Download NUR-120 Exam 2 Review with correct answers 2024 and more Exams Nursing in PDF only on Docsity!
answers 2024
What spinal deformity is most likely seen in an older adult with osteoporosis? A. Kyphosis B. Lordosis C. Scoliosis D. No change - answer-A. Kyphosis When testing the cranial nerves (CNs), the nurse has a patient sniff coffee. What cranial nerve does this test? A. CN I B. CN III C. CN V D. CN VII - answer-A. CN I What action should the nurse take to assess whether a patient with a left above-the-knee amputation has adequate lower extremity circulation to the stump? Select all that apply. A. Palpate the stump for warmth. B. Assess pedal pulses bilaterally.
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C. Evaluate the left popliteal pulse rate. D. Inspect the stump & right leg for color. E. Check the left femoral pulse for strength. - answer-A. Palpate the stump for warmth, D. Inspect the stump & right leg for color, & E. Check the left femoral pulse for strength. Which action by a patient with a family history of macular degeneration would demonstrate use of a prevention strategy that has been found to help prevent deterioration of the macula? A. Using medicated eyedrops. B. Avoiding the use of sunglasses. C. Taking vitamin B6 & B12 supplements. D. Minimizing dietary intake of antioxidants. - answer-C. Taking vitamin B6 & B12 supplements. When percussing the abdomen, what sound would the nurse expect to hear? A. Dullness B. Tympany C. Resonance
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A. Septal B. Frontal C. Maxillary D. Sphenoidal - answer-D. Sphenoidal During a comprehensive assessment, which area is the nurse most likely to examine when palpating a client's tonsillar, submandibular, & submittal lymph nodes? A. Neck B. Thorax C. Inguinal D. Abdomen - answer-A. Neck Which action is best when the nurse auscultates anterior lungs with rhonchi & posterior lungs with crackles at bases? A. Order a diuretic to treat the client for heart failure (CHF) B. Prepare to treat the client for chronic obstructive pulmonary disease (COPD) C. Contact healthcare provider (HCP) to obtain order for chest x-ray to confirm pneumonia
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D. Delegate to unlicensed assistive personnel (UAP) teach client how to use an incentive spirometer - answer-C. Contact healthcare provider (HCP) to obtain order for chest x-ray to confirm pneumonia When auscultating the abdomen, how long should the nurse listen before concluding the bowel sounds are absent? A. 1 minute B. 5 minutes C. 10 minutes D. 15 minutes - answer-B. 5 minutes Which spinal deformity is seen in pregnant women during the last trimester? A. Kyphosis B. Lordosis C. Scoliosis D. No change - answer-B. Lordosis
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A. Keep the HOB elevated 30 degrees. B. Massage the client's bony prominences frequently. C. Apply lotion to the skin after bathing. D. Reposition the client at least every 3 hours while in bed. E. Straighten sheets & absorbent pad under client. - answer-A. Keep the HOB elevated 30 degrees, C. Apply lotion to the skin after bathing, & E. Straighten sheets & absorbent pad under client. Which of the following statements about wound healing would indicate further teaching for the student nurse? A. Wound healing can be a long process up to 3 months or more. B. Inflammation phase of wound healing is characterized by edema & erythema. C. Clot formation during wound healing is an unexpected finding. D. Maturation phase is the last stage of wound healing. - answer-C. Clot formation during wound healing is an unexpected finding. Which of the following clients is at greatest risk for developing a pressure injury?
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A. A 75-year-old client on prolonged bedrest. B. A 65-year-old who is on a high-protein diet. C. A 45-year-old with new onset of pre-diabetes. D. A 45-year-old 4 days post-operative from abdominal surgery. - answer-A. A 75-year-old client on prolonged bedrest. The nurse understands intrinsic factors that contribute to formations of pressure injuries include all of the following except: A. Age B. Nutrition C. Underlying health condition D. Friction - answer-D. Friction Of the following factors, which would put a client at greatest risk for impaired skin integrity? A. Medication B. Moisture C. Decreased sensation D. Dehydration - answer-C. Decreased sensation
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A. A client complaining of 3/10 pain. B. A client with stable vital signs (VS). C. A client expressing personal feelings. D. A client with sudden right-sided weakness. - answer-D. A client with sudden right-sided weakness. Which statement is most important for a new graduate nurse to follow regarding documentation? A. Document the client's feelings. B. Only document a sudden change in a client's health status. C. Use abbreviations approved by the healthcare facility. D. Use the narrative format of charting even if it is not the institution's charting method. - answer-C. Use abbreviations approved by the healthcare facility. Nursing documentation is based on: A. the nursing process. B. the state boards of nursing. C. the nurse's personal preference.
