NSG520 MODULE 2 ACTUAL EXAM
PAPER 2026 QUESTIONS WITH
ANSWERS GRADED A+
◍ A client is admitted to a comprehensive rehabilitation center for continuing
care following a motor vehicle crash. The admitting nurse will develop the
initial care, but who will be involved with the ongoing planning of this
client's care?.
Answer: Everybody involved in this clients careRationale:: Planning is
basically the nurse's responsibility, but input from the client and support
persons is essential if a plan is to be effective. In this case, therapies form
other disciplines (occupational, physical, speech, etc.) would be involved
because the client is in a comprehensive rehabilitation center. The client's
support people and caregivers are also going to be involved in the plan of
care, but not exclusively.
◍ restrictive respiratory disorders.
Answer: •Impair the ability of the chest wall and diaphragm to move with
respiration•Two categories: extrapulmonary and intrapulmonary•Reduced
total lung capacity (TLC) is hallmark feature
◍ obstructive respiratory disorder.
Answer: Air can get in but has trouble getting out → narrowed airways
cause air trapping-↓ Airflow / Expiration-“Can’t get air out” — air trapped
in lungs-ex= COPD, Asthma
◍ Restrictive rrespiratory Disorders.
Answer: Lungs can’t fully expand → restricted lung volume (stiff lungs,
weak muscles, or structural issues).-↓ Lung Expansion / Volume-“Can’t get
air in” — lungs too stiff or restricted-ex= sarcoidosis, stelectasis
,◍ A client is admitted for complication following a routine diagnostic
procedure of the colon. Which type of care plan will most likely be
implemented for this client?.
Answer: Individualized care planRationale: An individualized care plan is
tailored to meet a specific client need that is not addressed by the
standardized care plan. In this situation, the client had complications
following a relatively routine procedure - something that is unplanned and a
rate occurrence.
◍ A client is scheduled for elective hip replacement an will be admitted
postoperatively to the orthopedic unit for care. What should the nurses use
to help plan this clients care?.
Answer: Standardized care planRationale: A standardized care plan is a
formal plan that specifies the nursing care for groups of clients with
common needs. For example, all clients undergoing hip replacement surgery
would have basic, similar needs or problems such as pain, skin integrity
disruption, or risk for fall or injury.
◍ The nurse being oriented to a new position is reviewing the hospitals
standards of care, standard care plans protocols, policies, and procedures.
For which reasons should the nurse realize that these documents are being
used by the nursing staff? 1. Making sure all clients have the same types of
care. 2. Ensuring that minimally accepted standards are met. 3. Promoting
efficient use of the nurses time. 4. Eliminating care disparities among
clients.5. Ensuring medication errors do not occur..
Answer: 2. Ensuring that minimally accepted standards are met. 3.
Promoting efficient use of the nurses time.
◍ Types of Pleural Effusion (TEE).
Answer: •Transudate: non-inflammatory, low protein,
clear/yellow----Causes: HF, hypoalbuminemia•Exudate: inflammatory,
protein-rich-----Causes: infection, cancer•Empyema: purulent fluid
(pneumonia, TB, abscess, infected wounds)
◍ Normal troponin levels.
, Answer: Normal: <0.04 ng/mLSuspicious: 0.04-0.10 ng/mL Diagnostic for
MI: >0.10 ng/mL
◍ Heart Healing After an MI.
Answer: 0–1 day=Cells start dying, ECG changes, ↑ troponin “The
Attack” – damage begins1–3 daysNeutrophils =clean up dead tissue →
inflammation “Fire fighters arrive” (inflammation)3–7 daysMacrophages=
remove debris → heart wall weak “Soft spot” – risk of rupture!1–2
weeksGranulation tissue =forms (new healing tissue) “New growth” –
healing starts2–8 weeksScar tissue =forms – firm but not strong “Scarring
stage” – heart stiffens2+ monthsScar complete, no contraction in that area
“Healed but weaker” – permanent damage
◍ Defibrillation.
Answer: HIGH Emergency shock to restart a heart that has no effective
rhythm (like V-fib or pulseless V-tach).“Defib = DEAD rhythms.”(Use it
when the heart’s rhythm is chaotic or absent.)
◍ The neonatal intensive care nurse implements several actions to prevent
further complication in a newly admitted premature infant. Which type of
document did the nurse use to find these actions?.
Answer: ProtocolRationale: Protocols are preprinted to indicate the actions
commonly required for a particular group of clients. Protocols may include
both physicians' orders and nursing interventions.
◍ Cardioversion.
