NUR 337 Final Exam Questions With Correct
Answers
During |a |mental |status |examination, |a |hospitalized |client |states |that |she |cannot |remember |if |
she |is |married |or |if |she |has |children.
The |nurse |would |document |this |as |an |example |of |what |aspect |of |the |mental |status |
examination?
Decreased |judgment
Decreased |level |of |knowledge
Poor |insight
Poor |remote |memory |- |CORRECT |ANSWER✔✔-poor |remote |memory
Which |of |the |following |are |examples |of |subjective |assessment |data? |(Select |all |that |apply)
Client |states |he |has |"no |reason |to |live."
Client's |speech |is |slow |and |soft.
Client |has |jaundiced |skin |color.
Client |can |recall |three |numbers.
Client |"meditates |for |relaxation." |- |CORRECT |ANSWER✔✔-Client |states |he |has |"no |reason |to |
live"
Client |"meditates |for |relaxation"
While |performing |a |mental |status |examination |on |a |client, |the |nurse |notices |that |the |client |
has |a |slouched |posture.
,This |information |should |be |documented |as |part |of |the |client's |______________?
Appearance
Behavior
Thought |Process
Judgment |- |CORRECT |ANSWER✔✔-appearance
Why |is |it |important |to |label |the |dressing |covering |the |site |of |an |intravenous |access |device |
with |the |date, |time, |and |nurse's |initials?
Reminds |the |nurse |when |to |change |the |infusion |tubing.
Informs |the |nurse |and |other |staff |when |the |next |dressing |change |is |due.
Reminds |the |nurse |to |document |the |insertion |of |the |device.
Proves |that |the |access |site |was |assessed. |- |CORRECT |ANSWER✔✔-Informs |the |nurse |and |
other |staff |when |the |next |dressing |change |is |due
The |nurse |is |performing |an |IV |insertion |procedure |on |a |client.
Which |of |the |following |actions |puts |the |client |at |risk?
Select |All |That |Apply.
Verify |client's |name |and |birthdate.
Place |tape |for |anchoring |the |IV |on |the |hospital |bed |railing |or |tray |table |so |that |it |is |handy
Touch |the |open |hub |of |the |IV |catheter |after |removing |the |needle
Touch |the |area |that |has |already |been |cleansed |/ |prepared |for |the |IV |insertion
Perform |hand |hygiene |- |CORRECT |ANSWER✔✔-Place |tape |for |anchoring |the |IV |on |the |hospital
|bed |railing |or |tray |table |so |that |it |is |handy
Touch |the |open |hub |of |the |IV |catheter |after |removing |the |needle
,Touch |the |area |that |has |already |been |cleansed |/ |prepared |for |the |IV |insertion
Which |action |would |the |nurse |take |first |if |an |intravenous |(IV) |insertion |site |appeared |red, |
warm, |and |swollen?
Apply |a |heat |pack.
Elevate |the |extremity |the |IV |site |is |on.
Change |the |dressing.
Discontinue |the |infusion. |- |CORRECT |ANSWER✔✔-Discontinue |the |infusion.
What |is |the |primary |- |and |potentially |most |serious |- |danger |related |to |a |broken |IV |catheter |
tip?
Pain
Phlebitis
Embolus
Infection |- |CORRECT |ANSWER✔✔-Embolus
What |would |the |nurse |do |to |assess |a |patient's |risk |for |embolus |when |removing |a |venous |
access |device?
Ask |the |patient |to |rate |any |pain |at |the |site.
Palpate |the |site |for |possible |edema.
Visualize |the |tip |of |the |IV |catheter.
Inspect |for |redness. |- |CORRECT |ANSWER✔✔-Visualize |the |tip |of |the |catheter
, When |should |the |tourniquet |be |released |a |second |time |during |the |procedure |for |insertion |of |
a |peripheral |intravenous |device?
After |flushing |the |newly-placed |IV |with |sterile |saline |to |verify |patency.
Immediately |after |observing |a |"flashback" |of |blood |in |the |catheter.
After |a |"flashback" |of |blood |is |observed |and |the |catheter |has |been |advanced |off |the |stylet.
Immediately |after |the |catheter |punctures |the |skin. |- |CORRECT |ANSWER✔✔-After |a
|"flashback" |of |blood |is |observed |and |the |catheter |has |been |advanced |off |the |stylet.
A |client |states, |"The |voices |keep |telling |me |that |my |hands |are |dirty." |What |is |the |best |
response |by |the |nurse?
"I |don't |hear |anything; |you |must |be |imagining |it."
"Maybe |you |should |wash |your |hands."
"I |believe |you |are |hearing |the |voices |but |I |think |it |is |a |part |of |your |illness |because |I |cannot |
hear |them."
"Yes, |I |hear |that, |too. |Don't |worry, |the |voices |say |that |to |all |of |us." |- |CORRECT |ANSWER✔✔-"I |
believe |you |are |hearing |the |voices |but |I |think |it |is |a |part |of |your |illness |because |I |cannot |hear |
them."
A |client |states |that |she |hears |voices |constantly |and |that |they |interfere |with |her |ability |to |
sleep.
Which |intervention |suggested |by |the |nurse |would |be |appropriate |and |potentially |therapeutic |
for |the |client?
Drink |herbal |tea |before |bedtime.
Take |an |over-the-counter |sleep |medication |regularly.
Listen |to |soothing |music |with |headphones |while |you |are |trying |to |fall |asleep.