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D. the National League for Nurses (NLN). - answer-A. the nursing process. The client has fallen when trying to climb out of bed. The nurse: A. should omit this fall from the medical record. B. needs to complete an incident report as a risk management document. C. must document that an incident report was completed in the medical record. D. completes an incident report since it is a permanent part of the medical record. - answer-B. needs to complete an incident report as a risk management document. Which activity by a nurse demonstrates information literacy? A. Organizing client data to study trends. B. Researching an unfamiliar medical diagnosis online. C. Learning a new electronic health record (EHR) system. D. Using social media to contact a former client to go on a date. - answer-B. Researching an unfamiliar medical diagnosis online.
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A. Find another mobile computer. B. Document in the EHR under the outgoing nurse. C. Report the outgoing nurse to the nurse manager. D. Log off the outgoing nurse from the EHR before using it. - answer- D. Log ogg the outgoing nurse from the EHR before using it. The nurse has just admitted a patient with chest pain (CP). When completing the admission paperwork, the nurse needs to record: A. Health insurance status. B. An interpretation of patient behavior. C. Objective data that are observed. D. Subjective data that are observed. - answer-C. Objective data that are observed. What is the primary purpose of the medical record? A. Research B. Communication C. Professional standards D. Quality Improvement (QI) - answer-B. Communication
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The integration of computers, information science, & nursing for the communication & management of data, information, & wisdom is: A. Documentation. B. Health literacy. C. Medical informatics. D. Nursing informatics. - answer-D. Nursing informatics. The use of electronic health records (EHRs): A. decreases storage space. B. improves client health status. C. requires basic computer skills. D. has not been shown to reduce medication errors. - answer-B. improves client health status. Which of the following does the nurse recognize as data in an electronic health record? A. A client's personal opinions.
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E. Record telephone orders & full name & title of physician or nurse practitioner who issued orders. - answer-A. Sign the orders with name & title, B. Date & note the time orders were issued, C. Record the orders in patient's medical record, D. Read orders back to practitioner to verify accuracy & E. Record telephone orders & full name & title of physician or nurse practitioner who issued orders. Which of the following are potential breaches in patient confidentiality? Select all that apply. A. Displaying information on a public screen. B. Sharing printers among units with differing functions. C. Discarding copies of patient information in trash cans. D. Faxing confidential information to unauthorized persons. E. Sending confidential email messages via public networks. F. Sending minimal confidential information in an encrypted email. G. The healthcare team discussing a patient in a conference room with the door closed. - answer-A. Displaying information on a public screen, B. Sharing printers among units with differing functions, C. Discarding copies of patient information in trash cans, D. Faxing confidential information to unauthorized persons & E. Sending confidential email messages via public networks.
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The patient accuses the nurse of negligence after a fall when ambulating for the first time since hip replacement surgery. Which action is the best defense against this allegation? A. Keep an accurate medical record. B. Document patient data on the flow sheet. C. Notify the nursing supervisor of the patient's condition. D. Accurately document patient care of the patient record. - answer- D. Accurately document patient care of the patient record. The nurse has a two-way video communication with the specialist involved in the care of a patient in a long-term care (LTC) facility. What example of nursing informatics technology was involved? A. Social media. B. Electronic health record (EHR). C. Patient engagement technology. D. Mobile technology & telemedicine. - answer-D. Mobile technology & telemedicine. The nurse takes a patient's vital signs (VS). Where would the nurse document the VS?
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Which of the following changes are associated with normal aging process? Select all that apply. A. Presbyopia B. Reduced peristalsis C. Slower reaction time D. Slower immune response E. Enhanced ability to smell - answer-A. Presbyopia, B. Reduced peristalsis, C. Slower reaction time, & D. Slower immune response Dementia is a normal part of aging. A. True B. False - answer-B. False What are the common causes of death in older adults? - answer- Heart disease COVID- Cancer Stroke (CVA)
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Chronic lower respiratory diseases Diabetes mellitus (DM) Influenza Pneumonia (PNA) Accidents/falls Kidney disease Septicemia There are many myths about aging & older adults. Identify which of the following are facts about the older adult population. Select all that apply. A. All older adults have Alzheimer's disease. B. Most older adults live in institutional settings. C. Independence is often related to financial status. D. Cause of death is typically related to chronic disease. E. Older adults make up a small percentage of the population. - answer-C. Independence is often related to financial status & D. Cause of death is typically related to chronic disease. Which of the following statements are accurate for middle adults? Select all that apply.
