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Herzing NU216 Final Exam Part 1 Latest

1
...
The nurse should initially focus on which learning goal for
this patient?
a
...

b
...

c
...

d
...

2
...
How would the
nurse evaluate the patient's situation?
a
...

b
...

c
...

d
...

3
...
Which teaching strategy, if implemented by the nurse, is most likely to
be effective?
a
...

b
...

c
...

d
...


4
...
When
implementing patient teaching, what is the priority action for the nurse?
a
...

b
...

c
...

d
...

5
...
” When using the
Transtheoretical Model of Health Behavior Change, the nurse identifies that this patient is in
which stage of change?
a
...
Termination
c
...
Contemplation
6
...
How should the nurse use this information to plan teaching and learning
strategies?
a
...

b
...

c
...

d
...

7
...
I’ve
decreased my fat intake and I’ve stopped smoking
...
“Although those are important, it is essential that you make other changes, too
...
“Are you having any difficulty in maintaining the changes you have already made?”
c
...
“You have already accomplished changes that are important for the health of your heart
...
The nurse is planning a teaching session with a patient newly diagnosed with migraine
headaches
...
“What kind of work and leisure activities do you do?”
b
...
“Can you describe the types of activities that help you learn new information?”
d
...
The nurse considers a nursing diagnosis of ineffective health maintenance related to low
motivation for a patient with diabetes
...
The patient does not perform capillary blood glucose tests as directed
...
The patient occasionally forgets to take the daily prescribed medication
...
The patient states that dietary changes have not made any difference at all
...
The patient cannot identify signs or symptoms of high and low blood glucose
...
A patient with diabetic neuropathy requires teaching about foot care
...
The nurse will demonstrate the proper technique for trimming toenails
...
The patient will list three ways to protect the feet from injury by discharge
...
The nurse will instruct the patient on appropriate foot care before discharge
...
The patient will understand the rationale for proper foot care after instruction
...
The nurse educator teaches students how to be more assertive
...
Role playing
b
...
Printed materials
d
...
The nurse and the patient who is diagnosed with hypertension develop this goal: “The
patient will select a 2-gram sodium diet from the hospital menu for the next 3 days
...
Have the patient list substitutes for favorite foods that are high in sodium
...
Check the sodium content of the patient’s menu choices over the next 3 days
...
Ask the patient to identify which foods on the hospital menus are high in sodium
...
Compare the patient’s sodium intake before and after the teaching was implemented
...
The nurse prepares written handouts to be used as part of the standardized teaching plan
for patients who have been recently diagnosed with diabetes
...
Eating the right foods can help in keeping blood glucose at a near-normal level
...
Polyphagia, polydipsia, and polyuria are common symptoms of diabetes mellitus
...
Some diabetics control blood glucose with oral medications, injections, or nutritional
interventions
...
Diabetes mellitus is characterized by chronic hyperglycemia and the associated symptoms
than can lead to long-term complications
...
The hospital nurse implements a teaching plan to assist an older patient who lives alone to
independently accomplish daily activities
...
Make a referral to the home health nursing department for home visits
...
Have the patient demonstrate the learned skills at the end of the teaching session
...
Arrange a physical therapy visit before the patient is discharged from the hospital
...
Check the patient’s ability to bathe and get dressed without any assistance the next day
...
A patient who smokes a pack of cigarettes per day tells the nurse, “I enjoy smoking and
have no plans to quit
...
Health seeking behaviors related to cigarette use
b
...
Readiness for enhanced self-health management related to smoking
d
...
An older Asian patient, who is seen at the health clinic, is diagnosed with protein
malnutrition
...
Suggest the use of liquid supplements as a way to increase protein intake
...
Encourage the patient to increase the dietary intake of meat, cheese, and milk
...
Ask the patient to record the intake of all foods and beverages for a 3-day period
...
Focus on the use of combinations of beans and rice to improve daily protein intake
...
A middle-aged patient who has diabetes tells the nurse, "I want to know how to give my
own insulin so I don't have to bother my wife all the time
...
Demonstrate how to draw up and administer insulin
...
Discuss the use of exercise to decrease insulin needs
...
Teach about differences between the various types of insulin
...
Provide handouts about therapeutic and adverse effects of insulin
...
The nurse plans to teach a patient and the caregiver how to manage high blood pressure
(BP)
...
Give written information about hypertension to the patient and caregiver
...
Have the dietitian meet with the patient and caregiver to discuss a low sodium diet
...
Teach the caregiver how to take the patient’s BP using a manual blood pressure cuff
...
Ask the patient and caregiver to select information from a list of high BP teaching topics
...
A postoperative patient and caregiver need discharge teaching
...
Evaluate whether the patient and caregiver understand the teaching
...
Show the caregiver how to accurately check the patient's temperature
...
Schedule the discharge teaching session with the patient and caregiver
...
Give the patient a pamphlet reinforcing teaching already done by the nurse
...
A family caregiver tells the home health nurse, "I feel like I can never get away to do
anything for myself
...
Assist the caregiver in finding respite services
...
Assure the caregiver that the work is appreciated
...
Encourage the caregiver to discuss feelings openly with the nurse as needed
...
Teach the caregiver that family members can also provide excellent patient care
...
The nurse plans to provide instructions about diabetes to a patient who has a low literacy
level
...
Discourage use of the Internet as a source of health information
...
Avoid asking the patient about reading abilities and level of education
...
Provide illustrations and photographs showing various types of insulin
...
Schedule one-to-one teaching sessions to practice insulin administration
...
Obtain CDs and DVDs that illustrate how to perform blood glucose testing
...
When caring for an older patient with hypertension who has been hospitalized after a
transient ischemic (TIA), which topic is the most important for the nurse to include in the
discharge teaching?
a
...
Mechanism of action of anticoagulant drug therapy
c
...
Impact of the patient’s family history on likelihood of developing a serious stroke
2
...
Which question is the most important for
the nurse to ask?
a
...
“How frequently do you see a doctor?”
c
...
“Are you able to prepare your own meals?”
3
...
Review the patient's health record for previous assessments
...
Use a geriatric assessment instrument to evaluate the patient
...
Ask the patient to write down medical problems and medications
...
Interview both the patient and the primary caregiver for the patient
...
Which intervention should the nurse implement to provide optimal care for an older patient
who is hospitalized with pneumonia?
a
...

