(Answered) Rasmussen College NURISNG NUR2356LL FINAL NCLEX 2021/2022

(Answered) Rasmussen College NURISNG NUR2356LL FINAL NCLEX 2021/2022- A nurse identifies that a client on a prolonged bed rest may be developing a pressure ulcer. Which color over the bony prominence supports this conclusion? 1. Red 2. Blue 3. Black 4. Yellow 2. Which is an example of a response to a physiological physiological stressor? SELECT ALL THAT APPLY 1. A sunburn after being outside all day 2. Diarrhea after eating contaminated food 3. Shortness of breath while walking up a hill 4. A rapid heart rate during a final examination 5. Excess fluid volume as a result of renal disease 3. Why does turning a patient every 2 hours prevent pressure ulcers from developing? 1. Promotes muscle contractions, increasing the basal metabolic rate of the body 2. Relieves weight on the capillaries, allowing oxygen to reach peripheral blood cells 3. Keeps the extremities dependent, permitting blood flow to the distal cells by gravity 4. Drops the organs in the abdominal cavity by gravity, relieving pressure against the diaphragm 4. Which condition places a client at the highest risk for developing infection? A. Implantation of a prosthetic device B. Burns over more than 20% of the body C. Presence of an indwelling urinary catheter D. More than 2 puncture sites from a laparoscopic surgery 5. Which does the nurse determine is a specific line of defense against infection? A. Mucous membrane of the respiratory system B. Urinary tract environment C. Integumentary system D. Immune response 6. A nurse is concerned about a client’s ability to withstand exposure to pathogens. Which blood component should the nurse monitor? A. Platelets B. Hemoglobin C. Neutrophils D. Erythrocytes 7. An 83 year-old-woman fell at home and was diagnosed with a traumatic left femur fracture. She is alert and oriented and is able to make her own medical decisions. Which assessment is priority given her injuries and utilizes patient safety? A. Abdominal assessment B. Neuro vascular checks every hour C. Skin assessmentD. Mobility assessment 8. The patient has learned that she will need surgery and will be going to the operating room in a few hours. Given her age and history, the order set states the nurse is to reposition the patient every two hours. Which should be included in the nurse’s explanation and education to the patient? A. Turning every two hours will prevent a pressure injury B. Turning every two hours will alleviate gas C. Turning every two hours will promote blood flow of the fractured leg D. Turning every two hours will enhance nutrition 9. The patient has finished with her procedure and received an intramedullary rod placement of the left femur. Which nursing intervention can the nurse apply to prevent post-operative complications in the clinical setting? A. Initiating fluid replacement orders B. Eating as soon as possible after surgery C. Utilizing an incentive spirometer D. Turning the patient every two hours 10. The patient has completed the surgery without acute complications at this time and is moved to the post anesthesia care unit (PACU). Which nursing intervention is necessary to apply to the patient’s care during her temporary stay on this specific unit? A. Monitoring urinary output B. Assessing cognition status C. Assessing draining from the surgical site D. Suctioning any mucous from the patient’s airway 11. After the patient has arrived at the post anesthesia care unit (PACU), what is the most important information that the nurse should conclude about the patient? A. Type and extent of the surgery B. Medications that were delivered in surgery C. The name and phone number of the patient’s spouse D. Anxiety level pre and post procedure 12. The patient has been transferred out of the post anesthesia care unit (PACU) and has been assigned a room on the surgical progressive care unit. Which is most important for the nurse to utilize while positioning this patient post-operatively? A. Ensure the head of the bed is greater than 30 degrees B. Performing a log roll during linen changes C. Prevent pressure on bony prominences D. Avoid any friction or shear while turning the patient 13. The patient has started to develop pleuritic chest pain, tachypnea, and tachycardia. According to these findings, the nurse can identify this being which post-operative complication? A. Infection B. Pulmonary Emboli C. Anxiety D. Myocardial Infarction 14. The nurse is suspecting the patient is suffering from the post-operative complication pulmonary embolism. Which nursing action should the nurse apply first before notifying the doctor? A. Apply oxygen via nasal cannulaB. Place the bed in the lowest position C. Make the patient strict NPO D. Ensure the head of the bed is 30 degrees 15. The nurse is explaining pertinent education to the patient about pulmonary embolism. The nurse states that death from an acute pulmonary embolism commonly occurs within one hour of the onset of symptoms and it is necessary to begin treatment as soon as possible. Is this statement True or False? A. True B. False 16. Which diagnostic procedures are utilized in identifying an acute pulmonary embolism? Select all that apply. A. Cat scan of the chest B. Pulmonary angiogram C. CBC/BMP lab work D. Chest radiograph E. Electrocardiogram 17. A client’s stool specimen is positive for clostridium-difficle. Which isolation precautions should the nurse institute for this client? A. Droplet B. Contact C. Reverse D. Airborne 18. Which should the nurse do to interrupts the transmission link in the chain of infection? A. Wash the hands before providing care to the patients