low fluid volume unless he or she has been unable to drink for some time. If present, airway problems take priority over a circulation problem. An actual problem takes precedence over a risk for a problem. 12. An older client is hospitalized with Guillain-Barr syndrome. A family member tells the nurse the client is restless and seems confused. What action by the nurse is best? a. Assess the clients oxygen saturation. b. Check the medication list for interactions. c. Place the client on a bed alarm. d. Put the client on safety precautions. ANS: A In the older adult, an early sign of hypoxia is often confusion and restlessness. The nurse should first assess the clients oxygen saturation. The other actions are appropriate, but only after this assessment occurs. 4. An older adult client is hospitalized with Guillain-Barr syndrome. The client is given amitriptyline (Elavil). After receiving the hand-off report, what actions by the nurse are most important? (Select all that apply.) a. Administering the medication as ordered b. Advising the client to have help getting up c. Consulting the provider about the drug d. Cutting the dose of the drug in half e. Placing the client on safety precautions ANS: B, C, E 5. The nurse caring for a client with Guillain-Barr syndrome has identified the Priority client problem of decreased mobility for the client. What actions by the nurse are best? (Select all that apply.) a. Ask occupational therapy to help the client with activities of daily living. b. Consult with the provider about a physical therapy consult. c. Provide the client with information on support groups. d. Refer the client to a medical social worker or chaplain. e. Work with speech therapy to design a high-protein diet. ANS: A, B, E How do patients protect their eyes? What teaching can we provide? 1. The nurse has given a community group a presentation on eye health. Which statement by a participant indicates a need for more instruction? a. | always lose my sunglasses, so! dont wear them. b. | have diabetes and get an annual eye exam. c. | will not share my contact solution with others. NIU Viv ae ON a Xe) g a) (¢)\ Ven Oe) en aa d. | will wear safety glasses when | mow the lawn. ANS: A Know the normal range for the IOP 5. Aclients intraocular pressure (IOP) is 28 mm Hg. What action by the nurse is best? a. Educate the client on corneal transplantation. b. Facilitate scheduling the eye surgery. c. Plan to teach about drugs for glaucoma. d. Refer the client to local Braille classes. ANS: C This increased IOP indicates glaucoma. The nurses main responsibility is teaching the client about drug therapy. Corneal transplantation is not used in glaucoma. Eye surgery is not indicated at this time. Braille classes are also not indicated at this time. What should we teach patients about eye drops? How do they instill eye drops? 2. A client is seen in the ophthalmology clinic with bacterial conjunctivitis. Which statements by the client indicate a good understanding of home management of this condition? (Select all that apply.) a. As long as | dont wipe my eyes, | can share my towel. b. Eye irrigations should be done with warm saline or water. c. | will throw away all my eye makeup when | get home. d. | wont touch the tip of the eyedrop bottle to my eye. e. When the infection is gone, | can use my contacts again. ANS: C, D How do you treat external otitis? 5. A client has external otitis. On what comfort measure does the nurse instruct the client? a. Applying ice four times a day b. Instilling vinegar-and-water drops c. Use of a heating pad to the ear d. Using a home humidifier ANS: C A heating pad on low or a warm moist pack can provide comfort to the client with otitis externa. The other options are not warranted. What are the steps for instilling ear drops? 10. A nursing student is instructed to remove a clients ear packing and instill eardrops. What action by the student requires intervention by the registered nurse? a. Assessing the eardrum with an otoscope b. Inserting a cotton ball in the ear after the drops c. Warming the eardrops in water for 5 minutes d. Washing the hands and removing the packing NIU Viv ae ON a Xe) g a) (¢)\ Ven Oe) en aa ANS: D The student should wash his or her hands, don gloves, and then remove the packing. The other actions are correct. What should you teach patients concerning how to prevent hearing loss? 13. A nurse is teaching a community group about preventing hearing loss. What instruction is best? a. Always wear a bicycle helmet. b. Avoid swimming in ponds or lakes. c. Dont go to fireworks displays. d. Use a soft cotton swab to clean ears. ANS: A Avoiding head trauma is a practical way to help prevent