b
...


c
...

d
...

5
...
Which intervention should the nurse
implement to provide optimal care for this patient?
a
...

b
...

c
...

d
...

6
...
Which intervention
should the nurse plan to implement to best meet this patient’s needs?
a
...

b
...

c
...

d
...

7
...
Teach the patient to have all prescriptions filled at the same pharmacy
...
Instruct the patient to avoid taking over-the-counter (OTC) medications
...
Make a schedule for the patient as a reminder of when to take each medication
...
Have the patient bring all medications, supplements, and herbs to each appointment
...
A patient who has just moved to a long-term care facility has a nursing diagnosis of
relocation stress syndrome
...
Remind the patient that making changes is usually stressful
...
Discuss the reason for the move to the facility with the patient
...
Restrict family visits until the patient is accustomed to the facility
...
Have staff members write notes welcoming the patient to the facility
...
An older patient complains of having "no energy" and feeling increasingly weak
...
Which action should the nurse take
initially?
a
...

b
...

c
...

d
...

10
...
Which action should the
nurse take first?
a
...

b
...

c
...

d
...

11
...
Which intervention is themost appropriate for the nurse to
include in the discharge plan for this patient?
a
...

b
...

c
...

d
...

12
...
Which intervention, if
implemented by the nurse, would best encourage medication compliance?

a
...

b
...

c
...

d
...

13
...
Which new
information is of most concern to the nurse?
a
...

b
...
5 kg) during the past month
...
The patient is cared for by a daughter during the day and stays with a son at night
...
The patient's son uses a marked pillbox to set up the patient's medications weekly
...
Which statement, if made by an older adult patient, would be of most concern to the
nurse?
a
...
”
b
...
”
c
...
”
d
...
”
15
...
Which action should the nurse take first?
a
...

b
...

c
...

d
...

