NUR 215 Exam 2 with 100% accurate solutions + rationales 2026-2027

A nurse is caring for a client who has severe acute respiratory syndrome (SARS). The nurse knows that health care professional are required to report communicable and infectious diseases. Which of the following illustrate the rationale for reporting? (select all the apply)

A. Planning and evaluating control and prevention strategies

B. Determining public health priorities

C. Ensuring proper medical treatment

D. Identifying endemic disease

E. Monitoring for common-source outbreaks

A. Planning and evaluating control and prevention strategies

B. Determining public health priorities

D. Identifying endemic disease

E. Monitoring for common-source outbreaks

A nurse is caring for a client who has had a cough for 3 weeks and is beginning to cough up blood. The client has manifestations of which of the following conditions?

A. allergic reaction

B. ringworm

C. systemic lupus erythematosus

D. Tuberculosis

D. Tuberculosis

A nurse is caring for a client who repots a severe throat, pain when swallowing, and swollen lymph nodes. The client has manifestations of which of the following conditions?

A. prodromal

B. ringworm

C. convalescence

D. Illness

illness

A charge nurse is reviewing with a newly hired nurse the difference in manifestations of a localized vs a systemic infection. Which of the following are manifestations of a systemic infection. (select all that apply)

A. Fever

B. Malaise

C. Edema

D. Pain or tenderness

E. Increase in pulse and respiratory rate

A. Fever

B. Malaise

E. Increase in pulse and respiratory rate

A nurse is contributing to the plan of care for a client who is being admitted to the facility w/a suspected diagnosis of pertussis. Which of the following should the nurse include in the plan of care? Select all.

A. Place the client in a room that has negative air pressure of at least 6 exchanges/hr

B. Wear a mask when providing care within 3 ft of the client

C. Place a surgical mask on the client if transportation to another dept is unavoidable

D. Use sterile gloves when handling soiled linens

E. Wear a gown when preforming care that may result in contamination from secretions

B. Wear a mask when providing care within 3 ft of the client

C. Place a surgical mask on the client if transportation to another dept is unavoidable

E. Wear a gown when preforming care that may result in contamination from secretions

What is an infection?

occurs when a pathogen is present and leads to a chain of events

What is the best prevention against HAIs?

Hand hygiene

iatrogenic infections

result from diagnostic or therapeutic procedures

Transmission Chain of Infection

1. Causative agent

2. Reservoir

3. Portal of exit

4. Mode of transmission

5. Portal of entry

6. Susceptible host

Transmission chain of infection example of MRSA and the Wrestler

1. Causative agent- MRSA

2. Reservoir- Athlete

3. Portal of exit- Contact w/ mat

4. Mode of transmission- skin contact w/ gear

5. Portal of entry- nose, skin lesion, mouth

6. Susceptible host- broken skin, compromised, brewed skin

What is the reservoir in the chain of infection?

where pathogens can live and multiply,

ex. human, animal, food, or organic matter

what is the portal of exit in the chain of infection?

where the pathogen can leave the reservoir and spread

ex body fluids, respiratory, GI tract, skin, MM

What are the stages of an infection?

1. Incubation-Interval between the pathogen entering the body and presentation of the first finding

2. Prodromal stage-Interval from onset to more distinct findings, the pathogen multiples during this time

3. Illness stage- Interval when findings specific to the infection occur

4. Convalescence- Interval when acute findings disappear, total recovery taking days to months

Lab values associate with infections

Leukocytosis- WBC greater than 10,000

Left shift- increase neutrophils

Elevated Erythrocyte sedimentation over 20mm/hr

Positive culture

Contact transmission examples

D+, CDF, open wounds, and MRSA

Droplet Transmission examples

Pneumonia, pertussis, strep, COVID-larger than 5cmg, and RSV

Airborne examples

Covid-smaller than 5mcg, measles, TB, Varicella

vector transmission

lyme, mosquito transmission, west nile, and malaria

hand hygiene

Wash hands with antimicrobial soap when in contact with contaminants,

do not use soap and water, not alcohol if C. Diff is suspected

Cough etiquette

Using facial tissues to contain respiratory secretions & prompt disposal

Weaning surgical mask when coughing to minimize contamination of surrounding area

Turning head when coughing and staying a minimum distance of 3 feet away from others

Performing hand hygiene after contact with respiratory secretions or contaminated objects

standard precautions (tier 1)

Protect against the spread of infection through blood, body fluids, mucous membranes and non-intact skin

Must be used for all patients

Applies to all body fluids except sweat, non-intact skin, and MM

Includes hand hygiene, PPE, disinfection, sharps injury prevention, safe injection practices, cough etiquette and waste management

