NURSING 224 EXAM PREPARATIONS QUESTIONS WITH ANSWERS TESTED AND VERIFIED UPDATES RATED A+, Exams of Nursing

Download NURSING 224 EXAM PREPARATIONS QUESTIONS WITH ANSWERS TESTED AND VERIFIED UPDATES RATED A+ and more Exams Nursing in PDF only on Docsity!

NURSING 224 EXAM PREPARATIONS QUESTIONS WITH

ANSWERS TESTED AND VERIFIED UPDATES RATED A+

1. A nurse working in an emergency room is assessing a client who has a leg wound. The nurse noted a full thickness wound with jagged edges and muscle tissue visible. The nurse should document this as which of the following types of wounds? Laceration
2. The nurse is performing a pressure ulcer risk assessment. Which risk factor factors predispose a client to pressure ulcer development. (Select all that apply)? Urinary incontinence; Decreased ability to feel pain or discomfort
   3. A nurse is preparing administer the hepatitis B vaccine to a client. Which of the following techniques should the nurse use to locate the deltoid muscle? Place one finger across the acromion process and measure 3 fingerbreadths below to the midpoint and center of the lateral aspect of the upper arm
3. A nurse is caring for a client in a long-term care facility who is receiving enteral feeding via an NG tube. Which of the following actions should the nurse take prior to administering the tube feeding? Test the PH of gastric aspirate
4. A nurse is preparing an in-service program about preventing medical errors when transcribing a prescription. The nurse is using a dosage example of two tenths of a milligram. Which of the following examples should the nurse use to show appropriate transcription of this dosage? 0.2 mg
5. A nurse is collecting data from a client who is 3 days postoperative following abdominal surgery. The surgeon suspects an incisional wound infection and has prescribed wound culture and has prescribed wound culture and sensitivity. Which of the following findings should the nurse expect? Select all that apply. increase in

incisional pain increased WBC count fever and chills reddened wound edges

7. Which statement is true regarding a standing order? Administered until the dosage is changed or another medication is prescribing
8. A nurse is administering a skin testing tuberculosis drug intradermal. What are some of the thing’s nurses need to consider while administering the intradermal injection? the angle of insertion is less than 15 degrees; a small bled appears on the skin; the bevel of the needle is pointed up
9. A nurse accidentally sticks her hand with a syringe needle after administering an IM injection to a client. Which of the following actions should the nurse take first? Wash the area of the puncture thoroughly with soap and water

10. A nurse is teaching a client who has strained her back muscles while preparing to move to a new apartment. Which of the following instructions should the nurse include? Bend at the knees when picking up an object
11. A nurse is admitting a client who has meningitis. Which of the following types of transmission-based precautions should the nurse initiate? Droplet
12. What is the most important role of the nurse in preventing medication administration errors? Always following the ‘’six rights’’ of medication administration
13. A nurse is caring for a client who is receiving continuous enteral feeding. Which of the following nursing interventions is the highest priority when the nurse suspects aspiration of the feeding? Stop the finding
14. A client feels discomfort in his pubic area. He tells the nurse he has been voiding ‘’only a little bit, about every half hour. ‘’ What are these clinical signs indicating? Urinary retention
15. A nurse is experiencing some problems with joint stability. The doctor prescribed crutches for the client to use while still being allowed to bear weight on both legs. Which of the following gait should the client be taught to use? Four-point gait
16. A nurse is assessing a client’s ability to ambulate with crutches using a three-point gait. Which of the following actions should the nurse identify as a risk to client’s safety? The client places partial weight on the affected leg

17. A nurse is preparing to apply a transdermal analgesic patch. Which of the following actions should the nurse plan to take? Select all that apply. a) remove the old patch; b) cleanse the skin prior to procedure; d) Apply to intact skin; e) document patch placement, date and time
18. A nurse is delivering an enteral feeding to a client who has an NG tube in place for intermittent feedings. When the nurse pours water into the syringe after the formula is given, the client asks the nurse why the water is necessary. Which of the following responses should the nurse make? Water helps clear the tube so it doesn’t get clogged
19. A nurse finds an open vial of morphine lying on top cabinet in a client’s room. Which of the following actions should the nurse take? Report the discrepancy immediately
20. A charge nurse observe a nurse administer in intermittent tube feeding via an NG tube to a client. Which of the following actions should prompt the charge nurse to intervene? The nurse allows the client to rest in a supine position during feeding.
21. When reviewing the admitting prescriptions, the nurse notes that the dose of one medication is there times the usual dose of this medication. Which of the following actions should the nurse take? Contact the provider/ physician to question the dosage

