Chamberlain University NR 224 fundamentals skills Final comprehensive exam review questions and answers
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190 Terms
What factors impact the nurse's ability to recognize and cluster clinical cues?
Understanding of pathological changes within the body
Knowledge of normal human anatomy
Experience in the clinical setting
Ability to identify a single, significant cue and follow up
3 multiple choice options
Complete the nursing diagnosis statements below by dragging the diagnosis words/phrases to the corresponding etiology.
Anxiety - Related to Hospitalization
Ineffective airway clearance - Related to Bronchitis
Risk for imbalanced body temperature - Related to Hypothalamic dysfunction
Decreased cardiac output - Related to Hypovolemia
Constipation - Related to Low-fiber diet
1 multiple choice option
Patient Name: Gladys Smith Age: 58 Gender: Female
Ms. Smith lives alone. Up until four weeks ago, she was healthy and not taking any medication. Although Mrs. Smith has been tiring easily, she attributes that to a project at work that is behind schedule.
no known allergies
recent medical history: cerebral vascular accident (CVA, stroke) 4 weeks prior to admission
non-ambulatory
being admitted to a rehabilitation facility from the hospital
“I am so weak I cannot feed myself or brush my teeth.”
“All I want to do is sleep.”
“The doctor says I may never live by myself again.”
“My clothes are too big since I’ve lost so much weight.”
weight 100 lb (down from 115 lb when admitted to hospital)
limited range of motion bilateral shoulders
non-ambulatory, can transfer from chair to bed using a walker
thick, oral secretions
sores in mouth
halitosis
speaks slowly and quietly
Nutritional status
3 multiple choice options
After treatment with intravenous fluids and medication to lessen the cramps, Jim is discharged from urgent care and told to follow up with his primary care provider within two days. A nurse from the urgent care center called Jim the next day to check on his recovery. What cues will the nurse ask about to determine if Jim's status is improving?
Select all that apply.
Whether the fever is gone
Number of bowel movements
Presence of abdominal pain
3 multiple choice options
A longitudinal record of an individual's interactions with the healthcare system.
Electronic Health Record (EHR)
1 multiple choice option
The legal record documenting a single encounter between an individual and a healthcare professional.
Electronic Medical Record (EMR)
1 multiple choice option
What are the advantages to clients that are realized by using an electronic health record (EHR)?
Select all that apply.
Continuity of care
Increased safety
3 multiple choice options
Information shared by the patient, family member, or another individual; cannot be verified by the nurse.
Subjective Data
1 multiple choice option
Information that can be assessed and verified by the nurse using their senses.
Objective Data
1 multiple choice option
After a year of planning and saving, Davon (preferred pronouns: she, her) and her partner are taking a well-deserved beach vacation. During their bicycle tour, one of the other sight-seers stops suddenly, causing Davon to swerve and crash. Despite wearing a helmet, Davon loses consciousness. When paramedics arrive, they ask Davon's partner about her health history.
What is the best way to provide this information?
Electronically by Davon's partner accessing a copy of her EHR
3 multiple choice options
Two hours into the shift, the current nurse receives a call from the colleague who cared for Mr. Hilliard the previous shift. The colleague shares that they forgot to document a call to Mr. Hilliard's healthcare provider about a potential surgical wound infection and asks the current nurse to document that information.
What is the best response by the current nurse?
"You'll be back tonight, just add it as a late entry."
3 multiple choice options
The nurse is using soap and water to clean hands prior to client care. Proper hand hygiene is a nursing intervention that can break which links in the chain of infection?
Select all that apply.
Portal of exit
Portal of entry
Mode of transmission
Reservoir
3 multiple choice options
A client recovering from hip replacement asks what they should eat to help heal faster. How should the nurse reply?
"You should make sure you increase your protein intake."
3 multiple choice options
Today, Maria woke up with a sore throat and a cough.
Incubation Stage
3 multiple choice options
Maria waited a couple of days hoping it was just a cold, but a fever developed.
Prodromal Stage
3 multiple choice options
Maria tested positive for COVID-19 and her symptoms worsened.
Illness Stage
3 multiple choice options
Maria was hospitalized for a few days and then went home to recover.
Convalescence Stage
3 multiple choice options
A client was just diagnosed with a catheter-associated urinary tract infection (CAUTI). What causes this?
Break in sterile technique
2 multiple choice options
A client on broad spectrum antibiotics is now diagnosed with Clostridium difficile, an infectious diarrhea. What describes the link between antibiotics and Clostridium difficile?
