Download NUR 221 EXAM 1 | 2024 Questions & Answers | 100% Correct | Verified and more Exams Nursing in PDF only on Docsity!
NUR 221 EXAM 1 | 2024 Questions & Answers |
100% Correct | Verified
The nurse admits a patient to the critical care unit following a motorcycle crash. Assessment findings by the nurse include blood pressure 100/50 mm Hg, heart rate 58 beats/min, respiratory rate 30 breaths/min, and temperature of 100.5° F. The patient is lethargic, responds to voice but falls asleep readily when not stimulated. Which nursing action is most important to include in this patient's plan of care? A. Frequent neurological assessments B. Side to side position changes C. Range of motion to extremities D. Frequent oropharyngeal suctioning - ✔✔A. Frequent neurological assessments The nurse has just received a patient from the emergency department with an admitting diagnosis of bacterial meningitis. To prevent the spread of nosocomial infections to other patients, what is the best action by the nurse? A. Implement droplet precautions upon admission. B. Wash hands thoroughly before leaving the room. C. Scrub the hub of all central line ports prior to use. D. Dispose of all bloody dressings in biohazard bags. - ✔✔A. Implement droplet precautions upon admission. The nurse is caring for a patient admitted with bacterial meningitis. Vital signs assessed by the nurse include blood pressure 110/70 mm Hg, heart rate 110 beats/min, respiratory rate 30 breaths/min, oxygen saturation (SpO 2 ) 95% on supplemental oxygen at 3 L/min, and a temperature 103.5° F. What is the priority nursing action?
A. Elevate the head of the bed 30 degrees. B. Keep lights dim at all times. C. Implement seizure precautions. D. Maintain bed rest at all times. - ✔✔C. Implement seizure precautions. A patient seeks treatment for progressively deteriorating motor and sensory function. What question is essential for the nurse to ask when completing this patient's health history? A. "Have you been around any small children?" B. "When was the last time you had anything to eat?" C. "When was the last time you traveled out of the country?" D. "Have you recently experienced any lung or stomach infections?" - ✔✔D. "Have you recently experienced any lung or stomach infections?" A patient with Guillain-Barré syndrome (GBS) asks how the illness develops. What should the nurse respond about the pathophysiology of the disorder? A. "An infection eats away at the nerve endings." B. "An infection enters the spinal cord and erodes the nerves at the roots." C. "The nerves are killed by infiltration of your body's white blood cells used to fight an infection." D. "After an infection your immune system created antibodies that affect the covering of the nerves." - ✔✔D. "After an infection your immune system created antibodies that affect the covering of the nerves." A patient is experiencing bilateral symmetrical muscle weakness and sensory changes of both feet and legs. What should the nurse expect to assess that determines the presence of Guillain-Barré syndrome (GBS)? A. Areflexia
The nurse notes that a patient with Guillain-Barré syndrome (GBS) sweats profusely. What should the nurse do about this finding? A. Place on a cooling blanket B. Notify the health-care provider C. Monitor body temperature every two hours D. Change linen and gown and keep comfortable - ✔✔D. Change linen and gown and keep comfortable The nurse is planning care for a patient with Guillain-Barré syndrome (GBS). Which intervention will help with neuropathic pain? A. Administer gabapentin B. Turn and reposition every two hours C. Apply sequential compression devices D. Perform passive range of motion several times a day - ✔✔A. Administer gabapentin A patient is admitted for diagnosis and treatment of Guillain-Barré syndrome (GBS). What should the nurse expect to assess during the acute stage of this syndrome? Select all that apply. A. Edema B. Paralysis C. Difficulty breathing D. Urinary incontinence E. Numbness and tingling - ✔✔A. Edema B. Paralysis C. Difficulty breathing
E. Numbness and tingling The most common problem of children born with a myelomeningocele is A. Neurogenic bladder B. Intellectual impairment C. Respiratory compromise D. Cranioschisis - ✔✔A. Neurogenic bladder A recommendation to prevent neural tube defects is the supplementation of A. Vitamin A throughout pregnancy B. Multivitamin preparations as soon as pregnancy is suspected C. Folic acid for all women of childbearing age D. Folic acid during the first and second trimesters of pregnancy - ✔✔C. Folic acid for all women of childbearing age How much folic acid is recommended for women of childbearing age? A. 1.0 mg B. 0.4 mg C. 1.5 mg D. 2.0 mg - ✔✔B. 0.4 mg Latex allergy is suspected in a child with spina bifida. Appropriate nursing interventions include
C. "You will be on your side with the head of your bed slightly raised." D. "You will lie on your side and bend your knees so that they touch your chin." - ✔✔D. "You will lie on your side and bend your knees so that they touch your chin." What is the most appropriate nursing response to the father of a newborn infant with myelomeningocele who asks about the cause of this condition? A. "One of the parents carries a defective gene that causes myelomeningocele." B. "A deficiency in folic acid in the father is the most likely cause." C. "Offspring of parents who have a spinal abnormality are at greater risk for myelomeningocele." D. "There may be no definitive cause identified." - ✔✔D. "There may be no definitive cause identified." What is the priority nursing intervention for the child with ascending paralysis as a result of Guillain- Barré syndrome (GBS)? A. Immunosuppressive medications B. Respiratory assessment C. Passive range-of-motion exercises D. Anticoagulant therapy - ✔✔B. Respiratory assessment A nurse is explaining to parents how the central nervous system of a child differs from that of an adult. Which statement accurately describes these differences? A. The infant has 150 mL of CSF compared with 50 mL in the adult. B. Papilledema is a common manifestation of ICP in the very young child. C. The brain of a term infant weighs less than half of the weight of the adult brain.