Answers
During |a |mental |status |examination, |a |hospitalized |client |states |that |she |cannot |remember |if |
she |is |married |or |if |she |has |children.
The |nurse |would |document |this |as |an |example |of |what |aspect |of |the |mental |status |
examination?
Decreased |judgment
Decreased |level |of |knowledge
Poor |insight
Poor |remote |memory |- |CORRECT |ANSWER✔✔-poor |remote |memory
Which |of |the |following |are |examples |of |subjective |assessment |data? |(Select |all |that |apply)
Client |states |he |has |"no |reason |to |live."
Client's |speech |is |slow |and |soft.
Client |has |jaundiced |skin |color.
Client |can |recall |three |numbers.
Client |"meditates |for |relaxation." |- |CORRECT |ANSWER✔✔-Client |states |he |has |"no |reason |to |
live"
Client |"meditates |for |relaxation"
While |performing |a |mental |status |examination |on |a |client, |the |nurse |notices |that |the |client |
has |a |slouched |posture.
,This |information |should |be |documented |as |part |of |the |client's |______________?
Appearance
Behavior
Thought |Process
Judgment |- |CORRECT |ANSWER✔✔-appearance
Why |is |it |important |to |label |the |dressing |covering |the |site |of |an |intravenous |access |device |
with |the |date, |time, |and |nurse's |initials?
Reminds |the |nurse |when |to |change |the |infusion |tubing.
Informs |the |nurse |and |other |staff |when |the |next |dressing |change |is |due.
Reminds |the |nurse |to |document |the |insertion |of |the |device.
Proves |that |the |access |site |was |assessed. |- |CORRECT |ANSWER✔✔-Informs |the |nurse |and |
other |staff |when |the |next |dressing |change |is |due
The |nurse |is |performing |an |IV |insertion |procedure |on |a |client.
Which |of |the |following |actions |puts |the |client |at |risk?
Select |All |That |Apply.
Verify |client's |name |and |birthdate.
Place |tape |for |anchoring |the |IV |on |the |hospital |bed |railing |or |tray |table |so |that |it |is |handy
Touch |the |open |hub |of |the |IV |catheter |after |removing |the |needle
Touch |the |area |that |has |already |been |cleansed |/ |prepared |for |the |IV |insertion
Perform |hand |hygiene |- |CORRECT |ANSWER✔✔-Place |tape |for |anchoring |the |IV |on |the |hospital
|bed |railing |or |tray |table |so |that |it |is |handy
Touch |the |open |hub |of |the |IV |catheter |after |removing |the |needle
,Touch |the |area |that |has |already |been |cleansed |/ |prepared |for |the |IV |insertion
Which |action |would |the |nurse |take |first |if |an |intravenous |(IV) |insertion |site |appeared |red, |
warm, |and |swollen?
Apply |a |heat |pack.
Elevate |the |extremity |the |IV |site |is |on.
Change |the |dressing.
Discontinue |the |infusion. |- |CORRECT |ANSWER✔✔-Discontinue |the |infusion.
What |is |the |primary |- |and |potentially |most |serious |- |danger |related |to |a |broken |IV |catheter |
tip?
Pain
Phlebitis
Embolus
Infection |- |CORRECT |ANSWER✔✔-Embolus
What |would |the |nurse |do |to |assess |a |patient's |risk |for |embolus |when |removing |a |venous |
access |device?
Ask |the |patient |to |rate |any |pain |at |the |site.
Palpate |the |site |for |possible |edema.
Visualize |the |tip |of |the |IV |catheter.
Inspect |for |redness. |- |CORRECT |ANSWER✔✔-Visualize |the |tip |of |the |catheter
, When |should |the |tourniquet |be |released |a |second |time |during |the |procedure |for |insertion |of |
a |peripheral |intravenous |device?
After |flushing |the |newly-placed |IV |with |sterile |saline |to |verify |patency.
Immediately |after |observing |a |"flashback" |of |blood |in |the |catheter.
After |a |"flashback" |of |blood |is |observed |and |the |catheter |has |been |advanced |off |the |stylet.
Immediately |after |the |catheter |punctures |the |skin. |- |CORRECT |ANSWER✔✔-After |a
|"flashback" |of |blood |is |observed |and |the |catheter |has |been |advanced |off |the |stylet.
A |client |states, |"The |voices |keep |telling |me |that |my |hands |are |dirty." |What |is |the |best |
response |by |the |nurse?
"I |don't |hear |anything; |you |must |be |imagining |it."
"Maybe |you |should |wash |your |hands."
"I |believe |you |are |hearing |the |voices |but |I |think |it |is |a |part |of |your |illness |because |I |cannot |
hear |them."
"Yes, |I |hear |that, |too. |Don't |worry, |the |voices |say |that |to |all |of |us." |- |CORRECT |ANSWER✔✔-"I |
believe |you |are |hearing |the |voices |but |I |think |it |is |a |part |of |your |illness |because |I |cannot |hear |
them."
A |client |states |that |she |hears |voices |constantly |and |that |they |interfere |with |her |ability |to |
sleep.
Which |intervention |suggested |by |the |nurse |would |be |appropriate |and |potentially |therapeutic |
for |the |client?
Drink |herbal |tea |before |bedtime.
Take |an |over-the-counter |sleep |medication |regularly.
Listen |to |soothing |music |with |headphones |while |you |are |trying |to |fall |asleep.
