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Exam 4: NUR 210 / NUR210 (NEW 2026–2027 Updated) Transition to Practice – Capstone | Verified Questions & Answers | 100% Accurate Solutions | Grade A – Fortis

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Exam 4: NUR 210 / NUR210 (NEW 2026–2027 Updated) Transition to Practice – Capstone | Verified Questions & Answers | 100% Accurate Solutions | Grade A – Fortis Q. The ion that cannot be regulated properly in clients with cystic fibrosis is A) chloride B) sodium C) calcium D) potassium ANSWERS *P-15* A (chloride) Q. For couples in which both individuals carry one defective CF gene, any offspring from the couple has a ________ percent chance of inheriting two abnormal genes and developing cystic fibrosis. A) 100 B) 75 C) 50 D) 25 ANSWERS *P-15* D (25) Q. Besides the respiratory system, which system would be critical for the nurse to assess in a client recently diagnosed with cystic fibrosis? A) Nervous system B) Gastrointestinal system C) Musculoskeletal system D) Urinary system ANSWERS *P-15* B (Gastrointestinal system) Q. The nurse is caring for an 18-month-old client who is newly diagnosed with cystic fibrosis. The client is currently hospitalized due to a Pseudomonas aeruginosa infection in the lungs. The client's vital signs are: P 138, R 43, T 101.3°F, BP 86/40, SpO2 88%. The client is coughing up thick, green mucus. What independent nursing intervention can the nurse implement to improve the client's oxygenation? A) Administration of CFTR modulators B) Percussion and postural drainage C) Nutritional counseling D) Teaching the client to cough into a tissue ANSWERS *P-15* B (Percussion and postural drainage) Q. A 15-year-old client with cystic fibrosis asks why she has not started her menstrual period yet. Which response by the nurse is correct? A) "Usually girls with cystic fibrosis start menstruating earlier than their peers." B) "It is normal for girls with cystic fibrosis to start their period at age 16. Just be patient." C) "Some girls with cystic fibrosis do not experience menstruation due to nutritional problems." D) "Because secretions are thicker in people with cystic fibrosis, your period will be very heavy once it starts." ANSWERS *P-15* C ("Some girls with cystic fibrosis do not experience menstruation due to nutritional problems.") Q. The nurse is providing teaching to the client who is pregnant and has cystic fibrosis. The nurse should explain that the client is at increased risk for which condition? A) Emergency delivery B) Gestational diabetes C) Placenta previa D) Spontaneous abortion *P-15* ANSWERS B (Gestational diabetes) Q. The nurse is caring for a client diagnosed with dilated cardiomyopathy. Which clinical manifestations does the nurse anticipate during the physical assessment? (Select all that apply) A) Fatigue B) Lower extremity edema C) Syncope D) Dyspnea E) Angina ANSWERS *P-16* A, B, & D (Fatigue) (Lower extremity edema) (Dyspnea) Q. A client states to the nurse, "I know I have high blood pressure, but I don't want to take medication." Based on this data, which health problem is the client at risk for developing? A) Gastritis B) Diabetes C) Cardiomyopathy D) Metabolic syndrome ANSWERS *P-16* C (Cardiomyopathy) Q. A client diagnosed with cardiomyopathy reports having to rest between activities during the day. The client asks the nurse why this is occurring. Which reason should the nurse include in the response to the client? A) Increased stroke volume B) Decreased cardiac output C) An elongated and dilated aorta D) Increased blood pressure ANSWERS *P-16* B (Decreased cardiac output) Q. A client admitted with the diagnosis of cardiomyopathy becomes short of breath with ambulation and eating and fatigued with routine care activities. Which nursing diagnosis does the nurse include in the client's plan of care? A) Imbalanced Nutrition: Less than Body Requirements B) Deficient Knowledge C) Activity Intolerance D) Self-Care Deficit ANSWERS *P-16* C (Activity Intolerance) Q. The nurse identifies the diagnosis of Excess Fluid Volume as appropriate for a client with cardiomyopathy. Which interventions should the nurse emphasize when planning this client's care? (Select all that apply) A) Monitor B-type natriuretic peptide (BNP) level B) Provide oxygen as prescribed C) Assess respiratory status and lung sounds every 4 hours and as needed D) Provide information about activity upon discharge E) Monitor intake and output ANSWERS *P-16* C & E (Assess respiratory status and lung sounds every 4 hours and as needed) Q. The nurse is providing teaching to a client diagnosed with cardiomyopathy. What statement made by the client indicates the discharge teaching was effective? A) "I will exercise as much as possible, regardless of feeling weak and short of breath." B) "My pants getting tight around the waist means I'm eating too much and should cut back on food." C) "I will eat foods containing sodium only if drinking water with them." D) "I will see my cardiologist next week to discuss implanting a pacemaker." ANSWERS *P-16* D ("I will see my cardiologist next week to discuss implanting a pacemaker.") Q. The nurse is caring for a client with hypertrophic cardiomyopathy. Based on this diagnosis, which class of medications does the nurse anticipate being prescribed? A) Digoxin B) Vasodilators C) Nitrates D) Beta blockers ANSWERS *P-16* D (Beta blockers) Q. A client with cardiomyopathy receiving diuretic therapy has a urine output of 200 mL in 8 hours. Which action by the nurse is correct? A) Assist the client to ambulate B) Document a normal urine output C) Notify the healthcare provider D) Measure abdominal girth ANSWERS *P-16* C (Notify the healthcare provider) A client diagnosed with cardiomyopathy asks the nurse to explain the different types of the disease. Which is inappropriate for the nurse to include in the teaching session? A) Dilated cardiomyopathy B) Restrictive cardiomyopathy C) Hypotrophic cardiomyopathy D) Arrythmogenic right ventricular dysplasia *P-16* C (Hypotrophic cardiomyopathy) The nurse is caring for a client diagnosed with cardiomyopathy. The client experiences tachycardia. Which medication does the nurse anticipate being prescribed? A) ACE Inhibitor B) Angiotensin II receptor blocker C) Beta blocker D) Cardiac glycoside *P-16* C (Beta blocker) A nurse is caring for a client with cardiomyopathy who is experiencing activity intolerance. Which intervention is inappropriate for this nursing diagnosis? A) Spacing out nursing activities so client fatigue is lessened B) Assisting with client activities of daily living (ADLs) as necessary C) Using passive and active range-of-motion (ROM) exercises as tolerated D) Consulting with a physical therapist on an activity plan *P-16* A (Spacing out nursing activities so client fatigue is lessened) A nurse is educating a client with cardiomyopathy about diet choices that are appropriate for the client's condition. Which statement is inappropriate for the nurse to include in the teaching session? A) "It is important to monitor your sodium intake." B) "Increasing your dietary protein helps with cardiac cell repair." C) "Here is a list of high-fat, high-cholesterol foods to avoid." D) "I have notified the dietitian regarding your condition in order to provide you with more information." *P-16* B ("Increasing your dietary protein helps with cardiac cell repair.") A 14-year-old child was recently diagnosed with hypertrophic cardiomyopathy. During a follow-up appointment, the mother asks the nurse, "How will this affect my child's ability to play football in the fall?" How should the nurse respond? A) "This shouldn't affect his ability to play football." B) "Children with cardiomyopathy should not play football." C) "He could participate in flag football but not tackle football." D) "This may actually make him a better, stronger football player." *P-16* B ("Children with cardiomyopathy should not play football.") A 72-year-old client diagnosed with hypertrophic cardiomyopathy (HCM) is speaking to the healthcare team about treatment options. Which treatment option would likely not be recommended for this client, even though it is commonly used to treat younger clients with this condition? A) Defibrillator implantation B) Beta-blocker administration C) Calcium channel blocker administration D) Physical activity restrictions *P-16* A (Defibrillator implantation) While completing a health history with an older adult client, the nurse learns that the client experienced a transient ischemic attack (TIA) several months ago. The nurse should recognize that: A) the client is at risk for an ischemic thrombotic stroke B) the client will have minimal symptoms should a stroke occur