22. A nurse is preparing to administer Lovenox subcutaneous prophylactic to prevent deep vein thrombosis. Which of the following actions should prompt the clinical instructor to intervene? Displaced the skin back to prevent medication from leaking back into the subcutaneous skin and straining the skin
23. A nurse is assessing a client who has a pressure ulcer. The nurse should recognize which of the following findings is a manifestation of a stage 3 pressure ulcer? Necrotic subcutaneous tissue
24. A nurse is administering timolol eye drops to a client who has glaucoma. Which of the following actions should the nurse take? Drop prescribed amount of medication into the conjunctival sac
25. A nurse is preparing to transfer a client from a bed to a chair. Which of the following actions should the nurse take first? Determine if the client can bear weight
26. A nurse is teaching a class about medication reconciliation. Which of the following information should the nurse include in the teaching? Provide a list of the client’s current medications during the change of shift report
27. A nurse is administering an oral medication to an older client. The client states.’’ The pill I always take is green. I don’t take an orange pill. ’Which of the following responses should the nurse make? ‘’I will check your medication order again’’
28. A nurse is teaching a client how to administer medication through a Percutaneous Endoscopic Gastrostomy (PEG) tube. Which of the following instructions should the nurse include?’’ flush the tube before and after each medication.’’
29. A nurse is observing a nurse performing a Mantoux tuberculin skin test for a client. Which of the following actions should the nurse

prompt the charge nurse to intervene? Withdrawing the needle and massage the side gently

30. A charge nurse is observing a newly licensed nurse insert an indwelling urinary catheter for a male client. Which of the following actions by the newly-licensed nurse requires intervention by the charge nurse? Secures the tubing to the side rail of the client’s bed.
31. A nurse in a long-term care facility is observing assistant personnel (AP) changing the linen for a client who has fecal incontinence. Which of the following actions indicated that the AP understands the principal of infection control? Places clean linen that touched the floor in the soiled linen bag
32. A nurse is caring for a client who receive intermittent enteral feeding through an NG tube. Before administering a feeding, the nurse should measure the gastric residual for which of the fallowing purposes? To confirm the placement of the NG tube
33. A nurse is preparing to administer a pre-packaged oral medication to a client and complete the final medication check. At which of the following times or places should the nurse perform this final check? At the client’s bedside before administration
34. The patient has just been stared on enteral feeding and has developed diarrhea after being on the feeding for 2 hours. What does the nurse suspect is the most likely cause of diarrhea? Formula intolerance

35. A nurse is helping an older adult client ambulate in the hallway for the first time since admission. The client has brought her standard walker from home. To ensure proper use of the walker and the safety of the client. Which of the following actions should the nurse take? Check that the client lifts the walker and then places it down in front of her.
36. A nurse is teaching a client who has hemiparesis how to use a cane. Which of the following instructions should the nurse include? Hold the cane on the right side to provide support for the weaker leg.
37. A nurse is preparing a sterile field. Which of the following actions should the nurse should perform when opening the sterile pack? Open the top flap away from the body
38. A nurse reviewing a client’s health record notes a new prescription for lisinopril 10 mg Orally every day. The nurse should identify this as which of the following types of prescriptions? Route
39. The nurse is caring for a client who has a nonfunctional gastrointestinal tract. Which method would be appropriate for this client to receive nutrition? Total parenteral nutrition (TPN)
    40. A client receives a wrong medication. The nurse who made the medication error should take which of the following action? Assess the client
40. A nurse is caring for a client who is at risk for developing pressure injury. Which of the following interventions should the nurse use to help maintain the integrity of the skin? Select all that apply. A) reposition the client every 2 hr while in bed c) apply cornstarch liberally to the skin after bathing d) have the client sit on a gel cushion when in a chair
    42. A client who has indwelling catheter reports a need to urinate.

