NSG 3130 LATEST EXAM 2 2025 ACTUAL QUESTIONS WITH 100_ VERIFIED SOLUTIONS- GRADED A+, Exams of Nursing

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NSG 3130 LATEST EXAM 2 2025

ACTUAL QUESTIONS WITH

100% VERIFIED SOLUTIONS-

GRADED A+

The nurse is caring for a 6-year-old patient in the emergency department who just had a full left leg cast placed for a fracture. As the nurse is reviewing the discharge instructions with the patient's mother, she states, "You don't have to go over those—I'll read them at home." What should the nurse do? a. Contact the physician immediately. b. Consider the possibility of health literacy limitations and assess further. c. Stop the teaching, because the mother obviously has taken care of casts before. d. Explain to the mother that reading the instructions with her is required. b. Consider the possibility of health literacy limitations and assess further. A patient's mother may have limited reading skills or health literacy and should be further assessed. Contacting the physician in this situation would not be appropriate because ensuring that the patient and family understand discharge instructions is the responsibility of the nurse. Assuming that the mother has taken care of casts in the past may be inaccurate. Stating that reading the instructions with the nurse is a requirement does not ensure that the patient or mother comprehends the instructions. A 58-year-old man is admitted for a small-bowel obstruction late Saturday night. The admitting orders include the need to place a nasogastric (NG) tube to low intermittent suction. During the assessment, the nurse determines that the patient does not speak English. Which action should the nurse take first before placing the NG tube? a. Use two additional staff members when placing the tube so the patient can be restrained if needed. b. Request an interpreter per facility protocol. c. Do not place the NG tube because the physician would not want to frighten the patient. d. Document the inability to place the NG tube due to lack of ability to communicate. b. Request an interpreter per facility protocol. An interpreter employed by the hospital would be the best choice so that someone in the room can communicate and provide comfort for the patient. Taking additional staff into the room may increase the patient's anxiety, thereby decreasing his ability to comprehend the instructions. Although the physician would not want to frighten the patient, the physician ordered the nasogastric (NG) tube for the benefit of the patient; therefore, it needs to be placed. Documenting the inability to place the NG tube due to lack of means of communication is not acceptable and does not ensure that the patient gets the needed treatment. Which nursing diagnoses are used in developing a patient teaching plan? (Select all that apply.) a. Moral Distress b. Lack of Knowledge c. Difficulty Coping d. Teaching about Disease e. Anxiety b

d. Cognitive a. Psychomotor Demonstration along with a return demonstration by the patient is an example of psychomotor domain learning. Affective domain learning integrates new knowledge by recognizing an emotional component. Psychosocial is not one of the domains of learning. Cognitive domain learning is based on knowledge and material that is remembered, memorized, and recalled. The nurse is providing home care to a 62-year-old woman who was recently diagnosed with insulindependent diabetes mellitus. What is the most important reason for the nurse to document the teaching session? a. The patient's insurance company requires documentation. b. The nurse's employer requires documentation of home care sessions. c. Other members of the health care team need to know the patient's progress. d. Insulin is a potentially dangerous medication and needs to be documented. c. Other members of the health care team need to know the patient's progress. Although the remaining options may be true, the primary reason for specific documentation of a patient's progress in a teaching plan is to ensure that other nurses or members of other disciplines can pick up the teaching plan and know precisely what the patient has accomplished and where to begin additional sessions. Written instructions showing pictures of the steps necessary to test blood glucose, along with demonstration and a return demonstration of the steps, would most benefit which learners? a. Affective b. VARK c. Psychomotor d. Cognitive c. Psychomotor Psychomotor learning involves physical movement and the use of motor skills such as demonstration and return demonstration. The affective domain involves emotion, and the cognitive domain is memorization and recall. VARK (verbal, aural, read/write, kinesthetic) refers to a method of assessing learning style. The nurse is providing care to an 88-year-old male patient who just returned from the recovery room after a right hip replacement. The nurse plans to teach the patient prevention techniques for deep vein thrombosis. What is the best time to provide teaching? a. Do it right before the patient's next intravenous pain medication. b. Wait until tomorrow morning because he is in too much pain today. c. Leave written materials on his over-the-bed tray that he can read at his convenience. d. Wait until 10 to 15 minutes after his next intravenous pain medication. d. Wait until 10 to 15 minutes after his next intravenous pain medication.