The antibiotics kill the bad and good bacteria in the intestines.
3 multiple choice options
The nurse was inserting an intravenous (IV) catheter and the needle punctured her glove and finger. What should be the nurse's first action?
Dispose of the IV needle in a sharps container.
3 multiple choice options
The nurse (preferred pronouns: she, her) was exposed to a client with influenza two days ago. The nurse states that she feels fine, so she must not have gotten influenza. What is the best reply to this statement?
"You may still be in the incubation stage and not have symptoms yet."
3 multiple choice options
Yesterday, the client was fine but today the client has developed a low-grade fever and complains of fatigue. The nurse should interpret these findings as indicating which stage of infection?
Prodromal
3 multiple choice options
Healthcare agencies need to reduce the incidence of healthcare-associated infections (HAIs). Which nursing action directly meets this goal?
Perform hand hygiene as appropriate.
3 multiple choice options
Which client care aspect of asepsis is demonstrated when items are stored in a sterile packaging prior to use?
Client and equipment preparation
3 multiple choice options
If the nurse has sterile gloves and gown on and is touching a non-sterile pen and clipboard, this violates which client care aspect of asepsis?
Contact guidelines
3 multiple choice options
Which statement is an accurate description of medical asepsis?
The nursing assistant washes their hands with sanitizer.
3 multiple choice options
The nurse needs to sterilize a set of surgical instruments. What methods could the nurse use?
Select all that apply.
Radiation
Boiling water
Gas
Combination of heat and pressure
3 multiple choice options
Why can't multiple family members of a client be present in the operating room?
It violates environmental control.
3 multiple choice options
Which statement made by a client regarding use of hand sanitizer requires follow-up by the nurse?
"If the sanitizer doesn't dry fast enough, I can wipe it off."
3 multiple choice options
The nurse is performing surgical hand antisepsis. How long should they wash their hands for?
4 minutes
3 multiple choice options
In which situations would the nurse appropriately use soap and water to decontaminate the hands?
Select all that apply.
After exposure to a client with potentially infectious diarrhea
Has visibly soiled hands after changing the bedding of a client
3 multiple choice options
A new colleague asks why the fingers should be pointed down when performing handwashing. What is the nurse's correct response?
"The fingers are the dirtiest part during hand hygiene."
3 multiple choice options
A sterile item is rolling off the edge of a sterile field. What is the nurse's best action if they are wearing sterile personal protective equipment (PPE)?
Let it fall. Get a sterile replacement item.
3 multiple choice options
The nurse is inserting a sterile urinary catheter into a female client. The nurse inserts it into the vaginal area instead of the urethra. What is the best action by the nurse?
Request a new sterile catheter.
3 multiple choice options
The nurse is donning a pair of sterile gloves for tracheostomy suctioning. The nurse donned the left glove but the right one tore. What is the nurse's next best action?
Remove both gloves and get a new sterile set of gloves.
3 multiple choice options
A provider is placing a chest tube using sterile technique. Which action should the nurse question?
Provider opens sterile packages without checking expiration dates.
3 multiple choice options
When donning personal protective equipment (PPE), which item is last to put on?
Gloves
3 multiple choice options
A nurse is using a gown, gloves, and face shield when bathing a client diagnosed with C. difficile infection. Which nursing action promotes proper use of personal protective equipment (PPE)?
The nurse works from "clean" areas to "dirty" areas during the bath.
3 multiple choice options
When determining the best site for blood pressure measurement, which scenarios require the nurse to choose an alternative site?
Select all that apply.
Mastectomy on left side
Intravenous fluids infusing in right forearm
An arteriovenous shunt is present
3 multiple choice options
When assessing the oral temperature of an adult client, which findings indicate an alternate route is needed?
Select all that apply.
A hot or cold beverage consumed in the last 20 minutes
The client has eaten within the last 20 minutes
The client is chewing gum
The client smoked in the last 20 minutes
3 multiple choice options
Amber has been admitted for ulcerative colitis. Client's health history includes ulcerative moderate left-sided colitis unresponsive to medical therapy. Client has not had any previous surgical history. Client's abdomen is soft and flat and has hyperactive bowel sounds. Client is reporting 8-10 liquid bowel movements a day, decreased appetite. Treatment plan is to rehydrate and manage symptoms with medications.
Upon review of the client's chart, which site/method of temperature measurement would you avoid for this client?
Rectal
3 multiple choice options
After obtaining a set of vital signs on a client, the nurse determines that the results are abnormal for this client. Which factors may have impacted the client's vital signs?