C) the client will not experience a stroke in the future D) the client is at high risk for a hemorrhagic stroke *P-16* A (the client is at risk for an ischemic thrombotic stroke) While teaching a wellness class on the warning signs of stroke, a participant asks the nurse, "What's the most important thing for me to remember?" What is an appropriate response by the nurse? A) "Be alert for sudden weakness or numbness." B) "Know your family history." C) "Keep a list of your medications." D) "Call 911 if you notice a gradual onset of paralysis or confusion." *P-16* A ("Be alert for sudden weakness or numbness.") The nurse is planning care for a client admitted with a stroke. Which intervention would support the client's sensorimotor needs? A) Encourage use of nonaffected arm to feed self, bathe, and dress B) Speak in normal conversational pattern and tones C) Provide complete care D) Talk loudly and distinctly *P-16* A (Encourage use of nonaffected arm to feed self, bathe, and dress) A client diagnosed with a stroke is going to receive treatment with fibrinolytic therapy using the recombinant tissue plasminogen activator alteplase (rt-PA). Which information should the nurse include when performing medication teaching for the client's family? A) Used to treat thrombotic and hemorrhagic strokes B) Not associated with serious complications C) Indicated if the stroke symptoms have occurred within the last 6 hours D) Administered to break up existing clots and increase cerebral blood flow *P-16* D (Administered to break up existing clots and increase cerebral blood flow) The nurse is instructing the spouse of a client with a stroke on how to do passive range-of-motion exercises to the affected limbs. Which rationale for this intervention will the nurse include in the teaching session? A) Improve muscle strength B) Maintain cardiopulmonary function C) Improve endurance D) Maintain joint flexibility *P-16* D (Maintain joint flexibility) A client with a suspected transient ischemic attack (TIA) presents to the emergency department with aphasia. Based on this data, the nurse plans care based on ischemia to which portion of the brain? A) Anterior cerebral artery B) Vertebral artery C) Left hemisphere of the brain D) Right hemisphere of the brain *P-16* C (Left hemisphere of the brain) The community nurse is teaching a class at the community center regarding the cultural and ethnic risk factors for stroke. Which statement should nurse include in this presentation? A) Caucasians have an increased incidence of intracerebral hemorrhage B) African Americans have almost twice the number of first-ever strokes compared with Whites C) Asian Americans are more likely to die following a stroke than Whites D) The prevalence of hypertension among Hispanics is the highest in the world *P-16* B (African Americans have almost twice the number of first-ever strokes compared with Whites) What type of stroke occurs when the blood supply to a part of the brain is cut off by a thrombus, embolus, or stenosis? A) Intracerebral stroke B) Subarachnoid stroke C) Hemorrhagic stroke D) Ischemic stroke *P-16* D (Ischemic stroke) After a stroke, sensory-perceptual changes increase the client's risk for what? A) Aspiration B) Injury C) Bleeding D) Infection *P-16* B (Injury) The medication clopidogrel (Plavix) is most commonly given during which stage of treatment for a stroke? A) Stroke prevention B) Acute care immediately after a stroke C) Recovery care after a stroke D) Rehabilitation after a stroke *P-16* A (Stroke prevention) During a 6-month well-baby check up, the mother mentions to the nurse that her infant seems to be sleeping just as much as she did as a newborn, and she seems to do everything with her left hand. The nurse recognizes that these are warning signs of stroke that occurred early in life. What other question should the nurse ask to assess for signs of stroke? A) "Have you noticed your baby jerking any muscles of the face, arms, or legs?" B) "Have you noticed your baby having trouble forming words?" C) "Does your baby vomit frequently after feeding?" D) "Does your baby frequently seem to lose her balance?" *P-16* A ("Have you noticed your baby jerking any muscles of the face, arms, or legs?") The nurse is providing community health teaching on stroke in children and adolescents. Which risk factors for this population should the nurse identify? A) Hypertension B) Dysrhythmias C) Arteriosclerosis D) Head trauma *P-16* D (Head trauma) The nurse is providing care to a pediatric client who was admitted to the pediatric intensive care unit (PICU) with a partial-thickness thermal burn. When planning care for this client, which should the nurse consider regarding this type of burn? A) Partial-thickness burns are deeper than superficial burns but still involve the epidermis only B) A superficial partial-thickness burn extends from the skin's surface into the papillary layer of the dermis C) A deep partial-thickness burn is often bright red and has a moist, glistening appearance with blister formation D) A superficial partial-thickness burn is less painful than a deep partial-thickness burn *P-21* B (A superficial partial-thickness burn extends from the skin's surface into the papillary layer of the dermis) A nurse working at a burn center is caring for a client with an electrical burn. According to the American Burn Association, how would this burn be classified? A) Minor B) Moderate C) Major D) Significant *P-21* C (Major) A client is evaluated after suffering severe burns to the torso and upper extremities. The nurse notes edema at the burned areas. Which of the following best describes the underlying cause of this manifestation? A) Decreased osmotic pressure in the burned tissue B) Reduced microvascular permeability at the site of the burned area C) Increased potassium in the intracellular compartment D) Inability of the damaged capillaries to maintain fluids in the cell walls *P-21* D (Inability of the damaged capillaries to maintain fluids in the cell walls) Which data supports the nurse's concern that a client is at a high risk for a burn injury? (Select all that apply) A) Part-time employment at a convenience store B) Diagnosis of hypertension C) Age 71 years D) Uses public transportation for grocery shopping E) Currently smokes one pack of cigarettes per day *P-21* C & E (Age 71 years) (Currently smokes one pack of cigarettes per day) An older adult client with severe burns over more than half of the body has an indwelling catheter. When evaluating the client's intake and output, which of the following should be taken into consideration? A) The amount of urine will be elevated due to the amount of intravenous fluids administered during the initial phases of treatment B) The amount of urine will be reduced in the first 24 to 48 hours and will then increase C) The amount of urine will be reduced during the first 8 hours of the burn injury and will then increase as diuresis begins D) The amount of urine output will be greatest in the first 24 hours after the burn injury *P-21* B (The amount of urine will be reduced in the first 24 to 48 hours and will then increase) A client who sustained burns to both lower extremities reports feeling frustrated by not being able to provide self-care. Which nursing diagnosis would be appropriate for the client at this time? A) Ineffective Coping B) Powerlessness C) Anxiety D) Situational Low Self-Esteem *P-21* B (Powerlessness) The nurse is planning care for a client in the acute stage of a burn injury. Which aspects of care should the nurse identify as a priority? (Select all that apply) A) Nutrition B) Psychosocial support C) Pain management D) Fluid resuscitation E) Wound care *P-21* A, C, & E (Nutrition) (Pain management) (Wound care) The nurse is evaluating the adequacy of the burn-injured client's nutritional intake. Which laboratory value is the best indicator of nutritional status? A) Creatine phosphokinase (CPK) B) Blood urea nitrogen (BUN) levels C) Hemoglobin D) Albumin level *P-21* D (Albumin level) The nurse is caring for a client who is to receive mechanical debridement of burn wounds. Which methods should the nurse anticipate using to complete this treatment? (Select all that apply) A) Homograft B) Application of a topical agent to dissolve necrotic tissue C) Irrigation of the burn wounds D) Application of wet-to-dry gauze dressings E) Hydrotherapy *P-21* C, D, & E (Irrigation of the burn wounds) (Application of wet-to-dry gauze dressings) (Hydrotherapy) How should the nurse position a client who is returned to the burn unit following a graft procedure to the leg? A) Place the client flat with the affected extremity abducted. B) Elevate the head of bed 30 degrees