NUR 1600 PRIORITIZATION EXAM
QUESTIONS WITH CORRECT
ANSWERS
Question 1 | See |full |question
Several |hours |into |a |shift, |a |nurse |on |a |very |busy |medical-surgical |unit |privately |asks |the
|charge |nurse |to |change |her |assignment. |She |is |frustrated |because |she |has |had |to
|devote |so |much |time |and |energy |to |helping |a |newly |licensed |nurse |provide |discharge
|teaching |for |clients |with |diabetes |mellitus. |The |charge |nurse |should:
Correct |response:
• offer |to |assist |with |the |discharge |teaching |needs.
Explanation:
Staff |members |need |to |know |the |charge |nurse |is |a |supportive |leader |who |respects |their
|honesty |and |stands |behind |them. |By |offering |to |help |with |discharge |teaching, |the |charge
|nurse |is |actively |engaging |with |her |staff |at |a |time |of |need. |Changing |all |the |assignments
|on |this |extremely |busy |floor |would |be |counterproductive. |Insisting |that |the |staff |member
|follow |through |with |her |assignment |disrespects |her |request |and |genuine |need. |Providing
|a |float |nurse |could |help, |but |there |are |no |guarantees |a |float |nurse |is |available.
Remediation:
• Discharge
Question 2 | See |full |question
During |chemotherapy, |an |oncology |client |has |a |nursing |diagnosis |of |Impaired |oral
|mucous |membrane |related |to |decreased |nutrition |and |immunosuppression |secondary |to
|the |cytotoxic |effects |of |chemotherapy. |Which |nursing |intervention |is |most |likely |to
|decrease |the |pain |of |stomatitis
Correct |response:
• Providing |a |solution |of |viscous |lidocaine |for |use |as |a |mouth |rinse
Explanation:
To |decrease |the |pain |of |stomatitis, |the |nurse |should |provide |a |solution |of |hydrogen
|viscous |lidocaine |for |the |client |to |use |as |a |mouth |rinse. |(Commercially |prepared
|mouthwashes |contain |alcohol |and |may |cause |dryness |and |irritation |of |the |oral |mucosa.)
|The |nurse |also |may |administer |systemic |analgesics |as |ordered. |Stomatitis |occurs |7 |to |10
|days |after |chemotherapy |begins; |thus, |stopping |chemotherapy |wouldn't |be |helpful |or
,practical. |Instead, |the |nurse |should |stay |alert |for |this |potential |problem |to |ensure |prompt
|treatment. |Monitoring |platelet |and |leukocyte |counts |may |help |prevent |bleeding |and
|infection |but |wouldn't |decrease |pain |in |this |highly |susceptible |client. |Checking |for |signs
|and |symptoms |of |stomatitis |also |wouldn't |decrease |the |pain.
Remediation:
• Impaired |Oral |Membrane
Question 3 | See |full |question
A |nurse |has |been |caring |for |an |adolescent |client |in |a |residential |facility. |The |child |has
|been |through |a |series |of |foster |placements |since |infancy |with |no |success |in |any
|placement |until |the |age |of |7 |when |placed |with |a |middle-aged |single |woman. |The |client
|thrived |there |until |the |woman |was |killed |in |a |car |accident. |The |client |attempted |suicide
|after |her |foster |mother |died |in |response |to |the |loss |and |the |child |was |placed |in |the
|residential |facility. |The |nurse |has |become |close |to |this |client |and |wants |to |help |her
|address |her |issues |and |move |on |with |her |life. |Which |comment |to |the |manager
|demonstrates |that |the |nurse |understands |the |client’s |issues |and |is |able |to |respond
|appropriately |to |the |client’s |needs?
You |Selected:
• "It |is |difficult |for |her |to |love |and |trust |again |after |her |losses. |In |this |facility, |she
|can |learn |to |deal |with |her |loss |in |a |less |emotionally |charged |environment |than |a
|foster |home."
