Final Exam NUR 2214C

Final Exam NUR 2214C Latest 2023 - 2024

• A client is admitted with a large draining wound on the leg. What action does the nurse take first?

a.A dminister ordered antibiotics.b.Insert an intravenous line.c.Give pain medications if needed.d.Obtain cultures of the leg wound.

ANS: D

The nurse first obtains wound cultures prior to administering broad-spectrum antibiotics. The nurse would need to start the IV prior to giving the antibiotics as they will most likely be parenteral. Pain should be treated but that is not the priority.

• A client is going to be admitted for a scheduled surgical procedure. Which action does the nurse explain is the

most important thing the client can do to protect against errors?a.B ring a list of all medications and what they are for.b.Keep the doctor's phone number by the telephone.c.Make sure all providers wash hands before entering the room.d.Write down the name of each caregiver who comes in the room.

ANS: A

Medication errors are the most common type of health care mistake. The Joint Commission's Speak Up campaign encourages clients to help ensure their safety. One recommendation is for clients to know all their medications and why they take them. This will help prevent medication errors.

• A client with chronic osteomyelitis is being discharged from the hospital. What information is important for the

nurse to teach this client and family? (Select all that apply.) a.Adherence to the antibiotic regimen b.Correct intramuscular injection technique c.Eating high-protein and high-carbohydrate foods d.Keeping daily follow-up appointments e.Proper use of the intravenous equipment

ANS: A, C, E

The client going home with chronic osteomyelitis will need long-term antibiotic therapy—first intravenous, then oral.The client needs education on how to properly administer IV antibiotics, care for the IV line, adhere to the regimen, and eat a healthy diet to encourage wound healing. The antibiotics are not given by IM injection. The client does not need daily follow-up.

• Which nursing action is the best example of the ethical principle of veracity?
• Supporting the patient's right to refuse any part of planned nursing care
• Informing the patient that the pain medication to be given is not the same as what was administered the previous day
• Maintaining the privacy of the patient's personal medical information.
• Supporting the patient when ambulating and instructing the patient on the use of a walker

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Explanation: 1. This is an example of autonomy.

• Veracity is truth telling, which is essential for effective communication and trust.
• This illustrates confidentiality.
• This illustrates beneficence or "do no harm."
• A new graduate nurse is working with an experienced nurse to chart assessment findings. The new nurse notes that

the physical therapist wrote on the chart that the patient is lazy and did not want to participate in assigned therapies this AM.The experienced nurse asks the new nurse what may be going on here. What is the best explanation for this statement?

• Data on the chart can sometimes be documented in a biased manner.
• Data on the chart changes as the patient’s condition changes.
• Data on the chart is usually accurate and can be verified from the patient.
• Reading the chart is not a wise use of time as this can be time consuming and tedious.

ANS: A

It is important that the nurse records only what is assessed, without adding judgments or interpretations to the record.Data do indeed change (and need to be charted) as the patient’s condition changes, but this would not be the best 1 / 3

answer to this question. Assessment data may at times be difficult to obtain, but that would not occur often enough to warrant a warning about the difficulty in charting it. Also, obtaining data is clearly a different activity from charting it.Charting can be time consuming and tedious, but this is not the most complete answer to this question.

• A nurse assesses a client with a fracture who is being treated with skeletal traction. Which assessment should alert

the nurse to urgently contact the health provider?a.Blood pressure increases to 130/86 mm Hg b.Traction weights are resting on the floor c.Oozing of clear fluid is noted at the pin site d.Capillary refill is less than 3 seconds

ANS: B

The immediate action of the nurse should be to reapply the weights to give traction to the fracture. The health care provider must be notified that the weights were lying on the floor, and the client should be realigned in bed. The client's blood pressure is slightly elevated; this could be related to pain and muscle spasms resulting from lack of pressure to reduce the fracture. Oozing of clear fluid is normal, as is the capillary refill time.

• A nurse assesses a client with a pelvic fracture. Which assessment finding should the nurse identify as a

complication of this injury?a.Hypertension b.Constipation c.Infection d.Hematuria

ANS: D

The pelvis is very vascular and close to major organs. Injury to the pelvis can cause integral damage that may manifest as blood in the urine (hematuria) or stool. The nurse should also assess for signs of hemorrhage and hypovolemic shock, which include hypotension and tachycardia. Constipation and infection are not complications of a pelvic fracture.