Masks, eye protection, and face shields if possibility of body fluids splashing

Hand hygiene after removal of gloves

Clean all client care equipment

Contact transmission precautions

Precautions to protect visitors and caregivers when they are within 3ft

RSV, shigella, enteric diseases, wound infection, impetigo, scabies, MRSA

Private room

Gloves and gowns

Disposal of infectious dressing in single non-porous bag

Droplet Transmission Precautions

Droplets larger than 5mcg and can travel 3-6ft from the client

Streptococcal pharyngitis, pneumonia, haemophilus influenzae type B, scarlet fever, rubella, pertussis, mumps, meningococcal pneumonia

Private room

Masks for providers and visitors

Wear a mask when outside of the room

Airborne transmission precautions

Droplets less than 5mcg

measles, varicella, pulmonary or laryngeal tuberculosis

Require a private room, masks and respiratory protection

N95 or HEPA respirator if the client might have TB

Negative pressure airflow exchange in the room

Full face protection if body fluid splashing may occur

Clients should wear a mask when outside of room

Positive pressure vs negative pressure rooms

Risk factors for infection

1. Inadequate hand hygiene

2. Immunocompromised

3. Recent surgery

4. Break in skin

5. Indwelling device

6. Smoking or alcohol consumption

7. Older adults

8. Poor oxygenation or circulation

9. Clients with poor personal hygiene

10. Stress or sleep deprivation

A nurse is performing mouth care for a client who is unconscious. Which of the following actions should the nurse take?

A. Turn the clients head to the side

B. place two fingers in the client's mouth to open it

C. Brush the client's teeth once per day

D. Inject a mouth rinse into the center of the clients mouth

A. Turn the clients head to the side

A nurse is instructing a client who has diabetes mellitus about footsore. Which of the following guidelines should the nurse include. Select all that apply

A. Inspect the feet daily

B. Use moisturizing lotion on the feet

C. Wash the feet with warm water and let them air dry

D. Use over-the-counter products to treat abrasions

E. Wear cotton socks

A. Inspect the feet daily

B. Use moisturizing lotion on the feet (not in-between toes)

E. Wear cotton socks

A nurse is planning care for a client who develops dyspnea and feels tired after completing morning care. Which of the following guidelines should the nurse include. Select all that apply

A. Schedule rest periods during morning care

B. Discontinue morning care for 2 days

C. Perform all care as quickly as possible

D. Ask a family member to come in to bathe the client

A. Schedule rest periods during morning care

A nurse is beginning a complete bed bath for a client. After removing the client's gown and placing a bath blanket over the body, which of the following areas should the nurse wash first?

A. face

B. feet

C. chest

D. arms

A. face

A nurse is preparing to perform denture care for a client. Which of the following actions should the nurse plan to take?

A. Pull down and out at the back of the upper denture to remove

B. Brush the dentures with a toothbrush and denture cleaner

C. Rinse the dentures with hot water after cleaning them

D. Place the dentures in a clean, dry storage container after cleaning them

B. Brush the dentures with a toothbrush and denture cleaner

What are 5 benefits of good hygiene?

1. promotes comfort

2. improves self body image

3. decreases infection and disease

4. promotes autonomy

5. social interaction or relaxation

What roles does a nurse play in hygiene?

Assess self care abilities

Provide assistance with ADLS

Promote self care in ADLS

Delegate appropriate parts for hygiene care

What factors can affect a clients view on hygiene?

Cultural preferences

Socioeconomic status

Knowledge level

Physical factors include pain, limited mobility, sensory, cognitive or emotional impairments

When is hygiene routinely done?

Hourly rounds-Offer help with self-care needs

Early morning care-On awakening, wash face, hands and mouth care

AM care-After breakfast, bathing, toileting, hair, skin and bed making

PM care-Toileting, handwashing, oral care, readying for visitors

HS care-Prior to sleep, relaxation, activism reading environment to facilitate sleep

What are the different types of baths administered in the hospital setting?