Explanation:
The |severe |emotional |trauma |the |girl |has |experienced |will |likely |make |it |difficult |for |her |to
|be |successful |in |an |adoptive |placement |at |the |present |time, |whether |that |placement |is
|with |someone |she |knows |(the |nurse) |or |another |adoptive |family. |Additionally, |adoption
|by |the |nurse |is |inappropriate |because |it |blurs |the |lines |between |her |professional |and
|personal |life |and |is |likely |to |confuse |the |client. |It |is |clear |that |the |client |has |many |issues
|and |that |love |alone |is |not |likely |to |solve |all |her |problems. |Treatment |at |the |residential
|facility |will |allow |her |to |work |through |emotional |issues |in |a |more |therapeutic
|environment. |Though |not |currently |ready |for |adoption, |she |may |be |ready |for |adoption |in
|the |future |after |sufficient |treatment.
Question 4 | See |full |question
A |client |is |about |to |undergo |cardiac |catheterization |for |which |he |signed |an |informed
|consent. |As |the |nurse |enters |the |room |to |administer |sedation |for |the |procedure, |the
|client |states, |"I'm |really |worried |about |having |this |open |heart |surgery." |Based |on |this
|statement, |how |should |the |nurse |proceed?
Correct |response:
• Withhold |the |medication |and |notify |the |physician |immediately.
Explanation:
,The |nurse |should |withhold |the |medication |and |notify |the |physician |that |the |client |does |not
|understand |the |procedure. |The |physician |then |has |the |obligation |to |explain |the
|procedure |better |to |the |client |and |determine |whether |or |not |the |client |understands. |If |the
|client |does |not |understand, |he |cannot |give |a |true |informed |consent. |If |the |medication |is
|administered |before |the |physician |explains |the |procedure, |the |sedation |may |interfere
|with |the |client's |ability |to |clearly |understand |the |procedure. |The |nurse |may |not |just
|medicate |the |client |and |document |the |finding; |the |physician |must |be |notified. |The
|procedure |does |not |need |to |be |cancelled, |only |postponed |until |the |client |receives |more
|education |and |is |able |to |give |informed |consent.
Remediation:
• Decisional |Conflict
Question 5 | See |full |question
Which |action |associated |with |restraint |use |on |a |confused |client |can |be |delegated |to |an
|unlicensed |healthcare |worker/nursing |assistant?
• Completion |of |range |of |motion |on |limbs |restrained
Question 1 | See |full |question
Four |clients |have |been |admitted |to |the |cardiac |intensive |care |unit |after |experiencing
|acute |myocardial |infarctions. |Each |client |has |sustained |a |percentage |of |cardiac
|damage. |Which |client |is |most |in |need |of |interventions |to |prevent |the |development |of
|cardiogenic |shock?
Correct |response:
• The |client |with |40% |damage
Explanation:
At |least |40% |of |the |heart |muscle |must |be |involved |for |cardiogenic |shock |to |develop. |In
|most |circumstances, |the |heart |can |compensate |for |up |to |25% |damage. |An |infarction
|involving |70% |of |the |heart |would |have |likely |already |caused |cardiogenic |shock.
Question 2 | See |full |question
The |nurse |is |providing |postoperative |care |to |a |client |with |sickle |cell |anemia. |What |is |the
|most |important |intervention |for |the |nurse |to |include |in |the |plan |of |care?
Correct |response:
• Increasing |fluids
Explanation:
The |main |surgical |risk |of |anesthesia |is |hypoxia. |Emotional |stress, |demands |of |wound
|healing, |and |the |potential |for |infection |can |each |increase |the |sickling |phenomenon.
Increased |fluids |are |encouraged |because |hydration |promotes |hemodilution, |and
, decreases |sickling. |Preparing |the |child |psychologically |to |decrease |fear |will |minimize
|undue |emotional |stress, |but |is |not |a |priority. |Deep |coughing |is |encouraged |to |promote
|pulmonary |hygiene |and |prevent |respiratory |tract |infection. |Analgesics |are |used |to
|control |wound |pain |and |to |prevent |abdominal |splinting |and |decreased |ventilation.
