NURS 221 QUESTIONS AND ANSWERS 2024, Exams of Nursing

Download NURS 221 QUESTIONS AND ANSWERS 2024 and more Exams Nursing in PDF only on Docsity! NURS 221 QUESTIONS Which term is most appropriate for describing a healthcare practitioner who is respectful of the healthcare traditions of other cultures? A. Culturally appropriate B. Culturally impositive C. Culturally sensitive D. Culturally competent - correct answer ✔C The nurse is caring for several clients on a telemetry unit. Which clients' pulse rates need to be assessed for 1 full minute? Select all that apply. A. clients with fast pulse rates B. clients with irregular pulse rates C. clients with abnormally slow pulse rates D. clients with regular rhythms E. clients recovering from anesthesia - correct answer ✔A, B, C A nurse is explaining the use of sleep hygiene to a client experiencing insomnia. Which statement accurately describes recommended guidelines for the use of this technique? Select all that apply. A. Drink an alcoholic beverage before bedtime. B. Take a warm bath before bedtime. C. Eat a light meal before bedtime. D. Sleep in a dark room that is as warm as possible. E. Take frequent naps during the day. - correct answer ✔B, C The nurse is teaching a novice nurse about the therapeutic effects of laughter. Which example correctly identifies one of these effects? A. It decreases heart rate. B. It causes shallow breathing. C. It decreases the pain threshold. D. It activates the immune system. - correct answer ✔D The nurse observes the client's frequent use of the incentive spirometer. The client states "I do not want to have pneumonia while in the hospital." Which vital sign reading demonstrates effectiveness of this intervention? A. Respiratory rate of 8 breaths per minute B. Blood pressure of 126/84 mm Hg C. Pulse rate of 100 beats per minute D. Temperature of 98.2°F (36.7°C) - correct answer ✔D The nurse is caring for a client with terminal bone cancer. The client states, "My pain is getting worse and worse and the morphine doesn't help anymore." How would the nurse document the type of pain experienced by this client? A. Acute B. Diffuse C. Chronic D. Intractable - correct answer ✔D The nurse is implementing comfort measures to promote sleep for a client. Which intervention is the best choice for the client? A. Encourage the client to take a shower prior to bedtime. B. Create a warm, dark environment in the clients' rooms. C. Offer client a small carbohydrate and protein snack before bedtime. D. Have the client set an alarm clock so they are not worried about getting up. - correct answer ✔C B. Encourage client to eat alone for privacy during mealtime. C. Encourage client to decrease protein, but increase calcium intake. D. Provide frequent oral hygiene, especially before meals. E. Encourage client to eat 1 to 2 hours before breathing treatments and exercises. - correct answer ✔A, D A nurse monitoring an IV infusion notes the signs and symptoms of a thrombus. Which nursing interventions would the nurse perform? Select all that apply. A. Stop the infusion immediately. B. Apply warm compresses as ordered by the primary care provider. C. Monitor vital signs and pulse oximetry. D. Restart the IV at another site. E. Rub or massage the affected area. F. Place client on left side in Trendelenburg position. - correct answer ✔A, B, D The nurse is providing care to a client who has a serum potassium level of 5.2 mEq/L (5.2 mmol/L). Which findings would the nurse expect to assess? Select all that apply. A. Polyuria B. Muscle weakness C. Cardiac dysrhythmia D. Diarrhea E. Polydipsia - correct answer ✔C, D A client suffers from a genetic bleeding deficiency involving a deficit in factor VIII. Which blood product will the nurse most likely administer? A. Whole blood B. Albumin C. Platelets D. Cryoprecipitate - correct answer ✔D A new graduate nurse is performing a focused respiratory assessment. The nurse preceptor will intervene if which action by the graduate nurse is noted? A. The graduate nurse auscultates breath sounds as the client breathes through the nose. B. The graduate nurse palpates the point of maximal impulse (PMI). C. The graduate nurse attaches a pulse oximeter to the client's index finger. D. The graduate nurse explains the assessment procedure before performing it. - correct answer ✔A The client is having difficulty breathing. The respiratory rate is 44 and the oxygen saturation is 89% (0.89 L). The nurse raises the head of the bed and applies oxygen at 3 L/min per nasal cannula. How does the nurse determine the effectiveness of the interventions? Select all that apply. A. The client's oxygen