hearing loss. Swimming can lead to hearing loss if the client has repeated infections. Fireworks displays are loud, but usually brief and only occasional. Nothing smaller than the clients fingertip should be placed in the ear canal. What is mastoiditis and what complications can occur from it? -No answer for this one.. "Mastoiditis is an infection of the mastoid air cells caused by progressive otitis media. Antibx therapy is used to treat the middle ear infection before it progresses to mastoiditis. If mastoiditis is not managed appropriately, it can lead to brain abscess, meningitis and death. Know what labs to check with diabetes and polyuria -keytones and specific gravity, AlC 1.A nurse is teaching a client with diabetes mellitus who asks, Why is it necessary to maintain my blood glucose levels no lower than about 60 mg/dL? How should the nurse respond? Glucose is the only fuel used by the body to produce the energy that it needs. a b. Your brain needs a constant supply of glucose because it cannot store it. c Without a minimum level of glucose, your body does not make red blood cells. d Glucose in the blood prevents the formation of lactic acid and prevents acidosis. ANS: B 2.A nurse reviews laboratory results for a client with diabetes mellitus who presents with polyuria, lethargy, and a blood glucose of 560 mg/dL. Which laboratory result should the nurse correlate with the clients polyuria? a. Serum sodium: 163 mEq/L NIU Viv ae ON a Xe) g a) (¢)\ Ven Oe) en aa Deep and fast respirations Decreased urine output a b. c. Tachycardia d Dependent pulmonary crackles e Orthostatic hypotension ANS: A, C, E DKA leads to dehydration, which is manifested by tachycardia and orthostatic hypotension. Usually clients have Kussmaul respirations, which are fast and deep. Increased urinary output (polyuria) is severe. Because of diuresis and dehydration, peripheral edema and crackles do not occur. Know how to detect decreased kidney function and know the normal value for urine specific gravity 29.4 nurse assesses a client with diabetes mellitus. Which clinical manifestation should alert the nurse to decreased kidney function in this client? Urine specific gravity of 1.033 a b. Presence of protein in the urine c Elevated capillary blood glucose level d Presence of ketone bodies in the urine ANS: B Renal dysfunction often occurs in the client with diabetes. Proteinuria is a result of renal dysfunction. Know which electrolytes are affected by insulin and why 32.A nurse reviews the laboratory results of a client who is receiving intravenous insulin. Which should alert the nurse to intervene immediately? Serum chloride level of 98 mmol/L a b. Serum calcium level of 8.8 mg/dL c Serum sodium level of 132 mmol/L d Serum potassium level of 2.5 mmol/L ANS: D Insulin activates the sodium-potassium ATPase pump, increasing the movement of potassium from the extracellular fluid into the intracellular fluid, resulting in hypokalemia. In hyperglycemia, hypokalemia can also result from excessive urine loss of potassium. The chloride level is normal. The calcium and sodium NIU Viv ae ON a Xe) g a) (¢)\ Ven Oe) en aa levels are slightly low, but this would not be related to hyperglycemia and insulin administration. Know which medications are safe or not safe to give after IV contrast has been given (Actos, Amaryl, Glucotrol, Glucophage) 39.4 nurse reviews the medication list of a client recovering from a computed tomography (CT) scan with IV contrast to rule out small bowel obstruction. Which medication should alert the nurse to contact the provider and withhold the prescribed dose? Pioglitazone (Actos) a. b. Glimepiride (Amaryl) c. Glipizide (Glucotrol) d. Metformin (Glucophage) ANS: D Glucophage should not be administered when the kidneys are attempting to excrete IV contrast from the body. This combination would place the client at high risk for kidney failure. The nurse should hold the metformin dose and contact the provider. The other medications are safe to administer after receiving IV contrast. Know the normal ranges for : Fasting blood glucose, postprandial blood glucose, hemoglobin AlC 41.4 nurse reviews laboratory results for a client with diabetes mellitus who is prescribed an intensified insulin regimen: Fasting blood glucose: 75 mg/dL Postprandial blood glucose: 200 mg/dL Hemoglobin A.. level: 5.5% How should the nurse interpret these laboratory findings? Increased risk for developing ketoacidosis a. b. Good control of blood glucose c. Increased risk for developing hyperglycemia d. Signs of insulin resistance ANS: B NIU Viv ae ON a Xe) g a) (¢)\ Ven Oe) en aa (ola The client is maintaining blood glucose levels within the defined ranges for goals