Patients in pain are unable to focus on learning. Waiting 10 to 15 minutes after the administration of intravenous pain medication allows it to provide relief, but the patient is not sedated or resting soundly. Waiting until the following day is inappropriate because early intervention and prevention are necessary to avoid the development of deep vein thrombosis. Leaving important information where it can be easily covered up, set aside, or overlooked is not an effective method of patient education. The nurse should remember the concepts of health literacy and consider the potential effects of visual impairments, reading ability, and pain level in ensuring patient comprehension. LO: 14. A nursing instructor is explaining the teach-back method to nursing students on a medical-surgical unit. The instructor asks the students to identify benefits of using this method of patient education. Which should the students include in their response to their instructor? (Select all that apply.) a. The teach-back method allows the nurse to determine understanding of information taught and to reteach if necessary. b. The nurse can rephrase information to the patient if the patient is unable to repeat the information correctly. c. The nurse can ask the patient to repeat information until it is determined that the patient has verbalized understanding of the information taught. d. The nurse can teach the patient using pictures, videos, and examples. e. The teach-back method can be used in any health care setting. a, b, c, d, e The teach-back method allows the nurse to determine understanding of information taught and to reteach if necessary by rephrasing the information, using pictures, videos, and examples if the patient is unable to repeat the information correctly. The nurse can ask the patient to repeat information until it is determined that the patient has verbalized understanding of the information taught. The teach-back method can be used in any health care setting. What is health literacy? Health literacy is the unique ability of the patient to understand and integrate health-related knowledge. Identify the components and purposes of patient education. Components of patient education are preventing disease, promoting health, providing treatment instructions, clarifying information, and teaching patients to cope with limitations Provide at least two examples of how the gap between the health care information provided and the health literacy of the patient and caregiver can adversely influence patient safety. Examples of literacy/education gaps include providing the patient with important instructions to follow for medication administration and finding that the patient is unable to read English, or identifying when the patient should come back if complications arise and the caregiver cannot follow the verbal directions What are some of the expected competencies for patients and health literacy? It is expected that the patient will be able to:

-Patient does not comply with medication regimens. -Patient does not follow through with laboratory tests, imaging tests, or referrals to consultants. -Patient says he or she is taking medication, but laboratory tests or physiological parameters do not change in the expected fashion. -Patient asks to bring a written document home to discuss it with a spouse or child. Write a nursing diagnosis, goal, and nursing intervention for a patient who needs to learn how to perform wound care. Nursing diagnosis—Deficient Knowledge (wound care) related to new surgical incision as evidenced by patient's verbalized and demonstrated lack of knowledge. Goal statement—Patient will discuss and demonstrate the correct technique for wound care within 48 hours. Nursing intervention—Instruct the patient in the wound care procedure. Ask the patient to demonstrate and explain the procedure. Provide examples of possible teaching strategies to use for patient education. Examples of teaching strategies include verbal instruction, media such as computer-assisted programs, videotapes or audiotapes, demonstration, return demonstration, and written instructions. Indicate how the Quality and Safety Education for Nurses (QSEN) competency of teamwork and collaboration are related to patient education. Patient education is coordinated by the nurse but involves other members of the health care team. Teamwork is demonstrated when the nurse collaborates with the primary care provider, therapists, dietitians, and social workers to promote patient learning and outcomes. After teaching the patient, what needs to be documented by the nurse? Documentation includes a detailed description of the goals, what was taught, how it was taught, and the patient's reaction to the teaching Which of the following are accurate principles for patient teaching? Select all that apply. a. Teaching multiple concepts at once b. Keeping sessions short c. Continuing if the patient becomes fatigued d. Providing positive feedback to the patient e. Starting with familiar material and progressing to new information f. Reviewing key points at the end of the session b, d, e, f How do learning styles influence patient teaching? Some individuals are visual (seeing) learners, whereas others are auditory (hearing) or kinesthetic (doing actively). Visual learners do better with information presented in words or pictures. Auditory learners do better by listening to a presentation. Kinesthetic learners benefit from manipulating materials. The nurse may find that the patient is a multimodal learner or can work with different types of strategies

An occupational health nurse is going to provide a workshop to employees on basic body mechanics. In planning the presentation and preparing the materials, what information would be most helpful for the nurse to obtain in advance of the presentation? a. Specific ages of all the employees b. Names of the employees c. Names of the managers d. Number of participants d. Number of participants Which of the following strategies is the most appropriate for teaching a toddler about a hospital procedure? a. Discussion b. Pictures c. Role-playing d. Independent learning b. Pictures The nurse assesses the patient's readiness to learn wound care. What is the most important factor for the nurse to determine first? a. Intelligence level of the patient b. Willingness to learn the technique c. Financial resources available to the patient d. Support from the patient's family b. Willingness to learn the technique Which one of the following examples is an evaluation of a psychomotor skill? a. Patient is able to discuss side effects of medications b. Patient maintains eye contact with nurse c. Patient has planned menu within therapeutic diet d. Patient uses walker correctly d. Patient uses walker correctly When teaching an older adult patient, the nurse should incorporate which teaching strategy into the plan? a. Keep the teaching sessions short. b. Teach in the later evening. c. Include as many concepts as possible. d. Focus on teaching the family members. a. Keep the teaching sessions short.

