in order to establish an effective Plan of Care, the nurse must obtain data to assist in identifying health and environmental problems. The data...

Question Answered step-by-step 1. in order to establish an effective Plan of Care, the nurse must obtain data to assist in identifying health and environmental problems. The data collected should include information concerning the following: a. The client’s physical and mental statusb. Caregiver/support system, religious and cultural practices and home environmentc. Other service providersd. All of the above 2. Any unexpected changes in client status requiring emergency intervention should be handled in the following manner: a. Notify physicianb. Prevent further injury or deterioration, and call for emergency assistancec. Notify family, as appropriated. None of the above 3. The client is 76-years old, bed bound with a 4-week-oldStage 3 decubitus, and has been receiving daily wound care. At the time of your visit, the client has an oral temperature of 99.2 degrees F, pulse rate is 92, and respiration 26 and shallow with diminished lung sounds in the lower lobes. During the dressing change procedure, you observe a large amount of drainage on the old dressing. The wound bed shows the presence of yellow drainage and emits a slightly pungent odor. The client states, “I’m feeling the same as usual, tired of being in bed so much. The nurses always say that there is a lot of fluid coming from my back and sometimes my daughter needs to put an extra pad there.” After completing the dressing change, what action(s) should you take? a. Document your assessment and treatment on a Visit Note and submit it to the office per usual routine.b. Advise the clienUfamily to call the doctor if drainage comes through the dressing before the next visit.c. Notify the client’s physician and the Clinical Manager of findings.d. Assure the client that she seems to be doing well and that you or another nurse will visit her the next day. 4. The Plan of Care and the physician’s orders for a mentally impaired client direct that the client requires constant supervision. When providing care to the client, the nurse should: a. Never leave the client unattended.b. Only leave the client unattended when he/she is resting/sleeping.c. Allow the client to have privacy when asked.d. Provide the client with a bell, to call you if needed. 5. The physician’s order states that the client should have his Pulse Ox device on at all times. The caregiver/family thinks that it should only be on the client when the nurse is present in the home and has made the decision to remove the Pulse Ox monitor when the nurse leaves. How should the nurse respond to this situation? a. Respect the caregiver/family wishes and follow as directed.b. Notify the physician and educate the caregiver/family about the purpose for using the device.c. Disregard the caregiver/family requests.d. Instruct family to increase nursing staff. 6. You are providing care to a client who is receiving oxygen therapy. The durable medical equipment (DME) company delivered an extra oxygen cylinder. Safe storage should include: a. Keeping the cylinder away from open flames, grease, and other combustible objects.b. Storing the cylinder upright and anchored or laying flat in a ventilated area.c. The proper use of “Oxygen in Use” and “No Smoking” signs.d. All of the above. 7. Your client is an alert and oriented lady who likes to tell stories of her life experiences. At the beginning of your shift, you enter the client’s room and observe that the client has fallen and is lying on the floor. Your initial response should be: a. Check client’s response to verbal stimuli.b. Assist client to original position.c. Remove objects that may cause injury.d. Call 911. 8. The client is an alert woman who is oxygen dependent. The nurse leaves the room to perform other duties for approximately ten minutes. Upon the nurse’s return to the client’s room, she observes that the oxygen mask is displaced, and the client who was previously alert, is now unresponsive and not breathing. The nurse should immediately: a. Contact a family member.b. Call for emergency assistance and perform CPR, if certified.c. Make attempt to reapply the mask and increase the flow of oxygen.d. Notify physician. 9. Your client is an insulin dependent diabetic who administers her own medications. Upon your arrival, the client reports that she feels faint. As you hold her hand, you observe that her skin is hot and dry, her respirations are rapid and deep, and her breath has an acetone odor. What should be your first response? a. Ask the client if she took her insulin as prescribed.b. Offer her a glass of sweetened orange juice.c. Administer insulin as prescribed.d. Call 911. 10. A 75-year old client complains that she is experiencing abdominal pain. You are in the process of changing the client’s incontinence brief and you observe that there is moderate amount of bright red blood on the brief. The appropriate initial response would be to: a. Conduct a complete pain screening.b. Assess source of bleeding and related history, and inform physician.c. Administer prescribed pain medication.d. Change client’s brief and make her comfortable. 