C) Maintain the head of bed flat D) Elevate the affected extremity *P-21* D (Elevate the affected extremity) The nurse is planning to provide care to extended family members spanning three generations who are being treated for burn injuries after a fire. Based on an understanding of lifespan factors, the nurse should anticipate that which of the following is true? A) The 38-year-old pregnant mother is more likely to require an allograft than the other members of the family B) The 82-year-old grandmother is more likely to have burns to a greater percentage of her total body surface area (TBSA) than younger family members C) The 14-year-old son is less likely to experience edema associated with his injuries than older members of the family D) The 6-year-old daughter is more likely to go into burn shock than the other members of the family *P-21* B (The 82-year-old grandmother is more likely to have burns to a greater percentage of her total body surface area (TBSA) than younger family members) An adult burn patient is brought in to the intensive care unit (ICU) for treatment. Prior to sustaining the injury, the client was considered underweight for her height. The nurse understands that this may have important implications for the client because A) she will have lower fluid resuscitation calculations than patients of normal weight B) she will be at greater risk for developing cardiac or renal insufficiencies C) she will require more supportive care than patients who are normal weight D) she will lose as much as 20% of her preburn weight during rehabilitation *P-21* D (she will lose as much as 20% of her preburn weight during rehabilitation) An adult burn patient is receiving fluid resuscitation of warm, lactated Ringer's solution during the first 24 hours following injury. The client's hourly urine output is being monitored to determine whether the resuscitation is adequate. The most recent reading is 1.10 mL/kg/hr. The nurse understands that this amount of urine output is A) slightly higher than the normal range B) slightly lower than the normal range C) within the normal range D) extremely low *P-21* A (slightly higher than the normal range) A burn patient is currently in the acute stage. When did this stage begin, and when will it end? A) It began with the onset of the burn injury and will end with fluid resuscitation B) It began with wound closure and will end when the patient's health is fully restored C) It began with the start of diuresis and will end with the closure of the burn wound D) It began with the onset of the burn injury and will end with the closure of the burn wound *P-21* C (It began with the start of diuresis and will end with the closure of the burn wound) A client has a pressure injury on the medial malleolus. The client's skin is intact with purple discoloration and a blood-filled blister. When documenting this finding, which terminology is appropriate for the nurse to use? A) Partial-thickness loss of dermis B) Nonblanchable erythema C) Suspected deep tissue injury D) Full-thickness tissue loss *P-21* C (Suspected deep tissue injury) A nurse is caring for a client with a stage 2 pressure injury on the coccyx who is at risk for additional pressure injuries. Which nursing intervention is appropriate when caring for this client? A) Clean the pressure injury as needed B) Use hydrogen peroxide for chemical debridement of wound bed as needed C) Maintain the head of the client's bed at 30 degrees D) Avoid placing the client in the side-lying position *P-21* D (Avoid placing the client in the side-lying position) An 84-year-old client with poor skin turgor has slipped down in the hospital bed. Which action by the nurse is appropriate to safely reposition this client to prevent further skin breakdown? A) Using the bed sheet to slide the client up in bed B) Placing the bed in reverse Trendelenburg position C) Using the client's arms to pull the client up in bed D) Lifting the client, using the client's legs and arms for assistance *P-21* D (Lifting the client, using the client's legs and arms for assistance) The nurse is concerned that a client is at risk for pressure injuries. Which assessment data supports the nurse's concern? (Select all that apply) A) Age 54 B) Body temperature within normal limits C) Low serum albumin level D) Continence of urine and stool E) Prescribed bedrest *P-21* C & E (Low serum albumin level) (Prescribed bedrest) An older adult client is admitted to the medical-surgical unit for a hip fracture. During postoperative recovery, the nurse notices a stage 1 pressure injury forming on the client's sacrum. Which action by the nurse is appropriate to reduce the progression of this injury? A) Maintain the head of the bed at a 30-degree angle, with the client positioned on the right or left side B) Apply a heat lamp to the area to increase circulation C) Apply a dry dressing to the pressure injury D) Maintain the head of the bed at a 45-degree angle *P-21* A (Maintain the head of the bed at a 30-degree angle, with the client positioned on the right or left side) A client has a documented stage 3 pressure injury on the right hip. Which nursing diagnosis is most appropriate for this client? A) Impaired Skin Integrity B) Risk for Injury C) Impaired Tissue Integrity D) Ineffective Peripheral Tissue Perfusion *P-21* C (Impaired Tissue Integrity) When planning care for a client at risk for developing pressure injuries, which intervention(s) should be included? (Select all that apply) A) Initiate a frequent toileting schedule B) Raise the client's heels off the bed C) Turn the client every 4 hours D) Use inflatable doughnut-style devices to reduce pressure on the sacrum E) Massage pressure areas with lotion every 4 hours *P-21* A & B (Initiate a frequent toileting schedule) (Raise the client's heels off the bed) The nurse is caring for a client who failed to meet the outcome of healing of a stage 2 pressure injury over the coccyx. Which should the nurse identify as a likely contributing factor? A) The rubber doughnut pressure relief device was not delivered by central supply B) The client's serum albumin increased over the last month C) A right side-back-left side-back turning schedule was used D) Nurses did not document disinfection of the wound with alcohol at each dressing change *P-21* C (A right side-back-left side-back turning schedule was used) A client requests a small inflated doughnut-style device to sit on to relieve pressure. Which response by the nurse is most appropriate? A) "I will need to get an order from the physician." B) "Using the doughnut can cause skin breakdown." C) "You will need to wait until discharge, then use the doughnut at home." D) "I will obtain the device for you." *P-21* B ("Using the doughnut can cause skin breakdown.") A client's spouse reports the presence of a reddened area on the client's coccyx and wants to massage the area. Which response by the nurse is appropriate? A) "I will need to obtain an order from the healthcare provider to perform a massage." B) "Massaging the area twice daily will help restore circulation and should be incorporated into the plan of care." C) "I will record these findings in the medical record." D) "Massage may actually cause more harm to a potentially compromised area of skin." *P-21* D ("Massage may actually cause more harm to a potentially compromised area of skin.") A nurse is conducting a training session with new staff members at a nursing home. One of the staff members asks why the facility's older adult clients are at elevated risk for pressure injuries. Which response is best? A) "As people age, their epidermis becomes more elastic. This increased elasticity makes older adults' skin more susceptible to damage." B) "As compared to younger clients, older adults have higher average body temperatures, and excess body heat is a risk factor for pressure injuries." C) "Due to increased oil production, the skin of older adults tends to be moister than that of younger clients. Increased moistness increases the risk for impaired skin integrity." D) "Age-related changes in the veins and arteries put older adults at risk for diminished blood flow, which can contribute to impaired skin integrity." *P-21* D ("Age-related changes in the veins and arteries put older adults at risk for diminished blood flow, which can contribute to impaired skin integrity.") What stage of pressure injury presents as a shallow open ulcer with a viable, moist wound bed that is red or pink? A) Stage 1 B) Stage 2 C) Stage 3 D) Stage 4 *P-21* B (Stage 2) Softening of the skin as a result of prolonged wetting or soaking is also referred to as A) maceration B) debridement C) excoriation D) shearing *P-21* A (maceration) Which