You are working with a patient who has a new colostomy and needs to learn how to manage the care. You suspect that the patient does not understand English well. There are members of the family who are more fluent in English and visit frequently. a. What questions can you ask to determine the patient's comfort with English? b. What adaptations will you need to make to ensure that the patient understands how to perform the colostomy care? c. How will you evaluate the patient's knowledge about and ability to perform the colostomy care? a. Questions that you could ask to determine the patient's comfort with English include: "What is your preferred language?", "Do you read the local newspaper, books, or magazines?" "What language is spoken at home?", and "Would you read this paragraph for me?" b. In planning teaching sessions, you will want to have written information in the patient's language and photos or drawings. There may also be a need for an interpreter. Family members who will be involved with the patient's care should be included in the teaching, if the patient approves. c. In addition to asking the patient to explain the procedure, you will want the patient to demonstrate their ability to do the colostomy care (psychomotor learning). Again, an interpreter may be necessary to assist in evaluating the patient's cognitive learning. An uncooperative 70-year-old male with right-sided paralysis from a recent cerebrovascular accident (CVA) has to be transferred from the bed to a wheelchair. Which action indicates the best method to transfer this patient? a. A two-person lift is performed, with one person on each side of the patient. b. The patient is steadied under the arms and pivoted on his left leg. c. A full-body sling lift is used with the help of unlicensed assistive personnel (UAP). d. A stand assist lift is used with the help of another nurse. c. A full-body sling lift is used with the help of unlicensed assistive personnel (UAP). According to safe patient handling algorithms, a full-body sling with more than one caregiver is indicated because the patient is uncooperative and able to bear only partial weight. Lifting a patient manually has the potential to injure the patient and the care providers. The stand-and-pivot technique is not indicated because the patient is uncooperative. The stand assist lift is not indicated because the patient is uncooperative. After instruction, which action by a patient who can bear weight on both feet indicates an understanding of the proper use of crutches? a. Adjusting the crutches so that they rest directly under the axilla

b. Moving the opposing crutch and leg together for a two-point crutch walk c. Using a four-point crutch walk when not weight bearing on the left leg d. Placing the crutches 12 inches forward and then swinging both legs forward b. Moving the opposing crutch and leg together for a two-point crutch walk Moving the opposing crutch and leg together provides needed stability for patients who can bear partial weight on each foot. Crutches must rest at minimum of two to three finger widths below the axilla to prevent brachial nerve damage. The patient can bear weight on both legs. Crutches should be advanced no more than 6 to 8 inches, and the swing-to gait is not appropriate for this patient. What bony prominences are at greatest risk for skin breakdown on a patient who is restricted to bed rest and placed in the side-lying position? (Select all that apply.) a. Sternum b. Ears c. Elbows d. Hips e. Coccyx b, c, d The patient's ears, elbows, and hips are in contact with the bed surface in the side-lying position. Breakdown on the sternum would be a potential risk if the patient were in prone position. The coccyx experiences the most pressure when a patient is sitting or in the supine position. Which area of the central nervous system has most likely sustained damage if a patient exhibits a lack of coordination and an unsteady gait after a traumatic head injury? a. Medulla oblongata b. Articular disk c. Brainstem d. Cerebellum d. Cerebellum Injury to the cerebellum directly affects a patient's ability to ambulate and control movement. The medulla oblongata regulates heart rate, breathing, blood pressure, and reflexive actions (such as vomiting). The articular disk is fibrous connective tissue in the temporomandibular joint, which facilitates jaw movement. The brainstem connects the spinal cord to the hemispheres of the brain.