Remediation:
A |hospitalized |client, |with |a |productive |cough, |chills, |and |night |sweats |is |suspected |of
|having |active |tuberculosis |(TB). |What |is |the |nurse’s |most |important |intervention?
You |Selected:
• Maintain |the |client |on |respiratory |isolation
Correct |response:
• Maintain |the |client |on |respiratory |isolation
Explanation:
This |client |is |showing |signs |and |symptoms |of |active |TB |and, |because |of |the |productive
|cough, |is |highly |contagious. |He |should |be |admitted |to |the |hospital |and |placed |in
|respiratory |isolation. |Three |sputum |cultures |should |be |obtained |to |confirm |the
|diagnosis.
Question 4 | See |full |question
The |nurse |is |caring |for |a |client |with |type |1 |diabetes |mellitus. |At |3:00 |AM, |the |nurse |finds
|the |client |disoriented |to |time |and |place, |diaphoretic, |and |complaining |of |palpitations.
What |is |the |nurse’s |priority |intervention?
You |Selected:
• Check |blood |glucose |level
Correct |response:
• Check |blood |glucose |level
Explanation:
Check |the |blood |glucose |level |first |when |symptoms |arise, |then |proceed |with |treatment
|according |to |the |results. |If |the |client |is |hypoglycemic, |administration |of |a |simple
|carbohydrate |is |appropriate. |If |the |client |is |conscious, |the |carbohydrate |may |be |given
|orally. |If |consciousness |is |altered, |subcutaneous |or |intramuscular |glucagon |is
|appropriate. |This |client |is |showing |symptoms |of |hypoglycemia, |additional |insulin |would
|further |lower |the |blood |glucose.
Remediation:
• Diabetes |Mellitus |(Type |1), |Long-Term |Care
QUESTIONS WITH CORRECT
ANSWERS
Question 1 | See |full |question
Several |hours |into |a |shift, |a |nurse |on |a |very |busy |medical-surgical |unit |privately |asks |the
|charge |nurse |to |change |her |assignment. |She |is |frustrated |because |she |has |had |to
|devote |so |much |time |and |energy |to |helping |a |newly |licensed |nurse |provide |discharge
|teaching |for |clients |with |diabetes |mellitus. |The |charge |nurse |should:
Correct |response:
• offer |to |assist |with |the |discharge |teaching |needs.
Explanation:
Staff |members |need |to |know |the |charge |nurse |is |a |supportive |leader |who |respects |their
|honesty |and |stands |behind |them. |By |offering |to |help |with |discharge |teaching, |the |charge
|nurse |is |actively |engaging |with |her |staff |at |a |time |of |need. |Changing |all |the |assignments
|on |this |extremely |busy |floor |would |be |counterproductive. |Insisting |that |the |staff |member
|follow |through |with |her |assignment |disrespects |her |request |and |genuine |need. |Providing
|a |float |nurse |could |help, |but |there |are |no |guarantees |a |float |nurse |is |available.
Remediation:
• Discharge
Question 2 | See |full |question
During |chemotherapy, |an |oncology |client |has |a |nursing |diagnosis |of |Impaired |oral
|mucous |membrane |related |to |decreased |nutrition |and |immunosuppression |secondary |to
|the |cytotoxic |effects |of |chemotherapy. |Which |nursing |intervention |is |most |likely |to
|decrease |the |pain |of |stomatitis
Correct |response:
• Providing |a |solution |of |viscous |lidocaine |for |use |as |a |mouth |rinse
Explanation:
To |decrease |the |pain |of |stomatitis, |the |nurse |should |provide |a |solution |of |hydrogen
|viscous |lidocaine |for |the |client |to |use |as |a |mouth |rinse. |(Commercially |prepared
|mouthwashes |contain |alcohol |and |may |cause |dryness |and |irritation |of |the |oral |mucosa.)