16
...
72-yr-old who had a hip replacement after a fall at home
b
...
76-yr-old who had a cholecystectomy and bile duct drainage
d
...
An older adult being admitted is assessed at high risk for falls
...
Use a bed alarm system on the patient's bed
...
Administer the prescribed PRN sedative medication
...
Ask the health care provider to order a vest restraint
...
Place the patient in a "geri-chair" near the nurse's station
...
An older adult patient presents with a broken arm and visible scattered bruises healing at
different stages
...
Notify an elder protective services agency about possible abuse
...
Make a referral for a home assessment visit by the home health nurse
...
Have the family member stay in the waiting area while the patient is assessed
...
Ask the patient how the injury occurred and observe the family member's reaction
...
The family of an older patient with chronic health problems and increasing weakness is
considering placement in a long-term care (LTC) facility
...
Have the family select a LTC facility that is relatively new
...
Obtain the patient’s input about the choice of a LTC facility
...
Ask that the patient be placed in a private room at the facility
...
Explain the reasons for the need to live in LTC to the patient
...
The nurse manages the care of older adults in an adult health day care center
...
Obtain information about food and medication allergies from patients
...
Take blood pressures daily and document in individual patient records
...
Choose social activities based on the individual patient needs and desires
...
Teach family members how to cope with patients who are cognitively impaired
...
Which nursing actions will the nurse take to assess for possible malnutrition in an older
adult patient (select all that apply)?
a
...

b
...

c
...

d
...

e
...

2
...
Which action by the nurse is most appropriate?
a
...

b
...

c
...

d
...

3
...
How would the nurse document this wound?
a
...
Yellow wound
c
...
Stage III pressure ulcer
4
...
Which
nursing action is most likely to detect early signs of infection in this patient?
a
...


b
...

c
...

d
...

5
...
The base of the wound is yellow and involves subcutaneous tissue
...
Stage I
b
...
Stage III
d
...
A young male patient who is a paraplegic has a stage II sacral pressure ulcer and is being
cared for at home by his mother
...
Change the patient’s bedding frequently
...
Use a hydrocolloid dressing over the ulcer
...
Record the size and appearance of the ulcer weekly
...
Change the patient’s position at least every 2 hours
...
The nurse will perform which action when doing a wet-to-dry dressing change on a
patient’s stage III sacral pressure ulcer?
a
...

b
...

c
...

d
...


8
...

When planning interventions to promote wound healing, what is the nurse’s highest priority?
a
...
Ensuring that the patient has an adequate dietary protein intake
c
...
9° C)
d
...
After the home health nurse teaches a patient’s family member about how to care for a
sacral pressure ulcer, which finding indicates that additional teaching is needed?
a
...

b
...

c
...

d
...

SHORT ANSWER
1
...
3° C) for several days
...
Knowing that the metabolic
rate increases 7% for each Fahrenheit degree above 100° in body temperature, how many
total calories should the patient receive each day?
2140 calories
OTHER
1
...

All the following interventions are included in the patient’s plan of care
...

a
...

b
...


c
...

d
...

adbc
2
...
” Which example should the nurse use to
explain this type of immunity?
a
...
Bone marrow donation
c
...
Exposure to communicable diseases
3
...
The nurse expects elevation of
which laboratory value?
a
...
IgA
c
...
Neutrophils
4
...
“Do not eat anything for about 6 hours before the testing
...
“Take an oral antihistamine about an hour before the testing
...
“Plan to wait in the clinic for 20 to 30 minutes after the testing
...
“Reaction to the testing will take about 48 to 72 hours to occur
...
Which patient should the nurse assess first?
a
...
Patient who has graft-versus-host disease and severe diarrhea

c
...
Patient with multiple chemical sensitivities who has muscle stiffness
6
...
What
would the nurse suspect is the cause of this patient’s skin rash?
a
...

b
...

c
...

d
...