11. Chronic emphysema has troubled Mr. G, age 77, for 10 years. He is on oxygen 24 hours a day by nasal cannula. While caring for Mr. G, he suddenly exclaims, “Nurse, I can’t breathe!” The best response is: a. “OK, Mr. G, I’ll turn up the oxygen a little so you can breathe easier.”b. “Mr. G, I’m going to check your heart and lungs, and will call your Dr. to report how you are feeling.”c. “I’m sorry, Mr. G, I can’t turn up the oxygen unless I have your doctor’s written order.”d. “I’m not allowed to touch this oxygen. I’m sorry.” 12. When practicing Standard Precautions, gloves should be worn when: a. Performing wound care.b. Changing an incontinent client.c. Irrigating a urinary catheter.d. All of the above. 13. Mrs. R is home from the hospital after surgery and requires changing of her dressings. During this visit which of the following should be done? a. Discard the dressings in a secured plastic bag.b. Assess Mrs. R for post-surgical complications.c. Check on her bowel and bladder functions.d. All of the above. 14. Which of the following should be documented each shift? a. Any change in client’s condition.b. Outcome of system assessment.c. Client’s response to care, treatment and medications. Example: Pain relief.d. All of the above. 15. Mrs. B, a 44-year-old diabetic is exhibiting signs of tremors, sweating and dizziness. Mrs. B is most likely experiencing:a. Menopausal problemsb. An allergic reactionc. Hypoglycemiad. Shock 16. In the previous situation, what immediate action should be taken to help Mrs. B? a. Tell her to lie down until she feels better.b. Give her fruit juice, soft drinks, or candy.c. Give no sugar to Mrs. Bas she is diabetic; give only “protein foods.”d. Administer insulin injection. 17. All of the following apply to client safety except:a. Make sure that you are treating the correct client.b. Check medications for expiration dates.c. Follow physician’s orders.d. Document percentage of meal eaten by client.18. The client has an indwelling foley catheter and complains of pain in the bladder and urethra. What should be done first?a. Milk the tubing.b. Massage the bladder.c. Irrigate the bladder with normal saline.d. Check the patency of the catheter. 19. Mr. S. has had a CVA with right sided hemiplegia. All of the following should be done except: a. Monitor client’s blood pressure at each visit.b. Follow physician’s order for holding medication.c. Document findings and interventions.d. Use right arm for obtaining blood pressure reading. 20. When caring for the immobilized client, the nurse should utilize the principles of body mechanics by: a. Bending at the waist to provide the power for lifting.b. Placing the feet apart to increase the stability of the body.c. Keeping the body straight when lifting to reduce pressure on the abdomen.d. Relaxing the abdomen and using the extremities to prevent strain. NURSING QUIZ 21. Mr. B has a leg wound post-surgery. The home care nurse discovers at a visit that the old dressing has purulent drainage and there is an odor from the wound. The correct response is to: a. Follow the current treatment plan.·b. Keep the wound open to air and note changes next day.c. Assess client and wound and notify physician of findings.d. Pack wound and monitor healing process.22. An error in documentation has occurred. The appropriate method of correcting the error is to:a. Erase it.b. Use “White Out” and write over the area.c. Draw a single line through the error, sign first initial and last name and date correction is made.d. Completely obliterate the error.23. The client has a leg wound that requires daily treatment. As the nurse is about to perform wound care, the client’s caregiver informs the nurse that she has added the client’s Percocet to some crushed fruit, and requests that the nurse give the prepared mixture to the client. The nurse’s response should be to:a. Respect the family’s wishes, and give the mixture to the client.b. Explain to the client and family that you cannot give any medication mixture that you have not prepared.c. Tell the family that medication should never be crushed and mixed with food.d. Check the physician’s orders to see if a pain medication is ordered.24. In planning a client’s care, the first step in the nursing process is to:a. Call the physician for instructions.b. Obtain suggestions from the client or caregiver.c. Assess the client.d. Write up care plan based on diagnosis.25. The physician has ordered Dilaudid 3 mg IM from a 40 mg/20 ml vial. The correct dose for the nurse to give would be: a. 2ml.b. 1.5 ml.C. 1 ml.d. 1.75 ml. 26. Mrs. Smith receives Coumadin. Her order was changed to 7.5mg every other day alternated with 2.5 mg every other day for 1 week. She has 5 mg tablets available. She should be instructed to take: a. 1&1/2 tablets on Monday, Wednesday, Friday, Sunday and 1/2 tablet on Tuesday, Thursday, Saturday.b. 2 tablets on Monday, Wednesday, Friday, Saturday and none on Tuesday, Thursday, Sunday.c. 1&1/2 tablets on Monday, Tuesday, Wednesday, Thursday and 1/2 tablet on Friday, Saturday, Sunday.d. 1 tablet on Monday, Wednesday, Friday, Sunday and 1&1/2 tablets on Tuesday, Thursday, Saturday. 27. Mr. Tee’s discharge medication order reads: Lanoxin 0.25 mg po daily. His prescription bottle at home contains Lanoxin 0.125 mg. How many tablets should be administered?a. 1/2 tabletb. 1 tabletc. 2 tabletsd. 1 1/2 tablets Health Science Science Nursing NUR NUR-443 Share QuestionEmailCopy link Comments (0)