of the following clients would be the most appropriate candidate for autolytic debridement? A) A 47-year-old client with a stage 2 pressure injury B) A 68-year-old client with a suspected deep tissue injury C) A 71-year-old client with a stage 1 pressure injury D) A 59-year-old client with a stage 3 pressure injury *P-21* D (A 59-year-old client with a stage 3 pressure injury) A client has a laceration that was closed with tissue adhesive. By what process will this wound heal? A) Tertiary intention B) Secondary intention C) Delayed primary intention D) Primary intention *P-21* D (Primary intention) A client recovering from abdominal surgery tells the nurse that "something popped" in his abdominal incision. Upon inspection, the nurse finds that evisceration has occurred. What actions by the nurse are appropriate? (Select all that apply) A) Notify the client's surgeon B) Pack the client's wound with nonadherent gauze C) Turn the client onto his abdomen D) Position the client in bed with his knees bent E) Cover the incision with a large, saline-soaked dressing *P-21* A, D, & E (Notify the client's surgeon) (Position the client in bed with his knees bent) (Cover the incision with a large, saline-soaked dressing) An older adult client diagnosed with chronic obstructive pulmonary disease (COPD) is scheduled for a total knee replacement. What should the nurse include in this client's plan of care to address the risk of an alteration in tissue integrity? A) Monitor urine output B) Assess postoperative wound healing C) Restrict protein intake D) Expect purulent drainage *P-21* B (Assess postoperative wound healing) A client is admitted to the hospital with a gunshot wound to the leg. Which nursing diagnosis is a priority? A) Situational Low Self-Esteem B) Risk for Infection C) Anxiety D) Ineffective Coping *P-21* B (Risk for infection) The nurse is planning care for a client with a surgical wound. Which goal related to the surgical wound is most appropriate for this client? A) The client will discharge to home as soon as possible B) The client will resume independent activities of daily living (ADLs) C) The client will increase ambulation D) The client will regain intact skin *P-21* D (The client will regain intact skin) The nurse is assessing a client with a surgical wound. Which finding indicates that care has been effective for this client? A) The client's temperature is 100°F B) The client performs wound care independently C) There is only a scant amount of purulent drainage on the dressing D) A small area of erythema and edema is present *P-21* B (The client performs wound care independently) An older adult client with poor nutritional intake is demonstrating signs of poor wound healing. Which intervention best addresses the client's nutritional needs? A) Assist with deep-breathing exercises B) Medicate for pain prior to dressing changes C) Request a dietary consult D) Encourage ambulation *P-21* C (Request a dietary consult) A client has a wound on the left lateral aspect of the thigh. Which action by the nurse would best promote wound healing for this client? A) Positioning the client to keep weight off the wound B) Positioning the client with weight directly on the wound C) Restricting fluids D) Enforcing strict bedrest *P-21* A (Positioning the client to keep weight off the wound) A home care nurse is caring for a client who is recovering from recent surgical debridement that produced large amounts of exudate. Three days after the debridement, the client's surgical wound was closed with staples that are aiding in healing. Given this information, which of the following terms should the nurse use when documenting this client's care? A) Primary intention healing B) Secondary intention healing C) Tertiary intention healing D) Quaternary intention healing *P-21* C (Tertiary intention healing) A nurse working in the intensive care unit (ICU) is caring for a client who is 10 days postoperative after open abdominal surgery. The client has a well-approximated midline surgical incision that has numerous staples, and the nurse notes a "healing ridge" is present. Based on this information, the incision is currently in which phase of the healing process? A) Inflammatory phase B) Proliferative phase C) Maturation phase D) Synthesis phase *P-21* B (Proliferative phase) Which statement about wound care across the lifespan is correct? A) "When applying transparent dressings on older adult clients, do not hold the skin taut, because doing so can cause damage." B) "In young children, staph bacteria and fungi are the most common causes of infection in minor wounds." C) "Pressure injuries and contact irritation are rare among newborns and infants in NICUs." D) "As compared to younger clients, older adults have a heightened inflammatory response, which can contribute to delayed wound healing." *P-21* B ("In young children, staph bacteria and fungi are the most common causes of infection in minor wounds.") Hemostasis and phagocytosis are characteristic of which stage of the wound healing process? A) Inflammatory phase B) Proliferative phase C) Granulation phase D) Maturation phase *P-21* A (Inflammatory phase) Which of the following findings suggests that a wound is infected with pyogenic bacteria? A) Sanguineous exudate B) Serous exudate C) Serosanguineous exudate D) Purulent exudate *P-21* D (Purulent exudate) Which of the following medications may be discontinued in a client who is experiencing delayed wound healing? A) Oral prednisone B) Topical antibiotics C) Topical growth factors D) Oral antibiotics *P-21* A (Oral prednisone) The nurse provides care for a client diagnosed with stroke earlier that day. Which nursing assessment is PRIORITY? A) The client's ability to speak clearly B) The client's level of consciousness C) The color, temperature, and moisture of the client's skin D) The client's ability to follow simple commands *K* B (The client's level of consciousness) The nurse provides care for an adult client with deep partial-thickness and full-thickness burns involving 45% of the body surface area. Which information is MOST concerning to the nurse 24 hours after the client was burned? A) A urine output of 75/ mL/hr with hemochromogens B) A pulse rate of 110 bpm C) A arterial blood pressure of 75 mmHg D) A weight loss of 10% of baseline *K* D (A weight loss of 10% of baseline) The nurse provides care for a client diagnosed with a Stage III pressure injury on the coccyx. At this time the wound has no purulent drainage. Which intervention is the MOST appropriate for the nurse to implement? A) Massage the area carefully B) Cover the area with a transparent dressing C) Irrigate the wound with a sodium hypochlorite solution D) Irrigate the wound and apply a hydrocolloid dressing *K* D (Irrigate the wound and apply a hydrocolloid dressing) A client suffers a full thickness burn injury. The nurse provides care for the client during the emergent phase. The nurse understand which finding is expected during this phase? A) Increased blood pressure B) Decreased urine output C) Hypokalemia D) Decreased pulse *K* B (Decreased urine output) The nurse identifies which diet BEST meets the needs of a client with multiple wounds? A) High-protein, Low-fat, and High-iron diet B) High-vitamin C, High-protein, and High-carbohydrate diet C) High-vitamin A, High-calcium, and High-fat diet D) High-vitamin B, High-protein, and Low-carbohydrate diet *K* B (High-vitamin C, High-protein, and High-carbohydrate diet) A client is admitted to the hospital after sustaining severe electrical burns. A tracheostomy is performed, and the client is unable to use either hand. It is MOST important for the nurse to take which action? A) Obtain a closed-circuit video monitor B) Pad the side rails of the bed C) Obtain a blow-touch call bell D) Transfer the client with a Hoyer lift *K* C (Obtain a blow-touch call bell) The nurse assesses a client with a long arm cast. The client reports the presence of severe pain in the casted arm. Which finding would indicate to the nurse the possibility of an impending pressure injury in the casted arm? A) Pain over a bony prominence B) Numbness or tingling C) Swelling or discoloration D) Cool skin distal to the injury *K* A (Pain over a bony prominence) The nurse determines a client has a deep partial thickness burn injury of the back. Which is the best initial nursing action? A) Break the blister with scalpel using sterile technique B) Gently clean the area and determine the extent of the burn C) Apply a thin layer of petroleum jelly to the area D) Wrap the area snugly with sterile gauze *K* B (Gently clean the area and determine the extent of the burn) The nurse performs a home care visit for the child