B. Position a commode next to the clients bed C. Provide education about a balanced diet D. Change a dressing when it is soiled 19. Which stage pressure ulcer requires the nurse to measure the extent of undermining? A. Stage 0 B. Stage I C. Stage II D. Stage III 20. A nurse is caring for a client with impaired mobility. Which position contributes most to the formation of hip flexion contractures? A. Low-fowler B. Orthopneic C. Supine D. Sims 21. A client is diagnosed with a stage IV pressure ulcer with eschar. Which medical treatment should the nurse anticipate the primary health-care provider will prescribe for the client? A. Heath lamp treatment three times a day B. Application of a topical antibioticC. Cleansing irrigation twice daily D. Debridement of the wound 22. A nurse identifies that a client’s pressure ulcer has partial-thickness skin loss involving the epidermis and dermis. Which stage pressure ulcer should the nurse document have based on the assessment? A. Stage I B. Stage II C. Stage III D. Stage IV 23. A nurse places a client in the orthopneic position. Which is the primary reason for the use of this positioning? A. Facilitates breathing B. Supports hip extension C. Prevents pressure ulcers D. Promotes urinary elimination 24. An immobilized bedbound client placed on a 2 hour turning and positioning program. Which should the nurse explain to the client is the primary reason why this program is important? A. Supports comfort B. Promotes elimination C. Maintains skin integrity D. Facilitates respiratory function 25. A nurse is caring for a client with Parkinson’s disease who is experiencing difficulty swallowing. For which major potential problem associated with dysphagia should the nurse assess the client? a. Anorexia b. Aspiration c. Self-care deficit d. Inadequate intake 26. A nurse is caring for a confused client. Which should the nurse do to prevent this client from falling? a. Encourage the client to use the corridor handrails b. Place the client in a room near the nurses’ station c. Reinforce how to use the call bell d. Maintain close supervision 27. A nurse educator is teaching a group of newly hired nursing assistants. Which hospitalized client should they be taught is at the highest risk for injury? a. School-age child b. Comatose teenager c. Postmenopausal woman d. Confused middle-aged man 28. Which is the priority nursing intervention to prevent client problems associated with latex allergies? a. Use nonlatex gloves b. Identify persons at risk c. Keep a latex-safe supple cart available d. Administer an antihistamine prophylactically29. A primary health-care provider prescribes a medication that must be administrated via the intramuscular route. Which site should the nurse eliminate from consideration because it has the highest potential for injury when administering an intramuscular injection? a. Vastus lateralis b. Rectus femoris c. Ventrogluteal d. Dorsogluteal 30. Which information about a parenteral medication indicates that the nurse should use a filtered needle when preparing the medication? a. Has to be reconstituted b. Is supplied in an ample c. Appears cloudy in the vial d. Is to be mixed with another mediation 31. When the nurse brings a pill to a client, the client is unable to hold the paper cup with the medication. Which should the nurse do? a. Use the cup to introduce the pill into the client’s mouth b. Crush the pill and mix it with a small amount of applesauce c. Have the primary health-care provider prescribe the liquid from the drug d. Put the pill into the client’s hand and have the client self-administer the pill 32. A nurse is caring for client with a fever. Which is a well-designed goal for this client? A. “The client will have a lower temperature” B. “The client will be taught how to take an accurate temperature” C. “The client will maintain fluid intake adequate to prevent dehydration” D. “The client will be given aspirin every right hour whenever necessary” 33. Which should the nurse do during the evaluation step of the nursing process? A. Set the time frames for goals B. Revise a plan of care C. Determine priorities D. Establish outcomes 34. A client is admitted to a post operative surgical unit after abdominal surgery. During which step of the nursing process does the nurse determine which actions are required to meet the needs of this client? A. Implementation B. Assessment C. Planning D. Analysis 35. Which information supports the appropriateness to the nursing diagnosis? A. Defining characteristics B. Planned interventions C. Diagnostic statement D. Related risk factors 36. Which is the primary goal of the assessment phase of the nursing process? A. Build trust B. Collect data C. Establish goals D. Validate the medical diagnosis37. Which nursing assessment best indicates a client’s ability to tolerate activity? A. Vital signs that take three minutes to return to pre-activity level B. Absence of adventitious breath sounds on auscultation C. Flexibility of both muscles and joints D. Reports of weakness after activity 38. Which should the nurse do first when an adult who is choking on food becomes unconscious? A. Apply upward thrusts over the client’s xiphoid process B. Initiate cardiopulmonary resuscitation protocol C. Strike the middle of the client’s back firmly D. Perform a blind finger sweep of the mouth 39. A client has thick, tenacious respiratory secretions. Which should the nurse do to liquefy the client’s respiratory secretions? A. Change the client’s position every two hours B. Get a prescription for an antitussive agent C. Encourage the client to drink more fluid D. Teach effective deep breathing