used to safely transfer this patient. Quadriplegic patients should be given the opportunity to direct their care and fully participate in setting care plan goals. Which cue during an admission assessment of a patient transferred from a long-term care facility does the nurse recognize as the result of immobility? a. Bilateral elbow contractures b. Increased muscle tone c. Decreased cardiac workload d. Orthostatic hypertension a. Bilateral elbow contractures Joint contractures may begin within hours of immobility and cause irreparable damage to joint flexibility. Muscle tone decreases and cardiac workload increases with immobility. Pooling of blood in the lower extremities and quickly changing position may cause a rapid drop, rather than increase, in blood pressure, known as orthostatic hypotension. Which set of cues is most concerning in a patient with deep vein thrombosis (DVT) in the left calf? a. High blood pressure and low heart rate b. Coughing up blood and chest pain c. Low oral intake and urine output d. Bruising on the upper arm and torso b. Coughing up blood and chest pain The patient who is coughing up blood and has chest pain has the most concerning cues. A pulmonary embolism (PE) is suspected when a patient has sudden shortness of breath, chest pain, dizziness, irregular heartbeat or palpitations, low blood pressure or is coughing up blood. High blood pressure and low heart rate are the opposite of that seen in PE. Fluid intake is important in the prevention of venous thrombolytic events but is not the most concerning cue. Bruising might be related to anticoagulant therapy but is not the most concerning cue. After application of sequential compression devices (SCDs) on a patient, what assessment finding is essential for the nurse to include in documentation? a. Warmth of bilateral upper extremities b. Lower extremity circulatory status c. Circumoral cyanosis d. Altered bowel sounds b. Lower extremity circulatory status The nurse must document the date and time of initiating SCD placement and the results of a skin, circulatory, and neurologic assessment of the lower extremities. SCDs do not affect the upper

extremities, cardiac or respiratory status leading to circumoral cyanosis, or altered bowel sounds. Spasticity Increased muscle tone Quadriplegia Inability to move all four extremities Necrosis Death of cells, tissues, or organs Gait Manner of walking Ischemia Reduced blood flow Flaccidity Lack of muscle tone Atrophy Wasting Hemiparesis Weakness on one side of the body Proprioception Awareness of posture and movement Contracture Permanent fixation of a joint Provide examples of alterations in the following body systems that can lead to impaired mobility. a. Musculoskeletal— b. Neurological— c. Cardiopulmonary— a. Musculoskeletal -Impairment or injury; affects the body's ability to move. -Inadequate dietary intake of calcium and vitamin D or impaired calcium metabolism; osteoporosis, which increases bone fragility and may lead to fractures. -Decreased physical exercise contributes to bone deterioration, loss of strength, or hypotonicity.

Exercise, fluids (within any restriction) Antiembolism hose (stockings), sequential compression device (SCD) c. Gastrointestinal: decreased peristalsis: indigestion, anorexia, constipation, distention, impaction Nursing Interventions: Fluids (2 L/day, if not contraindicated), fiber, nutrients Positioning on bedpan, use of commode Exercise, turning, ambulation d. Integumentary—tissue ischemia, pressure ulcers Nursing Interventions: Frequent turning, positioning, support mat-tresses, heel and elbow protectors/cushions How does the nurse assess a patient's muscle strength? Muscle strength is assessed by asking the patient to squeeze the nurse's hands and having the patient plantar-flex the feet against resistance by the nurse's hands. Nurses must evaluate muscle symmetry by comparing one side of the patient's body with the other. While performing passive range of motion, the patient starts to grimace, moan, and become tense. The nurse should: In the presence of resistance or pain during range of motion, the activity should be stopped What is the purpose of "dangling?" Dangling can prevent postural hypotension and syncope (fainting) by allowing patients to sit with their legs in a dependent position for a few minutes before standing The nurse is teaching the UAP/aide about correct body mechanics. Which of the following principles are accurate and should be included in the teaching? Select all that apply. a. Elevate work surfaces to approximately neck height. b. Never lift more than 75 pounds independently. c. Push rather than pull patients or objects. d. Bend from the waist when lifting. e. Keep patients or objects close to the body to minimize reach. f. Keep the feet apart to provide a stable base. c, e, f What can the nurse do to prevent friction against the immobile patient's skin? Reducing friction includes slightly lifting rather than pulling patients, using a trapeze bar, transfer/slide board, or friction-reducing sheets. The patient may also benefit from the use of heel and elbow protectors. For range of motion: a. How many times daily is it usually performed? b. How many times should the joints be put through their motion?