D. Coordination and fine motor skills develop as myelinization of peripheral nerves progresses. - ✔✔D. Coordination and fine motor skills develop as myelinization of peripheral nerves progresses. A nurse should expect which cerebral spinal fluid (CSF) laboratory results on a child diagnosed with bacterial meningitis? Select all that apply. A. Elevated white blood count (WBC) B. Decreased protein C. Decreased glucose D. Cloudy in color E. Increase in red blood cells (RBC) - ✔✔A. Elevated white blood count (WBC) C. Decreased glucose D. Cloudy in color A nurse prepares a client for lumbar puncture (LP). Which assessment finding should alert the nurse to contact the health care provider? A. Shingles on the clients back B. Client is claustrophobic C. Absence of intravenous access D. Paroxysmal nocturnal dyspnea - ✔✔A. Shingles on the clients back A nurse assesses a client who is recovering from a lumbar puncture (LP). Which complication of this procedure should alert the nurse to urgently contact the health care provider? A. Weak pedal pulses
C. "What changes can I make to make me feel good about the choice to become a nurse?" D. "How can I get the rest of the staff to change?" - ✔✔C. "What changes can I make to make me feel good about the choice to become a nurse?" The novice nurse arrives on the nursing unit, is introduced to the staff, is assigned a preceptor, and is asked to participate in the next staff meeting. This introduction into nursing is appropriately identified using what term? A. Biculturalism B. Socialization C. Transition D. "Going-native" - ✔✔B. Socialization Several novice nurses share lunch breaks and have comments such as, "I have insomnia from worrying about what I forgot to do for my patient," and "I have no energy," and "I can't believe I can't do my job correctly." These novice nurses are each experiencing different symptoms of what process? A. Burnout B. Low self-esteem C. Lack of confidence D. Resilience - ✔✔A. Burnout Which nurse is more prone to burnout? A. The one who graduated last in the class B. The one who accepts most offers of overtime C. The one who has worked on the oncology unit for 3 years
D. The one who regularly states, "I'm not able to make it better for my patients" - ✔✔B. The one who accepts most offers of overtime A nurse notices the novice medication nurse hurriedly gathering medications to be administered for the entire day, removing them from the packages, and placing them in a paper cup with the patient's name and room number on the cup. When one of the patients points at a pill and asks, "What is this?" and "What does this do?" the medication nurse is uncertain, because it has long since been removed from the packaging. What role is the nurse playing when taking his/her observations, concerns, and suggestions to the nurse manager? A. Mentor B. Rutter C. Change agent D. Role model - ✔✔C. Change agent The novice nurse calls a supervisor and requests that a "float nurse" be assigned to help with all "assessments of new admissions and postoperative patients." The supervisor asks, "How many admissions and surgery patients have you received?" The novice nurse becomes flustered because she has not checked the census but simply bases the need on feeling overwhelmed. This situation best indicates a lack of what type of skills? A. Organizational B. Communication C. Interpersonal D. Clinical - ✔✔A. Organizational When the novice nurse asks, "What will happen if this task is not completed," which skill is being demonstrated?
