RNSG 2331 - Exam 2-Capstone-1.
Question:
The nurse makes selections from the hospital menu for a client who is
confused and suspicious of others. Which menu choice is best?
You answered this question Correctly
1. Ham and vegetable casserole
2. Cheese and crackers
3. Caffeine free tea
4. Packaged sugar free Jell-O
•
•
4. Correct: A client who is suspicious of others needs foods that are packaged
and can
see them opened.
1. Incorrect: A client who is suspicious of others needs to be able to identify
the ingredients in the food that is being eaten. A casserole contains many
ingredients and the client may fear that something has been added to the
food.
2. Incorrect: Finger foods are best for clients that are manic.
3. Incorrect: Drinks and foods with no caffeine are okay for the confused and
suspicious client but this menu choice is not the best choice from the list
here.
Question:
Two days after a myocardial infarction, a client begins reporting orthopnea
and dyspnea. Further assessment reveals bi-basilar crackles, jugular venous
distension, an S3 heart sound, a BP of 100/60 mm Hg, and apical pulse of 90
beats per minute. The urine output has steadily declined over the past 12
hours. What should the nurse
do first?
You answered this question Correctly
1. Notify the primary healthcare provider.
2. Increase the IV rate.
3. Elevate the head of the bed.
4. Observe for cardiac arrhythmias.
P a g e 1 | 130
, •
•
3. Correct: Elevate the head of the bed first. The client is reporting inability
to breathe. (Orthopnea means the client needs to sit up to breathe better.)
With ANY
client having difficulty breathing, the first intervention for the nurse is to sit
the client up. This client is showing s/s of heart failure.
1. Incorrect: Your next step is to call the primary healthcare provider
after you do something to try to fix the problem.
2. Incorrect: Increasing the IV rate is contraindicated and would make
the problem worse.
4. Incorrect: After an MI, all clients are observed for cardiac arrhythmias.
This, however, does not fix the problem.
Question:
Which menu selection by the client diagnosed with nephrotic syndrome
indicates that teaching of proper diet was understood?
You answered this question Correctly
1. Pancakes with whipped butter, syrup, bacon, apple juice
2. Scrambled eggs, sliced turkey, biscuit, whole milk
3. Grits, fresh fruit, toast, coffee
4. Bagel with jelly, hash browns, tea
•
•
2. Correct: Client needs low sodium and increased proteins.
1. Incorrect: This selection is too high in sodium and fats.
3. Incorrect: This selection has no protein. Remember, nephrotic
syndrome is the exception to the rule of limiting protein. These clients
need increased protein to compensate for the large loss of protein in
the urine.
4. Incorrect: This selection has no protein. Remember, nephrotic syndrome is
the exception to the rule of limiting protein. These clients need increased
protein to compensate for the large loss of protein in the urine.
Question:
The nurse assesses a multigravida who is four hours postpartum. Findings
include that fundus is firm, 1 centimeter above the umbilicus, and deviated
to the right side. The lochia is moderately heavy and bright red. Which
nursing intervention has priority?
P a g e 2 | 130
,You answered this question Correctly
1. Massage the fundus.
2. Administer intravenous oxytocin.
3. Document these normal findings.
P a g e 3 | 130
, 4. Assist the client up to void.
•
•
4. Correct: These findings are caused by a full bladder, which prevents the
uterus from
contracting down and achieving homeostasis. Once the bladder is empty, the
fundus will contract adequately and return to its normal location at level of
umbilicus or 1 finger breadth below the umbilicus and in the midline. A
distended bladder will displace the uterus, usually to the right.
1. Incorrect: The nurse may check fundus after client voids to ensure that
this fixes the problem.
2. Incorrect: Administering oxytocin is not the first intervention for this issue.
3. Incorrect: These are not normal findings so this would be incorrect
information for the nurse to document.
Question:
What risk factors should the nurse include when conducting a class about
type 2 diabetes mellitus?
You answered this question Correctly
1. Fat distribution greater in abdomen than in hips.
2. Being underweight.
3. Having type 1 diabetes as a child increases risk for type 2 diabetes.
4. Caucasians are more likely to develop type 2 diabetes than Hispanics.
5. Polycystic ovary syndrome.
•
•
1. , & 5. Correct: If the body stores fat primarily in the abdomen, risk of type
2 diabetes is greater than if body stores fat elsewhere, such as hips and
thighs. Women with polycystic ovary syndrome have increased risk of
diabetes.
2. Incorrect: Being overweight is a primary risk factor for type 2 diabetes.
The more fatty tissue, the more resistant cells become to insulin.
3. Incorrect: A type 1 diabetic will remain a type 1 diabetic.
4. Incorrect: Blacks, Hispanics, American Indians, and Asian Americans are
more likely to develop type 2 diabetes than Caucasians are.