Assist bath- Areas hard to reach

Complete bath

Partial bath-Bathe only areas absolutely necessary include peritoneal, a complete bath may be too stressful

Towel bath

Bag/ package

Shower

Tub bath

Therapeutic bath-Eczema, diaper rash

important factors to remember while preforming oral care

Decreases risk of infection that causes pneumonia,

risk for aspiration, impaired swallowing or decreased gag reflex

important factors to remember when performing oral care on altered patient

have suction ready,

do not place fingers in the mouth,

keep head turned to one side

important factors of foot care

Prevents skin breakdown, pain, and infection that could interfere with gait

Avoid applying moisturizer in between toes

Avoid alcohol products

Diabetes-Should be cared for by a qualified personnel to prevent injury and evaluate feet

important factors while preforming scalp care

Essential component of personal hygiene

brushing/combing hair- Removes tangles, stimulates the scalp and circulation

Use of soft bristle to prevent trauma

important factors of nail care

Observe size, shape, and condition of nails and nail beds

Check from cracking, clubbing, and fungus

Do not soak due to infection

File nails instead of cutting

Acute pain characteristics

protective, temporary, usually self-limiting has a direct cause

Physiologic response (sympathetic nervous system) tachycardia, hypertension, anxiety, diaphoresis, muscle tension

Behavioral response- grimacing, moaning, flinching, and guarding

Management aims to treat cause

Chronic pain characteristics

ongoing or recurs frequently, lasting longer than 6 months

Physiological responses do not affect vital signs, clients can have depression, fatigue and a decreased level of functioning

Management aims to treat symptomatic pain

idiopathic pain

a chronic pain w/o a known cause

ex. migraine or joint

nociceptive pain characteristics

arises from damage or inflammation of tissue, which triggers nociceptors and causes pain

Typically acute pain, responds to pain medication

Throbbing, aching or localizing

Three types of nociceptive pain

Somatic- pain in bone, muscle, joints or connective tissue

Visceral- pain in internal organs, stomach or intestines

Cutaneous

neuropathic pain characteristics

arises from abnormal or damaged nerves, includes phantom pain, diabetic neuropathy, sciatica

Responds to adjuvant medications

Topical medication can cause some relieve, antispasmodics

Pins and needles, intense shoot pains, buring

checklist of opioid administration

Allergies

Respiratory, pulse, and blood pressure status

Height and weight

Addiction considerations

LOC

What should you monitor after opioid administration?

urinary retention, constipation, orthostatic hypotension

Risk for falls

Safety- no driving, take with foods, safe disposal, watch to nausea/vomiting, constipation

who is at risk for under treatment of pain

infants, children, older adults, or those with a substance abuse disorder

what factors influence the under treatment of pain?

cultural and societal attitudes

lack of knowledge

fear of addiction

exaggerated fear of respiratory depression

What factors affect pain experience?

Infants can not verbalize

Older adults have multiple pathologies that cause pain and loss of function

Fatigue- increase pain sensitivity

Genetic sensitivity

Cognitive function

Prior experiences

Anxiety and fear

Culture

What are non-pharmacologic treatments for pain?

TENS stimulation

Distraction-TV or visitors

Acupuncture

Ice/ heat

elevation

Reposition

Music

Humor

Check bed linens/hygiene

exercise

a nurse at a clinic is collecting data about pain from a client who reports severe abdominal pain. the nurse asks the client whether he has nausea and has been vomiting. which of the following pain characteristics is the nurse attempting to determine?

a. presence of associated manifestations

b. location of the pain

c. pain quality

d. aggravating and relieving factors

a. presence of associate manifestations

a nurse is collecting data from a client who is reporting pain despite taking analgesia. which of the following actions should the nurse take to determine the intensity of the client's pain?

a. ask the client what precipitates the pain

b. question the client about the location of the pain

c. offer the client a pain scale to measure his pain

d. use open- ended questions to identify the client's pain sensations

c. offer the client a pain scale to measure his pain

a nurse is discussing the care of a group of clients with a newly licensed nurse. which of the following clients should the newly licensed nurse identify has experiencing chronic pain?

a. a client who has a broken femur and reports hip pain

b. a client who has incisional pain 72 hr following pacemaker insertion

c.a client who has food poisoning and reports abdominal cramping

d. a client who has episodic back pain following a fall 2 years ago

d. a client who has episodic back pain following a fall 2 years ago

a nurse is monitoring a client who is receiving opioid analgesia for adverse effects of the medication. which of the following effects should the nurse anticipate? select all that apply

a. urinary incontinence

b. diarrhea

c. bradypnea

d. orthostatic hypotension

e. nausea

c. bradypnea

d. orthostatic hypotension

e. nausea

a nurse is caring for a client who is receiving morphine via a Patient controlled analgesia infusion device after abdominal surgery. which of the following statements indicates that the client knows how to use the device?

a. i'll wait to use the device until it's absolutely necessary

b. i'll be careful about pushing the button too much so i don't get an overdose

c. i should tell the nurse if the pain does't stop while i am using the device

d. i will ask my adult child to push the dose button when i am sleeping

c. i should tell the nurse if the pain does't stop while i am using the device

A nurse is caring for a client scheduled for abdominal surgery. The client reports being worried. Which of the following actions should the nurse take?

a. Offer information on a relaxation technique and ask the client if he is interested in trying it.

b. Request a social worker to see the client to discuss meditation.

c. Attempt to use biofeedback techniques with the client

d. Tell the client many people feel the same way before surgery and to think of something else

a. Offer information on a relaxation technique and ask the client if he is interested in trying it.