7
...
Which statement
by the patient would indicate a need for further instructions?
a
...
”
b
...
”
c
...
”
d
...
”
8
...
Which patient would be the most
appropriate roommate for a patient who has acute rejection of an organ transplant?
a
...
A patient with second-degree burns
c
...
A patient with graft-versus-host disease after a recent bone marrow transplant
9
...
Which action should the nurse take first?
a
...


b
...

c
...

d
...

10
...
What is the nurse’s priority action?
a
...

b
...

c
...

d
...

11
...
Which assessment should the nurse perform?
a
...

b
...

c
...

d
...

12
...
Which results should be reported to the transplant surgeon?
a
...
Six antigen matches are present in HLA typing
c
...
Panel of reactive antibodies (PRA) percentage is low
13
...
In which
order should the nurse implement these prescribed actions?(Put a comma and a space
between each answer choice [A, B, C, D, E])
...
Discontinue the antibiotic infusion
...
Give diphenhydramine (Benadryl) IV
...
Inject epinephrine (Adrenalin) IM or IV
...
Prepare an infusion of dopamine (Intropin)
...
Start 100% oxygen using a nonrebreather mask
...

14
...

Which assessment data will be of most concern to the nurse?
a
...

b
...

c
...

d
...

15
...
Which
assessment would be the most accurate way for the nurse to evaluate fluid balance?
a
...
Daily weight
c
...
Hourly urine output
16
...
Which instructions should the nurse give to this patient related to fluid intake?
a
...

b
...
”
c
...
”
d
...
”
17
...
Which
statement by the patient indicates that the teaching about this medication has been effective?

a
...
”
b
...
”
c
...
”
d
...
”
18
...
When making room
assignments, the charge nurse should take which action?
a
...

b
...

c
...

d
...

19
...
Which action should the nurse take?
a
...

b
...

c
...

d
...

20
...
The patient now has a serum sodium level of 127 mEq/L (127
mmol/L)
...
Infuse 5% dextrose in water at 125 mL/hr
...
Administer IV morphine sulfate 4 mg every 2 hours PRN
...
Give IV metoclopramide (Reglan) 10 mg every 6 hours PRN for nausea
...
Administer 3% saline if serum sodium decreases to less than 128 mEq/L
...
A patient who was involved in a motor vehicle crash has had a tracheostomy placed to
allow for continued mechanical ventilation
...
48, PaO2 85 mm Hg, PaCO2 32 mm Hg, and HCO3 25
mEq/L?
a
...
Metabolic alkalosis
c
...
Respiratory alkalosis
22
...
2 g/dL
...
Pallor
b
...
Confusion
d
...
A patient receives 3% NaCl solution for correction of hyponatremia
...
Lung sounds
b
...
Peripheral pulses
d
...
The long-term care nurse is evaluating the effectiveness of protein supplements for an
older resident who has a low serum total protein level
...
Hematocrit 28%
b
...
Decreased peripheral edema
d
...
A patient who is lethargic and exhibits deep, rapid respirations has the following arterial
blood gas (ABG) results: pH 7
...
How should the nurse interpret these results?
a
...
Metabolic alkalosis
c
...
Respiratory alkalosis
26
...
1 mg/dL
...
Maintain the patient on bed rest
...
Auscultate lung sounds every 4 hours
...
Monitor for Trousseau’s and Chvostek’s signs
...
Encourage fluid intake up to 4000 mL every day
...
A nurse is assessing a newly admitted patient with chronic heart failure who forgot to
take prescribed medications and seems confused
...
Which assessment should the nurse
complete first?
a
...
Heart sounds
c
...
Capillary refill
28
...
The patient’s respiratory rate is 32
breaths/minute and the arterial blood gases (ABGs) indicate respiratory alkalosis
...
Discontinue the nasogastric suction
...
Give the patient the PRN IV morphine sulfate 4 mg
...
Notify the health care provider about the ABG results
...
Teach the patient how to take slow, deep breaths when anxious
...
Which action can the registered nurse (RN) who is caring for a critically ill patient with
multiple IV lines delegate to an experienced licensed practical/vocational nurse (LPN/LVN)?
a
...

b
...

c
...

d
...
9% normal saline in the peripheral IV line
...
A patient has a serum calcium level of 7
...
Which assessment finding is most
important for the nurse to report to the health care provider?
a
...

b
...

c
...

d
...