• A nurse is calling the on-call physician about a client who had a hysterectomy 2 days ago and has pain that is

unrelieved by the prescribed narcotic pain medication. Which statement is part of the SBAR format for communication?

a. A: "I would like you to order a different pain medication."

b. B: "This client has allergies to morphine and codeine."

c. R: "Dr. Smith doesn't like nonsteroidal anti-inflammatory meds."

d. S: "This client had a vaginal hysterectomy 2 days ago."

ANS: B

SBAR is a recommended form of communication, and the acronym stands for Situation, Background, Assessment, and Recommendation. Appropriate background information includes allergies to medications the on-call physician might order. Situation describes what is happening right now that must be communicated; the client's surgery 2 days ago would be considered background. Assessment would include an analysis of the client's problem; asking for a different pain medication is a recommendation. Recommendation is a statement of what is needed or what outcome is desired; this information about the surgeon's preference might be better placed in background.

• The 14-year-old boy who is scheduled for left leg amputation says to the nurse, "What in the world am I going to do

with only one leg?" What is the nurse's most therapeutic response?

• "What are you thinking about right now?"
• "With a prosthesis, you will be as good as new."
• "It is way too early to be concerned about that now."
• "When my brother had his leg removed, he did great!"

ANS: A

The patient's concern should be acknowledged and the patient encouraged to express feelings.

• The nurse finds a client pulseless and breathless. The client's skin is pale and cool, but not cyanotic. Because of

this finding, the nurse suspects which of the following?

• Arrest was caused by airway obstruction.
• Respiratory arrest occurred prior to cardiac arrest.
• Cardiac arrest occurred prior to respiratory arrest.
• The client cannot be resuscitated.
• An emergency room nurse is triaging victims of a multi-casualty event. Which client should receive care first? 2 / 3

a.A 30-year-old distraught mother holding her crying child b.A 65-year-old conscious male with a head laceration c.A 26-year-old male who has pale, cool, clammy skin d.A 48-year-old with a simple fracture of the lower leg

ANS: C

The client with pale, cool, clammy skin is in shock and needs immediate medical attention. The mother does not have injuries and so would be the lowest priority. The other two people need medical attention soon, but not at the expense of a person in shock.

• A nurse on the unit makes an error in the calculation of the dose of medication for a critically ill patient. The

patient suffered no ill consequences from the administration. The nurse decides not to report the error or file an incident report.The nurse is violating which principle of ethics?

• Fidelity
• Individuality
• Justice
• Values clarification

ANS: A

Fidelity is the principle that requires us to act in ways that are loyal. In the role of a nurse, such action includes keeping your promises, doing what is expected of you, performing your duties, and being trustworthy. Individuality is something that distinguishes one person or thing from others. Injustice is when a person is denied a right or entitlement. Values clarification is a tool that allows the nurse to examine personal values in terms of ethical situations.

• A nurse teaches a client about prosthesis care after amputation. Which statements should the nurse include in this

client's teaching? (Select all that apply.)

• "The device has been custom made specifically for you."
• "Your prosthetic is good for work but not for exercising."
• "A prosthetist will clean your inserts for you each month."
• "Make sure that you wear the correct liners with your prosthetic."
• "I have scheduled a follow-up appointment for you."

ANS: A, D, E

A client with a new prosthetic should be taught that the prosthetic device is custom made for the client, taking into account the client's level of amputation, lifestyle (including exercise preferences), and occupation. In collaboration with a prosthetist, the client should be taught proper techniques for cleansing the sockets and inserts, wearing the correct liners, and assessing shoe wear. Follow-up care and appointments are important for ongoing assessment.

• A nurse wants to explore why clients who receive patient-controlled analgesia (PCA) after abdominal surgery

ambulate sooner than clients who receive nurse-administered pain medications. Which action should the nurse take first?a.Contact the medical center's clinical pharmacist.b.Search the medical library for the best evidence.c.Recommend PCA for all clients.d.Appraise data obtained through client chart audits.

ANS: B

After asking the "burning" question, the nurse should find the very best evidence to try to answer it. The clinical pharmacist may be knowledgeable, but this is not the best evidence available. Information from client chart audits may demonstrate better outcomes with PCA, but this again is not the best evidence. The nurse should wait and recommend clinical practice changes until best evidence is found, appraised, and synthesized.

• A patient has been admitted for a skin graft following third degree burns to the bilateral calves. The plan of care

involves 3 days inpatient and 6 months outpatient treatment, to include home care and dressing changes.When should the nurse initiate the educational plan?

• After the operation and the patient is awake
• On admission, along with the initial assessment
• The day before the patient is to be discharged
• When narcotics are no longer needed routinely

ANS: B

Initial discharge planning begins upon admission. After the operation has been completed is too late to begin the

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