A nurse is assessing a client as part of an admission history. The client reports drinking an herbal tea every afternoon at work to relieve stress. The nurse should suspect the tea includes which of the following ingredients?

a. Chamomile

b. Ginseng

c. Ginger

d. Echinacea

a. chamomile

A nurse is reviewing complementary and alternative therapies with a group of nursing students. The nurse should classify which of the following interventions as a mind-body therapy? (Select all that apply.)

a. Art therapy

b. Acupressure

c. Yoga

d. Therapeutic touch

e. Biofeedback

a. Art therapy

c. Yoga

e. Biofeedback

A nurse is teaching a group of nursing students on complementary and alternative therapies they can incorporate into their practice without the need for specialized licensing or certification. Which of the following should the nurse encourage the students to use? (Select all that apply.)

a. Guided imagery

b. Massage therapy

c. Meditation

d. Music therapy

e. Therapeutic touch

a. Guided imagery

c. Meditation

d. Music therapy

A nurse is planning to use healing intention with a client who is recovering from a lengthy illness. Which of the following is the priority action the nurse should take before attempting this particular mind-body intervention?

a. Tell the client the goal of the therapy is to promote healing.

b. Ask whether the client is comfortable with using prayer.

c. Encourage the client participate actively for best results.

d. Instruct the client to relax during the therapy.

b. Ask whether the client is comfortable with using prayer.

A nurse is caring for a client who has several risk factors for hearing loss. As the nurse reviews the client's medication history, which of the following medications the client takes should alert the nurse to a further risk for ototoxicity? (Select all that apply.)

A. Furosemide (Lasix)

B. Ibuprofen (Advil)

C. Cimetidine (Tagamet)

D. Simvastatin (Zocor)

E. Amiodarone (Cordarone)

A. Furosemide (Lasix)

B. Ibuprofen (Advil)

A nurse is reviewing instructions with a client who has a hearing loss and has just started wearing hearing aids. Which of the following statements should the nurse identify as an indication that the client understands the instructions?

A. "I will use a damp cloth to clean the outside of my hearing aids"

B. " I clean the ear molds of my hearing aids with rubbing alcohol"

C. "I keep the volume of my hearing aids turned up so I can hear better"

D. "I'll take the batteries out of my hearing aids when I take them off at night"

D. "I'll take the batteries out of my hearing aids when I take them off at night"

A nurse is caring for a client who reports difficulty hearing. Which of the following assessment findings indicate a sensorineural hearing loss in the left ear? (Select all that apply.)

A. Weber test showing lateralization to the right ear

B. Light reflex at 10 o'clock in the left ear

C. No signs of obstruction in the left ear canal

D. Rinne test showing length of time is decreased for air and bone conduction

E. Rinne test showing air conduction less than bone conduction in the left ear

A. Weber test showing lateralization to the right ear

D. Rinne test showing length of time is decreased for air and bone conduction

A nurse is caring for a client who had an amphetamine overdose and has sensory overload. Which of the following interventions should the nurse implement?

A. Immediately complete a thorough assessment.

B. Put the client in a room with a client who is hearing impaired.

C. Provide a private room, and limit stimulation.

D. Talk loudly to the client, and encourage ambulation.

C. provide a private room with a client who is hearing impaired

A nurse is caring for a client who recently had a cerebrovascular accident and has aphasia. Which of the following interventions should the nurse use to promote communication with this client? (Select all that apply.)

A. Speak fast and loudly.

B. Minimize background noise.

C. Write down what the client does not understand.

D. Allow plenty of time for the client to respond.

E. Use brief sentences with simple words.

A. Speak fast and loudly.

B. Minimize background noise.

How do nurses provided comfort?

Empathy

Therapeutic communication

Providing privacy

Honor dignity and humanity

Sensory perception

the ability to receive and interpret sensory impressions through visual, auditory, tactile, olfactory, gustatory, and kinesthetics

Affects consciousness, arousal, awareness, memory, affect, judgement, reality, and language

sensory overload

excessive sustained and unmanageable muscular stimulation

Includes racing thoughts, anxiousness, and restles

sensory depriation

reduced sensory input from the internal or external environment

Can result from illness or trauma, or isolation

sensory deficit

a change in reception and or perception, can affect any of the senses

factors the affect sensory stimulation

Neurologic deficit

Stroke

Environment

fear/anxiety

Aging