|The |nurse |also |may |administer |systemic |analgesics |as |ordered. |Stomatitis |occurs |7 |to |10
|days |after |chemotherapy |begins; |thus, |stopping |chemotherapy |wouldn't |be |helpful |or
,practical. |Instead, |the |nurse |should |stay |alert |for |this |potential |problem |to |ensure |prompt
|treatment. |Monitoring |platelet |and |leukocyte |counts |may |help |prevent |bleeding |and
|infection |but |wouldn't |decrease |pain |in |this |highly |susceptible |client. |Checking |for |signs
|and |symptoms |of |stomatitis |also |wouldn't |decrease |the |pain.
Remediation:
• Impaired |Oral |Membrane
Question 3 | See |full |question
A |nurse |has |been |caring |for |an |adolescent |client |in |a |residential |facility. |The |child |has
|been |through |a |series |of |foster |placements |since |infancy |with |no |success |in |any
|placement |until |the |age |of |7 |when |placed |with |a |middle-aged |single |woman. |The |client
|thrived |there |until |the |woman |was |killed |in |a |car |accident. |The |client |attempted |suicide
|after |her |foster |mother |died |in |response |to |the |loss |and |the |child |was |placed |in |the
|residential |facility. |The |nurse |has |become |close |to |this |client |and |wants |to |help |her
|address |her |issues |and |move |on |with |her |life. |Which |comment |to |the |manager
|demonstrates |that |the |nurse |understands |the |client’s |issues |and |is |able |to |respond
|appropriately |to |the |client’s |needs?
You |Selected:
• "It |is |difficult |for |her |to |love |and |trust |again |after |her |losses. |In |this |facility, |she
|can |learn |to |deal |with |her |loss |in |a |less |emotionally |charged |environment |than |a
|foster |home."
Explanation:
The |severe |emotional |trauma |the |girl |has |experienced |will |likely |make |it |difficult |for |her |to
|be |successful |in |an |adoptive |placement |at |the |present |time, |whether |that |placement |is
|with |someone |she |knows |(the |nurse) |or |another |adoptive |family. |Additionally, |adoption
|by |the |nurse |is |inappropriate |because |it |blurs |the |lines |between |her |professional |and
|personal |life |and |is |likely |to |confuse |the |client. |It |is |clear |that |the |client |has |many |issues
|and |that |love |alone |is |not |likely |to |solve |all |her |problems. |Treatment |at |the |residential
|facility |will |allow |her |to |work |through |emotional |issues |in |a |more |therapeutic
|environment. |Though |not |currently |ready |for |adoption, |she |may |be |ready |for |adoption |in
|the |future |after |sufficient |treatment.
Question 4 | See |full |question
A |client |is |about |to |undergo |cardiac |catheterization |for |which |he |signed |an |informed
|consent. |As |the |nurse |enters |the |room |to |administer |sedation |for |the |procedure, |the
|client |states, |"I'm |really |worried |about |having |this |open |heart |surgery." |Based |on |this
|statement, |how |should |the |nurse |proceed?
Correct |response:
• Withhold |the |medication |and |notify |the |physician |immediately.
Explanation:
,The |nurse |should |withhold |the |medication |and |notify |the |physician |that |the |client |does |not
|understand |the |procedure. |The |physician |then |has |the |obligation |to |explain |the
|procedure |better |to |the |client |and |determine |whether |or |not |the |client |understands. |If |the
|client |does |not |understand, |he |cannot |give |a |true |informed |consent. |If |the |medication |is
|administered |before |the |physician |explains |the |procedure, |the |sedation |may |interfere
|with |the |client's |ability |to |clearly |understand |the |procedure. |The |nurse |may |not |just
|medicate |the |client |and |document |the |finding; |the |physician |must |be |notified. |The
|procedure |does |not |need |to |be |cancelled, |only |postponed |until |the |client |receives |more
|education |and |is |able |to |give |informed |consent.