diagnosed with cystic fibrosis. The nurse intervenes if which finding is observed? A) The child eats high-protein, high-calorie diet B) The child has two to three stools per day C) The child swallows the pancreatic enzyme capsules whole D) The child takes the pancreatic enzymes on hour after eating *K* D (The child takes the pancreatic enzymes on hour after eating) A client who sustained burns on the face and upper arms prepares for discharge. The nurse wants to help ease the client's adjustment back into the community. Which of the nurse's actions would be MOST helpful? A) Discuss the use of make-up to minimize the scars B) Encourage the client to be alone until comfortable with the physical changes C) Persuade the client to view the face and arms in the mirror D) Encourage the client to walk in the hall with family members *K* D (Encourage the client to walk in the hall with family members) The nurse provides care for a client diagnosed with a pressure injury on the sacrum that is 3 cm deep and 2 cm wide with an irregular border. The muscular tissue is sloughing. Which stage does the nurse classify this pressure injury? A) Stage 1 B) Stage 2 C) Stage 3 D) Stage 4 *K* C (Stage 3) A client is diagnosed with a possible stroke. The client has a history of poorly controlled hypertension. The client takes antihypertensive medication and hormone therapy. The client appears overweight and admits to mostly watching television or working on the computer all day. The nurse identifies which risk factor as MOST significant for development of a stroke for this client? A) Obesity B) Hypertension C) Sedentary lifestyle D) Hormone replacement therapy *K* B (Hypertension) The nurse assesses a client diagnosed with a transient ischemic attack (TIA). The nurse anticipates the client will report which symptom? A) Inability to speak for 7 to 10 days B) Intermittent sharp, stabbing pain on one side of the head C) Acute right lower extremity weakness that lasts about 15 minutes D) Bilateral upper extremity weakness that progresses downward *K* C (Acute right lower extremity weakness that lasts about 15 minutes) A preschooler client sustains a deep partial-thickness burn. Based on an understanding of growth and development, the nurse anticipates which hospital experiences will probably be the MOST upsetting to the client? A) Receiving intramuscular (IM) injections B) Being examined daily by the health care provider C) Taking oral medicine when a parent is not there D) Having the nurse say "no" to requests *K* A (Receiving intramuscular (IM) injections) The nurse provides care for a client who has full thickness burns. The nurse understands that the Rule of Nines is used to help determine the treatment the client will receive. Which explanation BEST describes the Rule of Nines as applied to burns? A) Each arms constitutes 9% of body surface area B) Fluid resuscitation is increased by 9% every hour C) The amount of hourly urine output should be 9% of hourly IV intake D) For every % of body surface area burned, the client's chance of survival is decreased by 9 *K* A (Each arms constitutes 9% of body surface area) The 7-year-old child is diagnosed with cystic fibrosis. The nurse instructs the parents about required dietary modifications. Which adjustment is likely to be made in a normal diet? A) Increased protein B) Increased fat C) Increased carbohydrates D) Increased potassium *K* A (Increased protein) A client has a major burn injury. The nurse knows medication is best absorbed by which route for this client? A) Intramuscularly (IM) B) Orally (PO) C) Intravenously (IV) D) Topically *K* C (Intravenously (IV)) The nurse provides care for a client diagnosed with right-sided hemiplegia due to a stroke. The nurse observes the client has an inability to eat without total assistance. Which intervention is MOST appropriate to improve the client's nutrition? A) Assist the client to eat with the left hand B) Provide a pureed diet C) Stroke the client's throat D) Provide a wide variety of food choice on the meal tray *K* B (Provide a pureed diet) The nurse provides care for an adult client during the resuscitation phase of a severe burn injury. Which assessment finding indicates to the nurse that the amount of intravenous fluid replacement needs to be increased? A) Urine output 15 mL/hour B) Engorged neck veins C) Electrolytes within normal limits D) Decreased core body temperature *K* A (Urine output 15 mL/hour) An older client has a reddened area on the coccyx. Which action does the nurse take FIRST? A) Continues assessment of the area B) Repositions the client every 1 to 2 hours C) Massages the reddened area four times per day D) Places the client in a semi reclining position *K* B (Repositions the client every 1 to 2 hours) The 4-year-old child was sitting near the fireplace when the clothing caught fire and enveloped the child in flames. The nurse was in the home. Which action does the nurse take FIRST? A) Obtains the child's respirations B) Transports the child to the hospital C) Pushes the child to the ground and makes the child roll D) Removes the child's clothing as quickly as possible *K* C (Pushes the child to the ground and makes the child roll) The nurse in the Emergency Department assesses a client admitted with splash burns to the chest and arms. The client states the burns occurred when a pot of hot water was knocked off of the stove. The client's skin appears red, moist, and very painful to touch. Fluid filled vesicles are present. Which statement BEST describes the depth of the burn injury? A) A first degree thermal burn is present B) A superficial partial-thickness burn is present C) A deep partial-thickness burn is present D) A full-thickness burn is present *K* C (A deep partial-thickness burn is present) The nurse provides care for a client admitted to the medical/surgical unit diagnosed with a stroke. The nurse plans care to prevent the client form experiencing sensory overload. The nurse determines which plan is MOST effective? A) The nurse obtains the vital signs and assists the client with morning care in one visit B) The nurse obtains vital signs, and completes morning care two hours later C) The nurse completes morning care and schedules physical therapy to follow immediately D) The nurse instructs the family to visit the client every other day *K* A (The nurse obtains the vital signs and assists the client with morning care in one visit) The nurse identifies which as a risk factor for the client to develop a pressure ulcer? A) Decreased skin moisture B) Ambulation with an assistive device C) Anemia D) Alzheimer's disease *K* C (Anemia) The nurse assesses a client who sustained a thermal burn injury. The nurse is MOST concerned if which observation is made? A) The client has singed nasal hairs B) The client has a blood pressure of 100/62 mmHg C) The client has blisters on the hands D) The client's capillary refill times is less than 3 seconds *K* A (The client has singed nasal hairs) The nurse provides care for a client at risk for an intracranial hemorrhage. Which of the following are risk factors for an intracranial hemorrhage? A) Atherosclerosis and hypertension B) Anemia and kidney disease C) Hypothyroidism and glaucoma D) Arteriosclerosis and hypertension *K* D (Arteriosclerosis and hypertension) The nurse assesses a client who sustained a burn injury. The burn area is red, blistered, and painful. Which classification BEST describes the burned area? A) Third degree B) Full thickness C) Superficial partial thickness D) Deep partial thickness *K* C (Superficial partial thickness) A preschooler client experiences deep superficial burns on the back, the entire right arm, and entire right leg. Using the Rule of Nines, what percentage does the nurse correctly estimate the extent of the burns to be? A) 27% B) 31.5% C) 42.5% D) 45% *K* C (42.5%) A toddler client diagnosed with cystic fibrosis is admitted to the hospital with a respiratory infection. The nurse expects to see which characteristic feature of cystic fibrosis? A) Absence of gastric enzymes B) Increased viscosity of mucus C) Absence of liver enzymes D) Inability to cough *K* B (Increased viscosity of mucus) Which outcome does the nurse recognize as an indication of normal wound healing after surgery? A) A tender localized point beneath the wound B) The wound is reddened and warm C) Dehiscence has begun D) A hematoma has begun to form *K* B (The wound is reddened and warm) The nurse monitors a client who experienced partial-thickness and full-thickness burns over the lower extremities 24 hours ago. Which signs does the nurse anticipate during this phase of burn injury? A) Decreased urinary output B) Increased blood pressure C) Decreased