Answer: Used to correct abnormal but organized rhythms (like A-fib,
A-flutter, or SVT) when the patient has a pulse.LOW-energy, synchronized
shock timed with the heart’s R-wave to safely reset the
rhythm.“Cardioversion = Conscious Correction.”
◍ PacemakernursingSafety RulesPost-op Care.
Answer: Pacemaker = keeps rhythm steady------Gentle electrical pacing for
bradycardia and heart block check for ECG for spikes + capture, Check
pulse dailyAvoid magnets & MRIs, Phone 6 in away, Keep site clean, Carry
ID cardArm down 1-2 days Watch for swelling, bleeding, infection,
, ◍ A nurse in the intensive care unit consults unit policy and administers a
routinely used medication to a client admitted to the unit with severe
hypotension. What did the nurse implement in this situation?.
Answer: A standing order.Rationale: Standing orders are a written document
about policies, rules, regulations, or orders regarding client care
◍ According to the care plan, a client is to receive chest physiotherapy twice
daily. The client lives alone in a rural area, does not drive, and is 40 miles
away from a hospital. What should the home care nurse do when setting
priorities for this client?.
Answer: assist the client in finding an alternative plan for the achieving the
therapy's outcomes.Rationale: The nurse must consider a variety of factors
when assigning priorities, including resources available to the nurse and
client. Factors in this case include the distance between the client's home
and the hospital and the fact that therapy is ordered on a twice-daily basis.
Driving 80 miles two times a day may not be feasible, but perhaps there are
other alternatives that could be considered (a neighbor who might be willing
to drive the client, or someone in the area who may be able to assist with the
therapy.
◍ ICD (defibrillation)nursingsafety rulespost-op care.
Answer: Shocks heart back to normal (dangerous rhythms),High-energy
shock (feels like a “kick”)----V-fib, V-tachmonitor ECG + report if it shocks
more than onceAvoid magnets & MRIs, Phone 6 in away, Keep site clean,
Carry ID card,No driving until cleared, Teach family CPRArm down 1–2
days Watch for swelling, bleeding, infection
◍ A discharge goal for a client is to have improved mobility. Which outcome
statement did the nurse write appropriately?.
Answer: Client will ambulate without a walker by 6 weeks.Rationale:
Desired outcomes are the more specific, observable criteria used to evaluate
whether the goals have been met. Ambulating without a walker by a certain
date is specific as well as measurable.
◍ The nurse identifies for a client the nursing diagnoses Fluid volume deficit,
PAPER 2026 QUESTIONS WITH
ANSWERS GRADED A+
◍ A client is admitted to a comprehensive rehabilitation center for continuing
care following a motor vehicle crash. The admitting nurse will develop the
initial care, but who will be involved with the ongoing planning of this
client's care?.
Answer: Everybody involved in this clients careRationale:: Planning is
basically the nurse's responsibility, but input from the client and support
persons is essential if a plan is to be effective. In this case, therapies form
other disciplines (occupational, physical, speech, etc.) would be involved
because the client is in a comprehensive rehabilitation center. The client's
support people and caregivers are also going to be involved in the plan of
care, but not exclusively.
◍ restrictive respiratory disorders.
Answer: •Impair the ability of the chest wall and diaphragm to move with
respiration•Two categories: extrapulmonary and intrapulmonary•Reduced
total lung capacity (TLC) is hallmark feature
◍ obstructive respiratory disorder.
Answer: Air can get in but has trouble getting out → narrowed airways
cause air trapping-↓ Airflow / Expiration-“Can’t get air out” — air trapped
in lungs-ex= COPD, Asthma
◍ Restrictive rrespiratory Disorders.
Answer: Lungs can’t fully expand → restricted lung volume (stiff lungs,
weak muscles, or structural issues).-↓ Lung Expansion / Volume-“Can’t get
air in” — lungs too stiff or restricted-ex= sarcoidosis, stelectasis
,◍ A client is admitted for complication following a routine diagnostic
procedure of the colon. Which type of care plan will most likely be
implemented for this client?.
Answer: Individualized care planRationale: An individualized care plan is
tailored to meet a specific client need that is not addressed by the
standardized care plan. In this situation, the client had complications
following a relatively routine procedure - something that is unplanned and a
rate occurrence.
◍ A client is scheduled for elective hip replacement an will be admitted
postoperatively to the orthopedic unit for care. What should the nurses use
to help plan this clients care?.
Answer: Standardized care planRationale: A standardized care plan is a
formal plan that specifies the nursing care for groups of clients with
common needs. For example, all clients undergoing hip replacement surgery
would have basic, similar needs or problems such as pain, skin integrity
disruption, or risk for fall or injury.
◍ The nurse being oriented to a new position is reviewing the hospitals
standards of care, standard care plans protocols, policies, and procedures.
