NUR 233 Exam #4 Questions and Correct CORRECT ANSWER wers Updated Version 2023 Score 100% A client diagnosed with delirium becomes disoriented and confused at night. Which intervention should the nurse implement initially?
- Move the client next to the nurses' station
- Use an indirect light source and turn off the TV
- Keep the TV and a soft light on during the light
- Play soft music during the night, maintain a well-lit room - CORRECT ANSWER B
A patient is being discharged 4 days after hip arthroplasty using the posterior approach.Which patient action requires intervention by the nurse?
- Using crutches with a swing to gait
- Sitting upright on the edge of the bed
- Leaning over to pull on shoes and socks
- Bending over the sink while brushing teeth - CORRECT ANSWER C
A patient who had open reduction and internal fixation of the left lower leg fractures continues to report severe pain in the leg 15 mins after receiving the prescribed IV morphine. The nurse determines pulses are faintly palpable and the foot is cool to the touch. Which action should the nurse take next?
- Notify the HCP
- Assess the incision for redness
- Reposition the left leg on the pillow
- Check the patient's blood pressure - CORRECT ANSWER A
A patient with Alzheimer's disease who is being admitted to a long-term care facility has had several episodes of wandering away from home. Which action will the nurse include in the plan of care?
- Reorient the patient several times daily
- Have the family bring in familiar items
- Place the patient in a room close to the nurse's station
- Remind the patient not to wander from the nursing unit - CORRECT ANSWER C
An older client is brought to the ED by a neihbor who heard the client talking and found him wandering in the street at 3 am. The nurse should first determine which data about the client.
- his insurance status
- blood toxicology levels 1 / 2
- whether he ate an evening meal
- whether this is a change in usual level of orientation - CORRECT ANSWER D
As the nurse admits a patient in end-stage renal disease to the hospital, the patient tells the nurse "if my heart or breathing stop, I do not want to be resuscitated." Which action should the nurse take first?
- Place DNR notation in patients care plan
- Invite the patient to add a notarized advance directive in the health record
- Advise the patient to designate a person to make future health care decisions
- Ask if the decision has been discussed with the patient's health care provider -
CORRECT ANSWER D
D.B. is admitted to a long-term facility. He has a nursing diagnosis for impaired memory related to effects of dementia. An appropriate nursing intervention for him is to
- Let him know what behavior is socially appropriate
- Assist him with all self-care to maintain self-esteem
- Maintain familiar routines of sleep, meals, meds and activities
- Promote orientation at every encounter with patient by asking day, time, place -
CORRECT ANSWER D
For a patient who has had a right hip arthroplasty, which nursing action can the nurse delegate to experienced UAP?
- Reposition the patient every 1-2 hours
- Assess for skin irritation on the patient's back C. Teach the patient quadriceps-setting
- Determine the patient's pain intensity and tolerance - CORRECT ANSWER A
exercises
One month after discharge, a client who had a left total hip replacement calls a clinic reporting acute constant pain in the left groin and hip area and feeling like the left leg is shorter than the right. A nurse advises the client to come to the clinic
- wound infection
- deep vein thrombosis
- dislocation of prosthesis
- aseptic loosening of the prothesis - CORRECT ANSWER
The client being admitted from the ED is diagnosed with a fecal impaction. Which
nursing intervention should be implemented:
- administer an antidiarrheal med every day prn
- perform bowel training every 2 hours
c) Administer an oil retention enema
d) Prepare for an UGI X-ray - CORRECT ANSWER C
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