Select all that apply.
The client just returned from a walk in the hallway.
The blood pressure (BP) cuff used by the nurse might have been too small.
The client's room is very warm.
3 multiple choice options
The nurse is measuring vital signs on a pediatric client. When analyzing the data obtained, the nurse considers that, compared with adults, children tend to have which of the following?
Select all that apply.
Lower blood pressure than adults
Higher respiratory rate than adults
Higher pulse than adults
2 multiple choice options
The nurse is delegating vital sign measurements to a nursing assistant. Which actions should be completed by the nurse?
Select all that apply.
Review the client's vital sign data obtained by the nursing assistant.
Assess the client's stability prior to delegating vital signs.
3 multiple choice options
In which scenario below will radiant heat loss occur?
A cool surgical room while the client's skin is exposed
3 multiple choice options
Which statements are true regarding the treatment of fever?
Select all that apply.
It is important to avoid causing shivering when treating a fever.
Shivering greatly increases heat production; however, it is counterproductive in a client with a fever.
3 multiple choice options
The nurse on a medical-surgical unit measures the temperature using an infrared thermometer that measures cutaneous blood temperatures across the forehead and behind the ear.
Which type of thermometer is being used?
Superficial temporal artery
3 multiple choice options
Fever: Interventions
will be aimed at increasing heat loss, reducing heat production, and preventing complications
The nurse is caring for a client with a fever of 101.6⁰F (38.7°C). Based on the concept of thermoregulation, the nurse knows that the body will attempt to cool itself by various means of heat loss.
Select the interventions that are not safe to use use to decrease the client's fever.
Ice packs
Ice bath
Cooling blanket
Tepid sponge bath
Moisten skin and turn on a fan
3 multiple choice options
Which statements are true regarding the measurement of the peripheral pulse?
Select all that apply.
Palpate the peripheral pulse for 30 seconds and multiply this number by 2 to calculate the pulse rate.
The normal range for pulse rate varies by age.
3 multiple choice options
To assess an apical pulse, the nurse must use:
A stethoscope
2 multiple choice options
When assessing vital signs routinely, the ___________ pulse sites are most used because of their relative superficiality, which should not require deep palpation.
carotid and radial
3 multiple choice options
Used to assess pulse in children
Temporal
3 multiple choice options
Age
Infant
Normal Heart Rate Range (bpm)?
120-160
3 multiple choice options
Age
Preschooler
Normal Heart Rate Range (bpm)?
80-110
3 multiple choice options
The nurse will be performing a nursing assessment on Tina (preferred pronouns: she, her), a 38-year-old female, who has been hospitalized for a recent compound fracture of the left femur. Tina's history has been reviewed and the previous shift report shared that she has been experiencing acute pain in her fractured leg on and off since admission and is now due for her next dose of morphine. The nurse enters the room and finds the client asleep in bed in a supine position.
Which of the respiratory assessment findings might the nurse anticipate observing based only on this information?
Labored breathing because she is lying flat in bed
3 multiple choice options
have an irregular cyclical pattern that alternates from slow and shallow, then the rate increases and deepens, but then the pattern reverses and ends with apnea and resumed respirations.
Cheyne-Stokes respirations
2 multiple choice options
A nurse is assessing the vital signs of a postoperative adult client. The client's respiratory rate is 22 breaths/minute. What is the next step for the nurse to take?
Assess the depth and rhythm of the respirations.
3 multiple choice options
Which factors must the nurse consider when measuring vital signs?
Select all that apply.
Medications
Gender
Age
3 multiple choice options
A rise in temperature of 1 degree Fahrenheit may cause an increase in the pulse rate by ___ beats per minute.
4
3 multiple choice options
The nurse, who is assessing a client for cues that would indicate that nursing action is required, knows which statements are true regarding the relationship of thermoregulation, oxygen requirements, and fluid volume?
Select all that apply.
A fever can lead to fluid volume deficit.
A fever increases metabolism.
3 multiple choice options
Adam, a 54-year-old client on bed rest, has a Stage 1 pressure injury on the coccyx. Which interventions should the nurse implement?
Select all that apply.
Provide proper skin care.
Reposition the client every 1 to 2 hours.
Get the client a specialty air or foam mattress.
3 multiple choice options
A 77-year-old is recovering from spinal surgery and using a walker as an assistive device. The client states, "I don't want any visitors or to go anywhere. No one should see me using a walker. I want to be left alone." What is the most appropriate nursing diagnosis?