potassium and sodium levels D) Decreased hematocrit level *K* A (Decreased urinary output) The nurse provides care for a client diagnosed with a stroke resulting in right hemiplegia, sensory loss, and cognitive dysfunction. During the client's first 72 hours of hospitalization, which is the priority nursing action? A) Teach the client how to transfer from bed to chair B) Use a picture board to help the client communicate C) Perform neurological assessments every 2 hours D) Assist the client to comb hair and brush teeth *K* C (Perform neurological assessments every 2 hours) A client is brought to the emergency department by a family member. The client has full thickness burns to the head, neck, chest, and right upper extremity. Which nursing intervention is the PRIORITY? A) Insert an intravenous catheter B) Cover burns with a sterile dressing C) Establish and maintain a patent airway D) Administer Lactated Ringer at 200 mL/hour *K* C (Establish and maintain a patent airway) The nurse provides care for a client diagnosed with a left hemispheric stroke. One moment the client is very depressed and cries, and the next the client is euphoric and breaks into inappropriate laughter. The client's family is distressed by the changes in the client's mood. How should the nurse address this behavior in the plan of care? A) Point out the inappropriate behavior to the client B) Request prescriptions for a sedative and an anti-depressive C) Ask the client's family to stay with the client and provide constant distraction D) Provide education to the client's family about the effects of left hemispheric stroke *K* D (Provide education to the client's family about the effects of left hemispheric stroke) Which state BEST describes the events leading to death of neurons after an ischemic stroke? A) Increased metabolic activity in the neurons surrounding the affected area B) Movement of potassium ions into the cells from the extracellular area C) Accumulation of sodium and water inside the neurons in the affected area D) Increased formation of adenosine (ATP) in the neurons in the affected area *K* C (Accumulation of sodium and water inside the neurons in the affected area) A client sustains burns to the anterior portions of both upper extremities, the trunk, and the right leg. The nurse uses the Rule of Nines to estimate the percentage of body surface area burned. Which is the correct percentage? A) 23% B) 36% C) 45% D) 54% *K* B (36%) During which stage of healing by primary intention does the nurse normally expect to see a purplish, irregular wound with a raised scar? A) Defensive stage B) Reconstructive stage C) Maturative stage D) Granulation stage *K* B (Reconstructive stage) A client has sustained deep partial thickness and full thickness burns over approximately 40% total body surface area (TBSA). Which clinical findings suggest that the client is experiencing burn shock? A) Extreme dryness of the skin, elevated temperature over 104, and cardiac dysrhythmias B) Generalized body edema, tachycardia, and low urine output C) Bounding pulses, hypertension, diuresis, and hyponatremia D) The client would not experience shock phase unless TBSA burned is greater than 50% *K* B (Generalized body edema, tachycardia, and low urine output) A client reports dyspnea the third day after a major burn episode. The client has crackles in both lower lung fields, the urine output is 125 mL/hr, and the CVP is 14 mmHg (19 cm of water). Which statement is the correct interpretation of this data? A) The client is developing shock B) The client is in the acute phase of burn injury C) The client is exhibiting a normal response to the burn injury D) The client is developing hypostatic pneumonia *K* B (The client is in the acute phase of burn injury) The nurse provides care for a client diagnosed with a stroke resulting in right hemiplegia. Which is the CORRECT technique for the nurse to use when transferring the client from the bed to a chair? A) Assist the client from a sitting to a standing position by pulling up no the affected side B) Support the standing client for a minute before pivoting towards the chair C) Ask the client to roll to the right side of the bed and assist the client form the right side D) Instruct the client to place arms around the nurse's neck to move from a standing position to the chair *K* B (Support the standing client for a minute before pivoting towards the chair) The nurse provides care for a client that is at high risk for a stroke. Which is a known risk factor for a stroke? A) Atrial fibrillation B) Senile dementia C) Chronic constipation D) Coagulopathies *K* A (Atrial fibrillation) The nurse provides care for an adolescent client diagnosed with a superficial, partial-thickness burn. Which finding does the nurse expect? A) The client's skin has very painful blisters B) The client's skin is red and tender with no blisters C) The client's skin has white and dry burns with no blisters D) The client reports decreased sensation to the burn area that does not blanch with pressure *K* B (The client's skin is red and tender with no blisters) Forty-eight hours after a client's burn injury, the nurse notes large amounts of edema in all burned areas. The nurse monitors the client for signs and symptoms of hypovolemic shock. Which is a factor that contributes to the development of hypovolemic shock in the burn client? A) Large urine output B) Decreased insensible fluid loss C) Decreased hematocrit D) Increased capillary permeability *K* D (Increased capillary permeability) The nurse knows a client has a good understanding of emotional/psychological needs post severe burn injury when the client makes which statement? A) "Everything will fall into place at the right time, I'm choosing to see the good in all of this." B) "I will have to talk to future partners honestly about my decreased sensation and body image issues." C) "I'm determined to return to 100% function within six months." D) "I will have to find new friends, as I won't be able to participate in rugby again." *K* B ("I will have to talk to future partners honestly about my decreased sensation and body image issues.") Which is the MOST appropriate nursing intervention to prevent flexion contractures in the client diagnosed with a stroke? A) Place a hand roll in the affected hand and maintain the client in a semi-fowler position B) Place the client in a prone position for 10 to 15 minutes three or four times a day C) Place the affected arm in a sling and encourage the client to sit in a chair for all meals D) Provide three exercise sessions lasting one and a half hours each day *K* B (Place the client in a prone position for 10 to 15 minutes three or four times a day) The nurse teaches a class on first aid at a community center. Which instruction is the MOST appropriate initial care for a person experiencing an electrical burn? A) Tell the burned person to stop, drop, and roll B) Assess the burned person for an unobstructed airway C) Turn off the electrical current D) Remove the burned peron's clothing *K* C (Turn off the electrical current) A client is recovering from abdominal surgery and has a large abdominal wound. The nurse should encourage the client to eat which food item that is naturally high in vitamin C to promote wound healing? A) Milk B) Oranges C) Bananas D) Chicken *Rationale: Review Book pg. 147* B (Oranges) A client who has had abdominal surgery complains of feeling as thought "something gave way" in the incisional site. The nurse removes the dressing and notes the presence of a loop of bowel protruding through the incision. Which interventions should the nurse take? (Select all that apply) A) Contact the surgeon B) Instruct the client to remain quiet C) Prepare the client for wound closure D) Document the findings and actions taken E) Place a sterile saline dressing and ice packs over the wound F) Place the client in a supine position without a pillow under the head *Rationale: Review Book pg. 207* A, B, C, & D (Contact the surgeon) (Instruct the client to remain quiet) (Prepare the client for wound closure) (Document the findings and actions taken) The nurse is caring for a client with a severe burn who is scheduled for an autograft to be placed on the lower extremity. The nurse creates a postoperative plan of care for the client and should include which intervention in the plan? A) Maintain the client in a prone position B) Elevate and immobilize the grafted extremity C) Maintain the grafted extremity in a flat position D) Keep the grafted extremity covered with a blanket *Rationale: Review Book pg. 216* B (Elevate and immobilize the grafted extremity) A 2-year-old child is treated in the emergency department for a burn to the chest