relationship continues and builds, allowing the novice nurse to become more confident. This relationship is identified by what term? A. Mentoring B. Role modeling C. A preceptorship D. Socialization - ✔✔A. Mentoring A novice nurse is unsure how to correctly administer an injection using the Z-track method. What is the best approach for learning this procedure? A. Read the procedure manual and follow the steps exactly. B. Make an appointment at the skills laboratory of the former nursing school to practice. C. Ask to observe an experienced nurse as the skill as it is being performed; then perform it under direct supervision. D. Try to remember how the task was previously performed during a simulation. - ✔✔C. Ask to observe an experienced nurse as the skill as it is being performed; then perform it under direct supervision. A student nurse wants to meet other nursing students from different countries and to learn of employment possibilities. The student nurse should consider doing what? A. Participating in the clinical facility's employee satisfaction task force B. Joining the Student Nurses Association C. Taking part in self-mentoring D. Postponing the licensure examination to take a tour of foreign countries - ✔✔B. Joining the Student Nurses Association
An experienced nurse working in oncology is shocked to realize that he/she feels little empathy when a patient explains, "I developed cancer from having to work in the dry cleaning industry since I was only 8 years old to help support my younger siblings during the depression. Now they have all moved away and refuse to help me financially, and it takes everything I have to pay for my chemotherapy medicine." What term is used to describe this situation? A. Burnout B. Compassion fatigue C. Reality shock D. Horizontal hostility - ✔✔B. Compassion fatigue A recruiter is explaining benefits to a group of nursing externs who are highly sought for employment. The recruiter states, "We are the only hospital in town that offers a residency program." What further information should the recruiter provide about a residency program? A. It provides housing for the graduate nurse to decrease expenses until income is established. B. It partners a medical resident with a nurse resident to learn interprofessional care. C. It allows new graduates to work on a higher degree in nursing while being paid full-time. D. It offers extended time for both theory and clinical activities that promote problem solving and clinical decision making. - ✔✔D. It offers extended time for both theory and clinical activities that promote problem solving and clinical decision making. A novice nurse is stressed due to always being behind with her assignments. She is overheard saying, "No one here worries about checking nasogastric tube placement before they give medications and hang feedings. Skipping that step would save me an extra 30 minutes to be used for charting. If they can do it, so can I." This nurse is experiencing which stage of reality shock? A. Loner B. "Rutter"
In orientation, a new graduate is surprised to learn of workplace violence in health care agencies and asks, "What kind of violence is common in hospitals?" The educator describes workplace violence bases on what statement? (Select all that apply.) A. It is the care of patients admitted who are victims of domestic violence. B. It is experienced nurses withholding pertinent information from coworkers to portray them as incompetent. C. It encourages coworkers participating in an employee assistance program (EAP) to learn more about anger management for adult children living at home. D. It involves the care of persons being held for treatment prior to be incarcerated for committing homicide. E. It is demonstrated in statements such as "The new nurse has book sense but can't perform an admission physical without the help of everyone on the unit." - ✔✔B. It is experienced nurses withholding pertinent information from coworkers to portray them as incompetent. E. It is demonstrated in statements such as "The new nurse has book sense but can't perform an admission physical without the help of everyone on the unit." Faculty comes to class to present information about joining the Student Nurses Association (SNA). A student is heard saying, "Why join this organization? It is just a bunch of students like us. I'll wait and join the real nursing organization after graduation." This student is not aware of which benefits of SNA? (Select all that apply.) A. Members are eligible to sit for the licensure examination at a reduced rate. B. Leadership skills can be refined by working with other schools of nursing. C. The National SNA provides discounted rates for study abroad opportunities. D. A global view of nursing can be obtained through networking internationally. E. Lobbying efforts are a major benefit of belonging to SNA. - ✔✔B. Leadership skills can be refined by working with other schools of nursing. D. A global view of nursing can be obtained through networking internationally. Which statements demonstrate characteristics would be desirable in a mentor? (Select all that apply.)
A. "How were you taught to do this is school?" B. "Can you think of a way to make this easier for the patient?" C. "Let me know when it's a good time to show you how to do this new scale." D. "Everybody here does it this way." E. "Today was rough but there are fewer admissions scheduled for tomorrow. " - ✔✔A. "How were you taught to do this is school?" B. "Can you think of a way to make this easier for the patient?" C. "Let me know when it's a good time to show you how to do this new scale." E. "Today was rough but there are fewer admissions scheduled for tomorrow. "
