NUR221 ACTUAL EXAM QUESTIONS WITH CORRECT DETAILED ANSWERS || ALREADY GRADED A+ RECENT UPDATE

NUR221 ACTUAL EXAM QUESTIONS WITH CORRECT DETAILED ANSWERS || ALREADY GRADED A+ RECENT UPDATE 1.A patient is preparing for discharge following hip surgery and the patient will likely require extensive physiotherapy. What assessment question should the nurse prioritize? - ANSWER "Are you able to pay for the costs of your physiotherapy treatments?" 2. A nurse is providing care for a patient who has undergone a partial foot amputation for the treatment of osteomyelitis (bone infection). The nurse observes that the patient will not look at her foot when the nurse changes the dressing. How should the nurse best follow up this observation? - ANSWER Gather more data to better understand the patient's behaviour. 3. A nurse is interviewing a new client admitted to the hospital for surgery. Which action would the nurse perform in the introductory phase of the interview? - ANSWER The nurse assesses the client's comfort and ability to participate in the interview. 4. A client who gave birth yesterday refuses to eat the food provided by the hospital. She states that she must eat special food brought from home by her family. How would the nurse most appropriately address this situation? - ANSWER The nurse should plan no action because the client is not exhibiting a health problem. 5. A client who is scheduled for coronary angioplasty is concerned if the surgery is safe and wonders whether it would be beneficial to him. Which nursing diagnosis relates to this client's condition? - ANSWER Fear related to potential risk and surgical outcomes 6. A client with a new colostomy often becomes short and sarcastic when nurses attempt to teach him about the management of his new appliance. The nurse has consequently documented "Noncompliance related hostility" on the client's chart. What mistake has the nurse made when choosing and documenting this nursing diagnosis? - ANSWER presuming to know the factors contributing to the problem 7. A nurse is reviewing the plan of care for a client and notes the following: "The client verbalizes three signs of hypoglycemia to the staff accurately before discharge." The nurse interprets this statement as a(n): - ANSWER outcome criteria 8. A client with multiple leg fractures following a motor vehicle accident tells the nurse, "I am going crazy here. I have to wait 2 months before I can practice walking, again." What is the priority nursing diagnosis? - ANSWER deficient diversional activity 9. A preceptor reviews the client outcomes written by a new nurse. Which outcome is the priority for the client with paranoid delusions? - ANSWER Within 3 days, client will mingle in the day room without violence. 10. c-section - ANSWER birth of a fetus through an incision in the mother's abdomen and uterus can have negative affect on woman self-concept (due to wanting vaginal birth) 11. c-section purpose - ANSWER to persevere the well being of the mother and fetus Incisions are made in lower uterine segment 12. risk factors of c-section - ANSWER -fetal macrosomia -advanced maternal age -increased maternal BMI -gestational diabetes -multifetal pregnancy -dystocia in nulliparous women 13. indications for c-section - ANSWER -specific cardiac diseases -active HPV -nonreassuring fetal status -failure to progress -malpresentation (breech/transverse lie) -cord prolapse -placenta abruption/previa -history of c-section -vertical uterine incision 14. Elective c-section - ANSWER without medical reason reasons -fear of pain -surgery will prevent future problems (myth) offer prenatal education/medications NOT PERFORMED BEFORE 39 weeks 15. Scheduled c-section reasons - ANSWER -labor/vaginal birth are contraindicated (placenta previa) -birth is necessary but labor is not inducible (HTN complications) -chosen by OB/ woman 16. unplanned c-section - ANSWER negative psychosocial outcomes on woman -can experience feelings of anger or guilt 17. surgical techniques of c-section - ANSWER vertical or transverse determined by urgency of surgery, prior incision type. maternal obesity , placenta disorders, need to explore TYPE OF SKIN INCISION DOES NOT INDICATE TYPE OF UTERINE INCISION 18. low transverse - ANSWER Can have vaginal births after 19. Vertical incision indications - ANSWER underdeveloped lower uterine segment -transverse lie presentation -placenta previa/accreta -obstruction of lower uterine segment by leiomyomas NO VAGINAL BIRTHS AFTER MUST ALWAYS HAVE C-SECTIONS 20. maternal complications of c-sections - ANSWER -anesthesia events (intubation/drug reactions/aspirations/pneumonia) -hemorrhage -bowel/bladder injury -amniotic fluid embolism/ air embolism 21. postpartum complications of c-section - ANSWER -atelectasis (aveoli collapse) -endomyometritis -UTI -abdominal wound hematoma -dehiscence -infection -nectrotizing faciitis -thrombembolic disease -bowel dysfunction 22. fetal complications c-section - ANSWER fetus may be born prematurely if gestational age is inaccurate -fetal asphyxia if poor perfusion due to maternal hypotension caused by anesthesia or maternal positioning -fetal injuries (scalpel lacerations) -more likely to require respiratory resuscitation 23. Anesthesia c-sections - ANSWER spinal,epidural, general anesthesia may be used depends on -medical history -spinal injuries/hemorrhage/coagulopathy -time general will be used in emergency if epidural is already in effect 24. intraoperative care c-section - ANSWER taken place in OR -partner can accompany mother in operating room for support IF general anesthesia partner will not be allowed in operating room -care team is present 25. post op care c-section - ANSWER BP/pulse assessed every 15 minutes for 2 hours temp assessed every 4 hours conditions of incisional dressing/ fundus/amount of lochia are assessed -I/O through foley Cath -oxytocin given -assist women to cough dee[-breathe, turn and perform leg exercises -skin to skin -first 24 hours pain relief is provided -position changes/splinting if incision with pillows and relaxation techn 26. nonpharmacologic pain relief after c-section - ANSWER incisional -splint incision using pillows -use relaxation techniques (music/breathing/dim lights) Gas -walk often -do not eat/ drink gas forming foods(soda/milk/ice) -do not use straws -take antiflatulence meds -lie on left side -rock in rocking chair 27. interventions c-section - ANSWER foley Cath should be removed on 1st post day use TED hose/SCD boots as long as woman remains in bed -side lying or football hold positions/ support newborn with pillows to enhance comfort and facilitate breastfeeding Discharge on post op day 3 if not sooner 28. safety alert baby hold - ANSWER woman may become drowsy and fall asleep due to sedation or fatigue -Someone must stay with mom during these times to prevent newborn injury