saturation level increases. B. The client states, "I can breathe easier now." C. The client's respiratory rate decreases. D. The client's family asks if the client is going to be okay. E. The client is watching television. - correct answer ✔A, B, D An older adult client has lost significant muscle mass during recovery from a systemic infection. As a result, the client has made no progress toward meeting any of the outcomes for mobility and activities of daily living that are specified in the nursing plan of care. How should the nurse best respond to this situation? A. Terminate the plan of care because it does not now accurately reflect the client's abilities. B. Continue the current plan of care with the hope that the client will achieve the outcomes. C. Modify the plan of care to better reflect the client's current functional ability. D. Replace the client's individualized plan of care with a clinical pathway. - correct answer ✔C The nurse developed a plan for a client and has been working with the client for several months. The client reports feeling better due to an ability now to participate actively in water aerobics. What type of outcome is this? A. Psychomotor B. Physiologic C. Cognitive D. Affective - correct answer ✔A The nurse is responsible for recognizing significant data when developing nursing diagnoses. Which significant data would indicate a health problem may exist? Select all that apply. A. The client's urine output of 30 mL per hour is recorded. B. The client has an oral temperature of 98.7°F (37.0°C). C. The client has a blood pressure reading of 150/90 mm Hg. D. During assessment, the client is sweating and short of breath. E. The client only answers yes or no questions. - correct answer ✔C, D, E Which are accurate guidelines when formulating nursing diagnoses? Select all that apply. A. Write the diagnosis in legally advisable terms. B. Be sure the problem statement indicates what is unhealthy about the client. When used in a nursing diagnosis, the descriptor "impaired" has which meaning? A. Late, slow, or postponed B. Weakened or damaged C. Lack of proportion or relation between corresponding things D. Consisting of many interconnecting parts or elements - correct answer ✔B The nurse is assessing the wounds of clients. Which clients would the nurse place at risk for delayed wound healing? Select all that apply. A. a client who is taking corticosteroid drugs B. a client who is obese C. an older adult who is confined to bed D. a client with a peripheral vascular disorder E. a client who eats a diet high in vitamins A and C F. a 10-year-old client with a surgical incision - correct answer ✔A, B, C, D A nurse is caring for clients with alterations in mobility. Which nursing interventions are recommended for these clients? Select all that apply. A. For constipation, increase fluid intake and roughage. B. For increased cardiac workload, instruct the client to lie in the prone position. C. For impaired skin integrity, reposition the client in correct alignment at least every 1 to 2 hours. D. For ineffective breathing patterns, encourage shallow breathing and coughing. E. For impaired physical mobility, perform ROM exercises every 2 hours. F. For orthostatic hypotension, have the client sleep sitting up or in an elevated position. - correct answer ✔A, C, F Two nurses will transfer an older adult client from her bed to a chair later in the day. How can the nurses best facilitate a successful transfer? A. Avoid using handling aids unless absolutely necessary. B. Use assistive devices if either of the nurses will need to lift more than 60 lb (27.2 kg). C. If the client is in pain, administer analgesics in advance of the transfer. D. To ensure safety, do not allow the client to assist with the transfer. - correct answer ✔C A nurse is obtaining a wound culture from a sacral pressure injury. After swabbing the area, the nurses determines that the wound was not cleaned. What is the priority action by the nurse? A. Obtain the swab and then clean the wound B. Discard the swab, clean the wound with a nonantimicrobial cleanser, and obtain another swab C. Discard the swab and inform the health care provider that the wound is too infected to culture D. Obtain the swab as prescribed and send it to the lab for culture - correct answer ✔B The nurse observes an order for a client to receive furosemide, 20 mg once daily, and records the specific date and time of the order. What is the appropriate nursing action? A. Administer the drug. B. Call the health care provider for order clarification. C. Cosign the order. D. Show the order to the nurse manager. - correct answer ✔B