and abdomen. The child sustained the burn by grabbing a cup of hot coffee that was left on the kitchen counter. The nurse review safety principles with the parents before discharge. Which statement by the parents indicate an understanding of measures to provide safety in the home? A) "We will be sure not to leave hot liquids unattended." B) "I guess our children need to understand what the word hot means." C) "We will be sure that the children stay in their rooms when we work in the kitchen." D) "We will install a safety gate as soon as we get home so the children cannot get into the kitchen." *Rationale: Review Book pg. 245* A ("We will be sure not to leave hot liquids unattended.") The nurse is monitoring a child with burns during treatment. Which assessment provides the MOST accurate guide to determine the adequacy of fluid resuscitation? A) Skin turgor B) Level of edema at burn site C) Adequacy of capillary filling D) Amount of fluid tolerated in 24 hours *Rationale: Review Book pg. 378* C (Adequacy of capillary filling) The clinic nurse is providing instructions to a parent of a child with cystic fibrosis regarding the immunization schedule for the child. Which statement should the nurse make to the parent? A) "The immunization schedule will need to be altered." B) "The child should not receive any hepatitis vaccines." C) "The child will receive all of the immunizations except for the polio series." D) "The child will receive the recommended basic series of immunizations along with a yearly influenza vaccination." *Rationale: Review Book pg. 444* D ("The child will receive the recommended basic series of immunizations along with a yearly influenza vaccination.") The staff nurse reviews the nursing documentation in a client's chart and notes that the wound care nurse has documented that the client has a stage II pressure injury in the sacral area. Which finding would the nurse expect to note on assessment of the client's sacral area? A) Intact skin B) Full-thickness skin loss C) Exposed bone, tendon, or muscle D) Partial-thickness skin loss of the dermis *Rationale: Review Book pg. 520* D (Partial-thickness skin loss of the dermis) A burn client is receiving treatments of topical mafenide acetate to the site of injury. The nurse monitors the client, knowing that which finding indicates that a systemic effect has occurred? A) Hyperventilation B) Elevated blood pressure C) Local rash at the burn site D) Local pain at the burn site *Rationale: Review Book pg. 528* A (Hyperventilation) Silver sulfadiazine is prescribed for a client with a partial-thickness burn, and the nurse provides teaching about the medication. Which statement made by the client indicates a need for further teaching about the treatment? A) "The medication is an antibacterial" B) "The medication will help heal the burn" C) "The medication should be applied directly to the wound" D) "The medication is likely to cause stinging every time it is applied" *Rationale: Review Book pg. 529* D ("The medication is likely to cause stinging every time it is applied") The nurse is assigned to care for a client with complete right-sided hemiparesis from a stroke (brain attack). Which characteristics are associated with this condition? (Select all that apply) A) The client is aphasic B) The client has weakness on the right side of the body C) The client has complete bilateral paralysis of the arms and legs D) The client has weakness on the right side of the face and tongue E) The client has lost the ability to move the right arm but is able to walk independently F) The client has lost the ability to ambulate independently but is able to feed and bathe herself or himself without assistance *Rationale: Review Book pg. 851* A, B, & D (The client is aphasic) (The client has weakness on the right side of the body) (The client has weakness on the right side of the face and tongue) The nurse instructed the family of a client with stroke (brain attack) who has homonymous hemianopsia about measure to help the client overcome the deficit. Which statement suggests that the family understands the measures to use when caring for the client? A) "We need to discourage him from wearing eyeglasses." B) "We need to place objects in his impaired field of vision." C) "We need to approach him from the impaired field of vision." D) "We need to remind him to turn his head to scan the lost visual field." *Rationale: Review Book pg. 851* D ("We need to remind him to turn his head to scan the lost visual field.") A client is brought to the emergency department with partial-thickness burns to his face, neck, arms, and chest after trying to put out a car fire. The nurse should implement which nursing actions for this client? (Select all that apply) A) Restrict fluids B) Assess for airway patency C) Administer oxygen as prescribed D) Place a cooling blanket on the client E) Elevate extremities if no fractures are present F) Prepare to give oral pain medication as prescribed *Rationale: Review Book pg. 1062* B, C, & E (Assess for airway patency) (Administer oxygen as prescribed) (Elevate extremities if no fractures are present) What is the leading cause of death in idiopathic cardiomyopathy? A) Cardiomegaly B) Heart failure C) Dysrhythmias D) Embolization *Kahoot - Cardiomyopathy* C (Dysrhythmias) What is the priority teaching for a family of a client with severe dilated cardiomyopathy? A) CPR B) High protein diet C) Skin care D) Avoiding dehydration *Kahoot - Cardiomyopathy* A (CPR) Hypertrophic cardiomyopathy is most commonly found in which individuals? A) Soccer moms B) Athletic men C) African american women D) Frail elders *Kahoot - Cardiomyopathy* B (Athletic men) The most common sign and symptom of cardiomyopathy is? A) Hepatomegaly B) JVD C) Peripheral edema D) Dyspnea *Kahoot - Cardiomyopathy* D (Dyspnea) What is the treatment plan for restrictive cardiomyopathy? A) VAD B) Septal wall ablation C) Aggressive dobutamine infusions D) No specific treatment (treat signs/symptoms) *Kahoot - Cardiomyopathy* D (No specific treatment (treat signs/symptoms)) Which diagnostic study best differentiates the different kinds of cardiomyopathy? A) Echo B) ABGs C) Cardiac cath D) Endomyocardial biopsy *Kahoot - Cardiomyopathy* A (Echo) You are caring for a new admission with heart failure secondary to dilated cardiomyopathy (DCM). Which intervention would be a priority? A) Encourage caregivers to learn CPR B) Consider a consult with palliative care/hospice C) Monitor the patients response to prescribed medications D) Arrange for the patient to enter a cardiac rehab program *Kahoot - Cardiomyopathy* C (Monitor the patients response to prescribed medication) Which of the following types of cardiomyopathy can be associated with childbirth? A) Dilated B) Hypertrophic C) Myocarditis D) Restrictive *Kahoot - Cardiomyopathy* A (Dilated) Septal involvement occurs in which type of cardiomyopathy? A) Congestive B) Dilated C) Hypertrophic D) Restrictive *Kahoot - Cardiomyopathy* C (Hypertrophic) Which of the following recurring conditions most commonly occur in clients with cardiomyopathy? A) Heart failure B) Diabetes C) Myocardial infarction D) Pericardial effusion *Kahoot - Cardiomyopathy* A (Heart failure) In which of the following types of cardiomyopathy does cardiac output remain normal? A) Dilated B) Hypertrophic C) Myocarditis D) Restrictive *Kahoot - Cardiomyopathy* B (Hypertrophic) Which of the following classes of drugs is most widely used in the treatment of cardiomyopathy? A) Antihypertensive B) Beta blockers C) Calcium channel blockers D) Nitrates *Kahoot - Cardiomyopathy* B (Beta blockers) If medical treatment fails which invasive procedure is necessary for treating cardiomyopathy? A) Cardiac cath B) Coronary artery bypass graft C) Heart transplant D) Intra-aortic balloon pump *Kahoot - Cardiomyopathy* C (Heart transplant) Cystic fibrosis has what type of gene? A) Autosomal recessive B) Autosomal dominant C) Sexlinked recessive D) Sexlinked dominant *Kahoot - Cystic Fibrosis* A (Autosomal recessive) What does cystic fibrosis cause? A) Mucus build up B) Cramps C) Wheezing D) Spasms *Kahoot - Cystic Fibrosis* A (Mucus build up) Cystic fibrosis is passed on how? A) When both parents carry the dominant gene B) When both parent carry the recessive gene C) When one parent carries the recessive gene D) It is not a genetic disorder *Kahoot - Cystic Fibrosis* B (When both parent carry the recessive gene) What are some signs/symptoms of cystic fibrosis (CF)? A) Stomach ache with constipation, no bowl movement in first 48 hours of life B) Constant cough with increased mucus, respiratory infection C) Growth restriction, fatigue, failure to gain/lose weight D) All of the above