For which reasons should the nurse realize that these documents are being
used by the nursing staff? 1. Making sure all clients have the same types of
care. 2. Ensuring that minimally accepted standards are met. 3. Promoting
efficient use of the nurses time. 4. Eliminating care disparities among
clients.5. Ensuring medication errors do not occur..
Answer: 2. Ensuring that minimally accepted standards are met. 3.
Promoting efficient use of the nurses time.
◍ Types of Pleural Effusion (TEE).
Answer: •Transudate: non-inflammatory, low protein,
clear/yellow----Causes: HF, hypoalbuminemia•Exudate: inflammatory,
protein-rich-----Causes: infection, cancer•Empyema: purulent fluid
(pneumonia, TB, abscess, infected wounds)
◍ Normal troponin levels.
, Answer: Normal: <0.04 ng/mLSuspicious: 0.04-0.10 ng/mL Diagnostic for
MI: >0.10 ng/mL
◍ Heart Healing After an MI.
Answer: 0–1 day=Cells start dying, ECG changes, ↑ troponin “The
Attack” – damage begins1–3 daysNeutrophils =clean up dead tissue →
inflammation “Fire fighters arrive” (inflammation)3–7 daysMacrophages=
remove debris → heart wall weak “Soft spot” – risk of rupture!1–2
weeksGranulation tissue =forms (new healing tissue) “New growth” –
healing starts2–8 weeksScar tissue =forms – firm but not strong “Scarring
stage” – heart stiffens2+ monthsScar complete, no contraction in that area
“Healed but weaker” – permanent damage
◍ Defibrillation.
Answer: HIGH Emergency shock to restart a heart that has no effective
rhythm (like V-fib or pulseless V-tach).“Defib = DEAD rhythms.”(Use it
when the heart’s rhythm is chaotic or absent.)
◍ The neonatal intensive care nurse implements several actions to prevent
further complication in a newly admitted premature infant. Which type of
document did the nurse use to find these actions?.
Answer: ProtocolRationale: Protocols are preprinted to indicate the actions
commonly required for a particular group of clients. Protocols may include
both physicians' orders and nursing interventions.
◍ Cardioversion.
Answer: Used to correct abnormal but organized rhythms (like A-fib,
A-flutter, or SVT) when the patient has a pulse.LOW-energy, synchronized
shock timed with the heart’s R-wave to safely reset the
rhythm.“Cardioversion = Conscious Correction.”
◍ PacemakernursingSafety RulesPost-op Care.
Answer: Pacemaker = keeps rhythm steady------Gentle electrical pacing for
bradycardia and heart block check for ECG for spikes + capture, Check
pulse dailyAvoid magnets & MRIs, Phone 6 in away, Keep site clean, Carry
ID cardArm down 1-2 days Watch for swelling, bleeding, infection,
, ◍ A nurse in the intensive care unit consults unit policy and administers a
routinely used medication to a client admitted to the unit with severe
hypotension. What did the nurse implement in this situation?.
Answer: A standing order.Rationale: Standing orders are a written document
about policies, rules, regulations, or orders regarding client care
◍ According to the care plan, a client is to receive chest physiotherapy twice
daily. The client lives alone in a rural area, does not drive, and is 40 miles
away from a hospital. What should the home care nurse do when setting
priorities for this client?.
Answer: assist the client in finding an alternative plan for the achieving the
therapy's outcomes.Rationale: The nurse must consider a variety of factors
when assigning priorities, including resources available to the nurse and
client. Factors in this case include the distance between the client's home
and the hospital and the fact that therapy is ordered on a twice-daily basis.
Driving 80 miles two times a day may not be feasible, but perhaps there are
other alternatives that could be considered (a neighbor who might be willing
to drive the client, or someone in the area who may be able to assist with the
therapy.
◍ ICD (defibrillation)nursingsafety rulespost-op care.
Answer: Shocks heart back to normal (dangerous rhythms),High-energy
shock (feels like a “kick”)----V-fib, V-tachmonitor ECG + report if it shocks
more than onceAvoid magnets & MRIs, Phone 6 in away, Keep site clean,
Carry ID card,No driving until cleared, Teach family CPRArm down 1–2
days Watch for swelling, bleeding, infection
◍ A discharge goal for a client is to have improved mobility. Which outcome
statement did the nurse write appropriately?.
Answer: Client will ambulate without a walker by 6 weeks.Rationale:
Desired outcomes are the more specific, observable criteria used to evaluate
whether the goals have been met. Ambulating without a walker by a certain
date is specific as well as measurable.
◍ The nurse identifies for a client the nursing diagnoses Fluid volume deficit,