Remediation:
• Decisional |Conflict
Question 5 | See |full |question
Which |action |associated |with |restraint |use |on |a |confused |client |can |be |delegated |to |an
|unlicensed |healthcare |worker/nursing |assistant?
• Completion |of |range |of |motion |on |limbs |restrained
Question 1 | See |full |question
Four |clients |have |been |admitted |to |the |cardiac |intensive |care |unit |after |experiencing
|acute |myocardial |infarctions. |Each |client |has |sustained |a |percentage |of |cardiac
|damage. |Which |client |is |most |in |need |of |interventions |to |prevent |the |development |of
|cardiogenic |shock?
Correct |response:
• The |client |with |40% |damage
Explanation:
At |least |40% |of |the |heart |muscle |must |be |involved |for |cardiogenic |shock |to |develop. |In
|most |circumstances, |the |heart |can |compensate |for |up |to |25% |damage. |An |infarction
|involving |70% |of |the |heart |would |have |likely |already |caused |cardiogenic |shock.
Question 2 | See |full |question
The |nurse |is |providing |postoperative |care |to |a |client |with |sickle |cell |anemia. |What |is |the
|most |important |intervention |for |the |nurse |to |include |in |the |plan |of |care?
Correct |response:
• Increasing |fluids
Explanation:
The |main |surgical |risk |of |anesthesia |is |hypoxia. |Emotional |stress, |demands |of |wound
|healing, |and |the |potential |for |infection |can |each |increase |the |sickling |phenomenon.
Increased |fluids |are |encouraged |because |hydration |promotes |hemodilution, |and
, decreases |sickling. |Preparing |the |child |psychologically |to |decrease |fear |will |minimize
|undue |emotional |stress, |but |is |not |a |priority. |Deep |coughing |is |encouraged |to |promote
|pulmonary |hygiene |and |prevent |respiratory |tract |infection. |Analgesics |are |used |to
|control |wound |pain |and |to |prevent |abdominal |splinting |and |decreased |ventilation.
Remediation:
A |hospitalized |client, |with |a |productive |cough, |chills, |and |night |sweats |is |suspected |of
|having |active |tuberculosis |(TB). |What |is |the |nurse’s |most |important |intervention?
You |Selected:
• Maintain |the |client |on |respiratory |isolation
Correct |response:
• Maintain |the |client |on |respiratory |isolation
Explanation:
This |client |is |showing |signs |and |symptoms |of |active |TB |and, |because |of |the |productive
|cough, |is |highly |contagious. |He |should |be |admitted |to |the |hospital |and |placed |in
|respiratory |isolation. |Three |sputum |cultures |should |be |obtained |to |confirm |the
|diagnosis.
Question 4 | See |full |question
The |nurse |is |caring |for |a |client |with |type |1 |diabetes |mellitus. |At |3:00 |AM, |the |nurse |finds
|the |client |disoriented |to |time |and |place, |diaphoretic, |and |complaining |of |palpitations.
What |is |the |nurse’s |priority |intervention?
You |Selected:
• Check |blood |glucose |level
Correct |response:
• Check |blood |glucose |level
Explanation:
Check |the |blood |glucose |level |first |when |symptoms |arise, |then |proceed |with |treatment
|according |to |the |results. |If |the |client |is |hypoglycemic, |administration |of |a |simple
|carbohydrate |is |appropriate. |If |the |client |is |conscious, |the |carbohydrate |may |be |given
|orally. |If |consciousness |is |altered, |subcutaneous |or |intramuscular |glucagon |is
|appropriate. |This |client |is |showing |symptoms |of |hypoglycemia, |additional |insulin |would
|further |lower |the |blood |glucose.
Remediation:
• Diabetes |Mellitus |(Type |1), |Long-Term |Care