31
...
”
Which assessment should the nurse complete immediately?
a
...
Abnormal serum potassium level
c
...
Bleeding on the patient’s dressing
32
...
9 mg/dL for a patient who has chronic
malnutrition
...
Monitor ionized calcium level
...
Give oral calcium citrate tablets
...
Check parathyroid hormone level
...
Administer vitamin D supplements
...
During the admission process, the nurse obtains information about a patient through the
physical assessment and diagnostic testing
...
Deficient fluid volume
b
...
Risk for injury: Seizures
d
...
The patient will select the most appropriate colon cancer therapy
...
Choosing not to follow the diet is the behavior that resulted from learning
...
Teach the patient at each meal about the amounts of sodium in various foods
...
Teach glucose self-monitoring and medication administration
...
Preparation
6
...

7
...
”
8
...
The patient states that dietary changes have not made any difference at all
...
The patient will list three ways to protect the feet from injury by discharge
...
Role playing
12
...

13
...

14
...

15
...
sk the patient to record the intake of all foods and beverages for a 3-day period
...
Demonstrate how to draw up and administer insulin
...
Ask the patient and caregiver to select information from a list of high BP teaching topics
...
Give the patient a pamphlet reinforcing teaching already done by the nurse
...
Assist the caregiver in finding respite services
...
Provide illustrations and photographs showing various types of insulin
...

Obtain CDs and DVDs that illustrate how to perform blood glucose testing
...
Symptoms indicating that the patient should contact the health care provider

2
...
Use a geriatric assessment instrument to evaluate the patient
...
Consider the preadmission functional abilities
...
Consider the preadmission functional abilities when setting patient goals
...
Ensure transportation to appointments with the health care provider
...
Have the patient bring all medications, supplements, and herbs to each appointment
...
Have staff members write notes welcoming the patient to the facility
...
Ask the patient about daily dietary intake
...
Perform the physical assessment before interviewing the patient
...
Refer the patient to social services for further assessment
...
Use a marked pillbox to set up the patient's medications
...
The patient has lost 10 lb (4
...

14
...
”
15
...

16
...
Use a bed alarm system on the patient's bed
...
Have the family member stay in the waiting area while the patient is assessed
...
Obtain the patient’s input about the choice of a LTC facility
...
Take blood pressures daily and document in individual patient records
...
Observe for depression
...

Assess teeth and oral mucosa
...

2
...

3
...
Ask about fatigue or feelings of malaise
...
Stage III
6
...

7
...

8
...
The family member dries the wound using a hair dryer set on a low setting
...
2140 calories
OTHER
1
...
Breastfeeding her infant
3
...
“Plan to wait in the clinic for 20 to 30 minutes after the testing
...
Patient who has graft-versus-host disease and severe diarrhea
Patient who is sneezing after having subcutaneous immunotherapy
6
...

7
...
”
8
...
Administer epinephrine
...
Assess the patient’s airway
...
Check for swelling of the patient’s lips and tongue
...
Results of patient-donor cross matching are positive
13
...

14
...


15
...
“Increase fluids if your mouth feels dry
...
“I will drink apple juice instead of orange juice for breakfast
...
Assign the patient to a room near the nurse’s station
...
Infuse the KCl at a rate of 10 mEq/hour
...
Infuse 5% dextrose in water at 125 mL/hr
...
Metabolic acidosis
22
...
Lung sounds
24
...
Respiratory alkalosis
26
...

27
...
Give the patient the PRN IV morphine sulfate 4 mg
...
Monitor the IV sites for redness, swelling, or tenderness
...
The patient is experiencing laryngeal stridor
...
Presence of the Chvostek’s sign
32
...

33

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