a. Range of motion is usually performed twice daily. b. Each joint is moved 3 to 5 times. When using a mechanical lift, which of the following techniques are appropriate? Select all that apply. a. Use the device only in life-threatening situations. b. A safety algorithm should be used to determine the assistance required. c. Determine the operational status before using. d. Check the manufacturer's weight limit for the device before using. e. Use a transfer chair for confused or uncooperative patients. f. Instruct the patient in how the device will work. b, c, d, e, f A patient who is immobilized can suffer psychosocial effects. What can the nurse do to prevent or reduce this problem? The nurse can include patients in the decision making for their care, encourage visits from family and friends, spend time with the patient, explain procedures, institute reality orientation (clocks, calendars), and have books, TV, and pictures available in the environment. What products are available to prevent friction to the feet and legs? Products that are available for heel and lower leg skin protection include the following: Protectors of cloth-covered foam, foam, or sheepskin and can be tubular or shaped like boots. Special AFOs called pressure-relief ankle-foot orthotic (PRAFO) boots can be used to prevent pressure on the heels. A rigid aluminum frame lined in sheepskin is applied to the lower leg and foot using Velcro straps. PRAFO boots have the added benefit of keep-ing the ankle and foot in proper alignment What are two recommendations and goals for log-rolling a patient with a halo brace For logrolling, a Safe Patient Handling and Mobility algorithm is recommended to determine the number of personnel needed, and the use of a mechanical or assistive device should be determined. The goals are to pre-vent injury to the patient and nurse(s), maintain the patient's body alignment, and keep all tubes, etc., intact. The nurse observes that the patient is extremely uncomfortable during position changes. What can the nurse do to avoid discomfort for the patient? The nurse can obtain an order for an analgesic and pre-medicate the patient before the activity. What criteria should be used to determine if the patient is strong enough to ambulate? The patient needs to be able to raise the legs 1 inch off the bed in order to have strength for ambulation. A Timed Up and Go (TUG) test may also be given to evaluate the patient's mobility. Identify accurate statements regarding patient mobility. Select all that apply. a. Registered nurses are legally responsible for planning patient care related to pressure sore prevention. b. Immobile patients should be turned at least every 2 hours.

a, d, f A patient has been on bed rest for a prolonged period. To specifically promote the use of isotonic exercise, the nurse will instruct the patient to: a. turn side to side in bed. b. perform pelvic floor exercises. c. repeatedly tighten the thigh muscle. d. use a trapeze to lift and hold the upper body off the bed. a. turn side to side in bed. An average-size male patient has right-sided hemiparesis, requiring minimal assistance with ambulation. The nurse helps this patient walk by standing at his: a. left side and holding his arm. b. left side and holding one arm around his waist. c. right side and holding his arm. d. right side and holding the gait belt at the patient's back. d. right side and holding the gait belt at the patient's back. The nurse is working with a patient who has left-sided weakness. After instruction, the nurse observes the patient ambulate in order to evaluate the use of the cane. Which action indicates that the patient knows how to use the cane properly? a. The patient keeps the cane on the left side. b. Two points of support are kept on the floor at all times. c. There is a slight lean to the right when the patient is walking. d. After advancing the cane, the patient moves the right leg forward. b. Two points of support are kept on the floor at all times. A patient with a fractured left femur has been using crutches for the past 4 weeks. The physician tells the patient to begin putting weight on the left foot when walking. Which of the following gaits should the patient be taught to use? a. Two-point b. Three-point c. Four-point d. Swing-through c. Four-point While ambulating in the hallway of a hospital, the patient complains of extreme dizziness. The nurse, alert to a syncopal episode, should first: a. Support the patient and walk quickly back to the room. b. Lean the patient against the wall until the episode passes.

c. Lower the patient gently to the floor. d. Go for help. c. Lower the patient gently to the floor. A patient is admitted to the medical unit after a cerebrovascular accident (stroke). There is evidence of left-sided hemiparesis, and the nurse will be following up on range-of-motion and other exercises performed in physical therapy. The nurse correctly teaches the patient and family members which one of the following principles of range-of-motion exercises? a. Move the joints quickly. b. Work from the lower to upper body. c. Flex the joint to the point of resistance. d. Provide support above and below joints d. Provide support above and below joints Nurses need to implement appropriate body mechanics to decrease the chance of injury to themselves and patients. Which principle of body mechanics should the nurse incorporate into patient care? a. Flex the knees and keep the feet wide apart. b. Assume a position far enough away from the patient. c. Twist the body in the direction of movement. d. Use the strong back muscles for lifting or moving. a. Flex the knees and keep the feet wide apart. After an assessment of a patient, the nurse identifies the nursing diagnosis Intolerance to activity with the supporting evidence of Increased weight gain and inactivity. The physician wants the patient to improve her endurance and increase activity. Which of the following is an outcome identified for the patient? a. Resting heart rate will be 90 to 100/min. b. Blood pressure will be maintained between 140/80 and 160/90 mm Hg. c. Exercise will be performed 3 times per day over the next 2 weeks. d. Accommodation will be made for excess weight and fatigue c. Exercise will be performed 3 times per day over the next 2 weeks. A patient has been on prolonged bed rest, and the nurse is observing for signs associated with immobility. In assessment of the patient, the nurse is alert to: a. increased blood pressure.