Question:
P a g e 4 | 130
Question:
The nurse makes selections from the hospital menu for a client who is
confused and suspicious of others. Which menu choice is best?
You answered this question Correctly
1. Ham and vegetable casserole
2. Cheese and crackers
3. Caffeine free tea
4. Packaged sugar free Jell-O
•
•
4. Correct: A client who is suspicious of others needs foods that are packaged
and can
see them opened.
1. Incorrect: A client who is suspicious of others needs to be able to identify
the ingredients in the food that is being eaten. A casserole contains many
ingredients and the client may fear that something has been added to the
food.
2. Incorrect: Finger foods are best for clients that are manic.
3. Incorrect: Drinks and foods with no caffeine are okay for the confused and
suspicious client but this menu choice is not the best choice from the list
here.
Question:
Two days after a myocardial infarction, a client begins reporting orthopnea
and dyspnea. Further assessment reveals bi-basilar crackles, jugular venous
distension, an S3 heart sound, a BP of 100/60 mm Hg, and apical pulse of 90
beats per minute. The urine output has steadily declined over the past 12
hours. What should the nurse
do first?
You answered this question Correctly
1. Notify the primary healthcare provider.
2. Increase the IV rate.
3. Elevate the head of the bed.
4. Observe for cardiac arrhythmias.
P a g e 1 | 130
, •
•
3. Correct: Elevate the head of the bed first. The client is reporting inability
to breathe. (Orthopnea means the client needs to sit up to breathe better.)
With ANY
client having difficulty breathing, the first intervention for the nurse is to sit
the client up. This client is showing s/s of heart failure.
1. Incorrect: Your next step is to call the primary healthcare provider
after you do something to try to fix the problem.
2. Incorrect: Increasing the IV rate is contraindicated and would make
the problem worse.
4. Incorrect: After an MI, all clients are observed for cardiac arrhythmias.
This, however, does not fix the problem.
Question:
Which menu selection by the client diagnosed with nephrotic syndrome
indicates that teaching of proper diet was understood?
You answered this question Correctly
1. Pancakes with whipped butter, syrup, bacon, apple juice
2. Scrambled eggs, sliced turkey, biscuit, whole milk
3. Grits, fresh fruit, toast, coffee
4. Bagel with jelly, hash browns, tea
•
•
2. Correct: Client needs low sodium and increased proteins.
1. Incorrect: This selection is too high in sodium and fats.
3. Incorrect: This selection has no protein. Remember, nephrotic
syndrome is the exception to the rule of limiting protein. These clients
need increased protein to compensate for the large loss of protein in
the urine.
4. Incorrect: This selection has no protein. Remember, nephrotic syndrome is
the exception to the rule of limiting protein. These clients need increased
protein to compensate for the large loss of protein in the urine.
Question:
The nurse assesses a multigravida who is four hours postpartum. Findings
include that fundus is firm, 1 centimeter above the umbilicus, and deviated
to the right side. The lochia is moderately heavy and bright red. Which
nursing intervention has priority?
P a g e 2 | 130
,You answered this question Correctly
1. Massage the fundus.
2. Administer intravenous oxytocin.
3. Document these normal findings.
P a g e 3 | 130
, 4. Assist the client up to void.
•
•
4. Correct: These findings are caused by a full bladder, which prevents the
uterus from
contracting down and achieving homeostasis. Once the bladder is empty, the
fundus will contract adequately and return to its normal location at level of
umbilicus or 1 finger breadth below the umbilicus and in the midline. A
distended bladder will displace the uterus, usually to the right.
1. Incorrect: The nurse may check fundus after client voids to ensure that
this fixes the problem.
2. Incorrect: Administering oxytocin is not the first intervention for this issue.
3. Incorrect: These are not normal findings so this would be incorrect
information for the nurse to document.
Question:
What risk factors should the nurse include when conducting a class about
type 2 diabetes mellitus?
You answered this question Correctly
1. Fat distribution greater in abdomen than in hips.
2. Being underweight.
3. Having type 1 diabetes as a child increases risk for type 2 diabetes.
4. Caucasians are more likely to develop type 2 diabetes than Hispanics.
5. Polycystic ovary syndrome.
•
•
1. , & 5. Correct: If the body stores fat primarily in the abdomen, risk of type
2 diabetes is greater than if body stores fat elsewhere, such as hips and
thighs. Women with polycystic ovary syndrome have increased risk of
diabetes.
2. Incorrect: Being overweight is a primary risk factor for type 2 diabetes.
The more fatty tissue, the more resistant cells become to insulin.
3. Incorrect: A type 1 diabetic will remain a type 1 diabetic.
4. Incorrect: Blacks, Hispanics, American Indians, and Asian Americans are
more likely to develop type 2 diabetes than Caucasians are.
Question:
P a g e 4 | 130