Meer zien Lees minder
Instelling
NUR 210
Vak
NUR 210

Voorbeeld van de inhoud

Exam 4: NUR 210 / NUR210 (NEW 2026–2027
Updated) Transition to Practice – Capstone | Verified
Questions & Answers | 100% Accurate Solutions |
Grade A – Fortis

Q. The ion that cannot be regulated properly in clients with cystic fibrosis is
A) chloride
B) sodium
C) calcium
D) potassium

ANSWERS
*P-15*
A

(chloride)



Q. For couples in which both individuals carry one defective CF gene, any offspring from the couple has a
________ percent chance of inheriting two abnormal genes and developing cystic fibrosis.

A) 100
B) 75
C) 50
D) 25


ANSWERS
*P-15*
D

(25)




1

,Q. Besides the respiratory system, which system would be critical for the nurse to assess in a client recently
diagnosed with cystic fibrosis?

A) Nervous system
B) Gastrointestinal system
C) Musculoskeletal system
D) Urinary system


ANSWERS
*P-15*
B

(Gastrointestinal system)



Q. The nurse is caring for an 18-month-old client who is newly diagnosed with cystic fibrosis. The client is
currently hospitalized due to a Pseudomonas aeruginosa infection in the lungs. The client's vital signs are: P
138, R 43, T 101.3°F, BP 86/40, SpO2 88%. The client is coughing up thick, green mucus. What independent
nursing intervention can the nurse implement to improve the client's oxygenation?

A) Administration of CFTR modulators
B) Percussion and postural drainage
C) Nutritional counseling
D) Teaching the client to cough into a tissue


ANSWERS
*P-15*
B

(Percussion and postural drainage)




Q. A 15-year-old client with cystic fibrosis asks why she has not started her menstrual period yet. Which
response by the nurse is correct?
2

,A) "Usually girls with cystic fibrosis start menstruating earlier than their peers."
B) "It is normal for girls with cystic fibrosis to start their period at age 16. Just be patient."
C) "Some girls with cystic fibrosis do not experience menstruation due to nutritional problems."
D) "Because secretions are thicker in people with cystic fibrosis, your period will be very heavy once it starts."


ANSWERS
*P-15*
C

("Some girls with cystic fibrosis do not experience menstruation due to nutritional problems.")




Q. The nurse is providing teaching to the client who is pregnant and has cystic fibrosis. The nurse should
explain that the client is at increased risk for which condition?

A) Emergency delivery
B) Gestational diabetes
C) Placenta previa
D) Spontaneous abortion

*P-15*

ANSWERS
B

(Gestational diabetes)




Q. The nurse is caring for a client diagnosed with dilated cardiomyopathy. Which clinical manifestations does
the nurse anticipate during the physical assessment? (Select all that apply)

3

, A) Fatigue
B) Lower extremity edema
C) Syncope
D) Dyspnea
E) Angina


ANSWERS
*P-16*
A, B, & D

(Fatigue)

(Lower extremity edema)

(Dyspnea)



Q. A client states to the nurse, "I know I have high blood pressure, but I don't want to take medication." Based
on this data, which health problem is the client at risk for developing?

A) Gastritis
B) Diabetes
C) Cardiomyopathy
D) Metabolic syndrome


ANSWERS
*P-16*
C

(Cardiomyopathy)




Q. A client diagnosed with cardiomyopathy reports having to rest between activities during the day. The
client asks the nurse why this is occurring. Which reason should the nurse include in the response to the client?

4

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