Which of the of the following action should the nurse take? Assess that the catheter is not kink or clogged and urine is flowing in the bag.

43. A nurse is planning to perform a sterile dressing change for a client. Which of the following actions should the nurse plan to take? Don sterile gloves to move the sterile items on the field 44.A nurse is discharging a client who came to the outpatient clinic with an ankle sprain. Which of the following statements should the nurse identify as an indication that the client understands the discharge instruction? I’ll apply ice to my ankle today and tomorrow
44. A nurse is preparing to use the Z-track technique to administer a medication to a client. Which of the following is an appropriate action for the procedure? Aspirate for 5 to 10 second before injecting the medications
45. A charge nurse is observing a newly licensed nurse administer medications to a client. Which of the following actions by the newly licensed nurse should prompt the charge nurse to intervene? Documents medication administration prior to administering it.

47. A nurse is preparing to administer 10 units of regular insulin and 20 units of NPH insulin to a client. What is the sequence of events the nurse should follow? Move the steps of mixing insulin on the left into the box on the right, placing them in the selected order of performance. All steps must be use. Inspect vial for contaminants Roll NPH vial between palms hands Inject air into NPH insulin vial Inject air into regular insulin vial Add intermedial insulin to syringe Withdraw short acting insulin into syringe
48. The nurse is providing nutrition teaching to a client visiting from Korea. What must the nurse focus the teaching on for this client? Incorporating the client’s food preferences
    49. A nurse is preparing to administer penicillin IM to an adult client. Which of the following angles should the nurse use for injection into the clients? 90
49. A nurse educator is reviewing the wound d healing process with a group of nurses. The nurse educator should include in the information which of the following alterations for wound healing by secondary intention? Stage 3 pressure ulcer
50. A nurse is educating a client about urgency urinary incontinence. What is the most appropriate statement by the nurse regarding treatment of this type of incontinence?

Performing pelvic floor exercises three time a day may help

52. A nurse is caring for an elderly who is 2 days postoperative following an appendectomy and has types II diabetes mellitus/. The client hemoglobin is low., and the BMI is 17.2. The incision is well approximated and free of redness. With scant serous drainage on the dressing the nurse should recognize that the client has which of the following risk factors for impaired wound healing? b) low hemoglobin ; d) chronic illness; e) age
53. A nurse is planning care for a client who has manifestations of a Clostridium difficile (C. difficile) Which of the following action the nurse plan to take? Place the client on contact precautions
54. The nurse is staffing a medical- surgical unit that is assigned most of the patients with pressure ulcers. The nurse has become competent in the care of pressure wounds and recognizes with staged pressure ulcer wound that does not require a dressing? I

55. The nurse is performing a pressure ulcer risk assessment. Which risk factors predispose a client to pressure ulcer development? Select all that apply. Decrease ability to feel pain or discomfort; Urinary incontinance
56. The nurse is caring for a client diagnosed with a urinary tract infection (UTI). Which risk the factors increase the incidence of a UTI? Select all that apply. Poor perineal hygiene Urinary retention Having an indwelling catheter
57. A nurse is receiving a provider’s prescription for a client via telephone. Which of the following actions should the nurse take to ensure the accuracy? Select all that apply. Question any part of the order that is unclear or inappropriate Transcribe the order into the client’s health recording Repeat the order back to the provider
58. A nurse is administering nasal decongestant drops for a client. Which of the following actions should the nurse take? Tell the client to blow her nose gently before the is installation 59.A nurse at an extended care facility is instructing a class of assistive personal (AP) about client use of assistive devices during ambulation? Which of the following instructions should the nurse give the Aps about the clients’ use a cane? ‘’When the client moves, he should move the cane forward first.’’

60. A student nurse is preparing to administer lovenox subcutaneous prophylactic to prevent deep vein thrombosis. Which of the following action should prompt the clinical instructor to intervene? Select site that have an adequate fat pad size (abdomen, upper hips, lateral upper arms, thighs). Extra What statement made by a 2-year-old client’s mother indicates that she understands how to administer her son eardrops? I need to straighten his ear canal before administering the medication by pulling auricle down and back.
61. A nurse is teaching an older adult client who reports constipation, which of the following instructions should the nurse include in the teaching? Increase intake of fresh fruits and whole grains