in an intensified regimen. Because the clients glycemic control is good, he or she is not at higher risk for ketoacidosis or hyperglycemia and is not showing signs of insulin resistance. Know complications that occur after an implantation of a vagal nerve- stimulation device 8. A nurse assesses a client who is recovering from the implantation of a vagal nerve stimulation device. For which clinical manifestations should the nurse assess as common complications of this procedure? (Select all that apply.) a. Bleeding b. Infection c. Hoarseness d. Dysphagia e. Seizures ANS: C, D Know what meningitis is and what lab values can be affected 9. A nurse is caring for a client with meningitis. Which laboratory values should the nurse monitor to identify potential complications of this disorder? (Select all that apply.) a. Sodium level b. Liver enzymes c. Clotting factors d. Cardiac enzymes e. Creatinine level ANS: A, C Know the care of a patient wearing a halo fixator 8. A nurse plans care for a client with a halo fixator. Which interventions should the nurse include in this clients plan of care? (Select all that apply.) a. Tape a halo wrench to the clients vest. b. Assess the pin sites for signs of infection. c. Loosen the pins when sleeping. d. Decrease the clients oral fluid intake. e. Assess the chest and back for skin breakdown. ANS: A, B, E Know what Meniere’s disease is and the clinical manifestations No answer for this one? Meniere’s disease usually first occurs in people between the age of 20 and 50y/o. Its has 3 features tinnitus, one -sided sensor neural NIU Viv ae ON a Xe) g a) (¢)\ Ven Oe) en aa The nurse is preparing a patient for a Tensilon (edrophonium chloride) test. What action by the nurse is most important? “Obtaining atropine sulfate” A nurse cares for a patient with amyotrophic lateral sclerosis (ALS). The patient states “I do not want to be placed on a mechanical ventilator.” How would the nurse respond? “What would you like to be done if you begin to have difficulty breathing?” A nurse teaches a patient with a lower motor neuron lesion who wants to achieve bladder control. Which statement would the nurse include in this patient’s teaching? “Tighten your abdominal muscles to stimulate urine flow” A nurse assesses a patient who is recovering from anterior cervical discectomy and fusion. Which complication would alert the nurse to urgently communicate with the healthcare provider? “Auscultated stridor” A nurse delegates care for a client with early stage Alzheimer’s disease to an unlicensed assistive personnel (UAP). Which statement would the nurse include when delegating this client’s care? “Reorient the client to the day, time, and environment with each contact.” A nurse delegates care for a client with Parkinson disease to an unlicensed assistive personnel (UAP). Which statement would the nurse include when delegating this client’s care? “Allow the client to be as independent as possible with activities.” A nurse is teaching care to the unlicensed assistive personel (UAP). Which statement would the nurse include when delegating care for a patient with cranial nerve II impairment? “tell the patient where food items are on the breakfast tray” A nurse is teaching a patient with cerebellar function impairment. Which statement would the nurse include in this patient’s discharge teaching? “Ask a friend to drive you to your follow-up appointments.” NIU Viv ae ON a Xe) g a) (¢)\ Ven Oe) en aa (ola A nurse performs an assessment of pain discrimination on an older adult patient. The patient correctly identifies, with eyes closed, a sharp sensation on the right hand when touched with a pin. Which action would the nurse take next? Touch the pin on the same area of the left hand A nurse plans care for an 83-year old patient who is experiencing age-related sensory perception changes. Which intervention would the nurse include in this patient’s plan of care? Ensure that the path to the bathroom is free from clutter. A nurse obtains a focused health history for a patient who is scheduled for magnetic resonance angiography. Which priority question would the nurse ask before the test? “Do you have allergies to iodine or shellfish?” A nurse asks a patient to take deep breaths during an electroencephalography. The patient asks, “Why are you asking me to do this?” how would the nurse respond? “Hyperventilation causes cerebral vasoconstriction and increases the likelihood of seizure activity” A nurse assesses a patient who demonstrates a positive Romberg’s sign with eyes closed but not with eyes open. Which condition does the nurse associate with this finding? Difficulty with proprioception NIU Viv ae ON a Xe) g a) (¢)\ Ven Oe) en aa