Social isolation
3 multiple choice options
An 80-year-old fell at home and was not found for three days. The client was admitted to the hospital with a fractured hip. Which complications can occur due to immobility?
Select all that apply.
Urinary retention
Embolus
Muscle atrophy
3 multiple choice options
The nurse is assessing a client who recently had surgery. Lung sounds on the right base are diminished and there are no breath sounds in the left base. What complication does the nurse suspect?
Atelectasis
3 multiple choice options
A client has been on prolonged bed rest but now is able to get up. What should the nurse assess for?
Select all that apply.
Activity tolerance
Range of motion (ROM)
Gait
Strength
3 multiple choice options
Mary Brenner is a 60-year-old client who is less than 24 hours post-operative from abdominal surgery. To prevent immobility complications, what priority nursing intervention should be implemented?
Ambulate the client in the hall.
3 multiple choice options
A nurse works on an orthopedic surgical floor in a hospital. The nurse understands that clients are at risk of which physiological complication of immobility?
Decreased lung expansion
2 multiple choice options
An unlicensed assistive personnel (UAP) is putting compression stockings on a client following major surgery. The client asks why they have to wear them. What is the UAP's best answer?
"They promote circulation to the heart."
3 multiple choice options
The nurse has four clients on the unit with impaired mobility. Which client is at greatest risk of developing complications from immobility?
82-year-old woman who has suffered a cerebrovascular accident (CVA)
3 multiple choice options
When in a prone position, the nurse knows to examine the client for skin breakdown on which areas?
Select all that apply.
Knees
Toes
Ears
2 multiple choice options
To prevent complications, what is the maximum amount of time the nurse should wait to reposition a client?
Every two hours
3 multiple choice options
A client injured their spine in a skiing accident and is receiving rehabilitation services. Which position is contraindicated for this injury?
Prone
3 multiple choice options
A nurse is caring for a client who is experiencing difficulty breathing. Which position should the nurse place the client in to promote breathing?
Fowler's position
2 multiple choice options
The client is fully dilated and ready to push the baby out. What position is the client placed in?
Lithotomy
3 multiple choice options
when completing a bed bath what step is first
wash the eyes first without soap
3 multiple choice options
what is the last area that should be washed when doing a bed bath
the perineal area
3 multiple choice options
when making a bed it is ok to shake the bed linens
false
1 multiple choice option
when storing dentures it is important to store them how?
in a labeled denture cup with patient name and date of birth
with denture solution or water in the cup
3 multiple choice options
a patient on seizure precautions should have padded side rails on their bed
true
1 multiple choice option
a patient with seizure precautions should have oxygen and suction ready and available in the room
true
1 multiple choice option
a patient who is having a seizure
should be turned on their left side
3 multiple choice options
a patient having a seizure should have restrictive clothing removed
true
1 multiple choice option
a patient having a seizure should have a wallet or other soft form of padding inserted into their mouth to prevent them from biting their tongue
false
1 multiple choice option
a patient having a seizure should be restrained as much as possible to prevent them from injuring themselves
false
1 multiple choice option
of the options what is important to remember with a seizure
note the time the seizure started and how long it lasted for
3 multiple choice options
what's important to do after a patient is done seizing
try to reorient the patient
keep the patient calm
collect vital signs
perform a brief neurological exam
3 multiple choice options
what is strider
High pitch breathing
3 multiple choice options
how should a nurse educate a client on reducing constipation
increase fluids
increase fiber
increase activity
3 multiple choice options
how does increase fiber intake help in reducing constipation
increases peristalsis
1 multiple choice option
a nurses main concern for a client with diarrhea is what
fluid volume deficit
3 multiple choice options
how should a nurse educate a client on reducing diarrhea
increase fiber
increase their fluid intake
2 multiple choice options
one concern a nurse would have regarding a patient with diarrhea is impaired skin integrity
true
1 multiple choice option
a ostomy is a surgically created opening
true
1 multiple choice option
a ileostomy would result in what form of output
very very liquidy
3 multiple choice options
a colostomy is a ostomy located where?
the large intestine
3 multiple choice options
in terms of ostomy care how often should a ostomy bag be emptied
when it is a third full
3 multiple choice options
a stoma that is red, pink or moist is indicating that a stoma site is infected
false it SHOULD be red pink and moist
1 multiple choice option
a stoma site should be pale, dusky or blue
false
1 multiple choice option
if a stoma is pale, blue, or dusky what should a nurse do
report immediately to the provider there is nothing inside the nursing scope of practice that a nurse can do
3 multiple choice options