Nursing 392-900 Summer Capps Quiz 2 - Adelphi University
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The nurse formulates the following client outcome: Client will correctly draw up morning dose of insulin and identify four signs and symptoms of hypoglycemia by September 7. Which error has the nurse made?
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Included more than one client behavior in the outcome
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Wrote vague outcomes that will confuse other nurses
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Expressed the client outcomes as a nursing intervention
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Used verbs that are not observable and measurable
Explanation
Correct Answer: (A) Included more than one client behavior in the outcome
A well-written client outcome should focus on only one specific behavior to allow for clear and accurate evaluation. This outcome combines two distinct behaviors — drawing up insulin correctly and identifying signs/symptoms of hypoglycemia — which should be written as two separate outcomes.
Why the other options are incorrect:
B. Wrote vague outcomes that will confuse other nurses The outcome is actually quite specific and clear in what it expects the client to do; the issue is not vagueness.
C. Expressed the client outcomes as a nursing intervention The outcome is correctly written from the client's perspective (what the client will do), not as an action the nurse will perform.
D. Used verbs that are not observable and measurable The verbs "draw up" and "identify" are both observable and measurable actions, so this is not the error present in the outcome.
An adult woman of Chinese ancestry lives in a nursing home. The client refuses to eat at the nursing home stating "I am just not hungry". Which of the following factors would be most appropriate for the nurse to assess for?
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The food served may not be culturally appropriate
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The woman does not eat because she wants to go home
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The food served may violate her religious beliefs
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The client does not like to eat with other people
Explanation
The nurse should assess whether the food served aligns with the client's cultural background and food preferences, as unfamiliar or culturally inappropriate food is a common and appropriate first consideration when an older adult from a different cultural background shows decreased appetite in an institutional setting.
Why Other Options are Incorrect:
B. The woman does not eat because she wants to go home This assumes an emotional motive without assessment data to support it, making it a premature conclusion rather than an appropriate factor to assess first.
C. The food served may violate her religious beliefs While possible, this is a more specific assumption than cultural appropriateness and is not indicated by the information given, which centers on cultural background, not religion.
D. The client does not like to eat with other people This is an assumption unrelated to the client's stated reason or her cultural background and is not supported by the scenario.
Nurses' Notes
1200: Mrs. Jackson is a 78-year-old female who lives in a senior apartment with her cat. She has been recovering from stroke with mild right-sided weakness. She is independent with the use of a walker. Mrs. Jackson is receiving home care services. The home care nurse visits Mrs. Jackson today and notices that she is sitting in a recliner and reluctant to ambulate. When asked why she does not want to walk, Mrs. Jackson said she feels sad lately, and she has a lot of pain around her buttocks and right heel. According to Mrs. Jackson, she has decreased appetite over the past week, and she rarely finishes her meals.
On assessment, the client is dehydrated and emaciated. There is a strong smell of urine. Pressure injuries are noted on the sacrum and right heel. The client rates 6/10 pain on the sacrum and right heel. The home care nurse transfers her to the emergency department. Mrs. Jackson is admitted to the medical unit for further management of pressure injuries.
Past medical history: Peripheral vascular disease (reduced circulation of blood due to narrowing in the blood vessel)
The nurse is planning care for the management of pressure injuries. For each potential nursing intervention, use the Drop Down to specify whether the intervention is indicated or contraindicated for the care of the client. Indicated: An action that the nurse should take to resolve the problem. Contraindicated: An action that could harm the client and should not be taken.
Potential Intervention | Indicated or Contraindicated |
|---|---|
.Clean the wound with normal saline | Indicated |
Keep off sacrum with a donut ring | Contraindicated |
Reposition the client at least every 2 hours side to side | Indicated |
Place the client in a high-Fowler's position | Contraindicated |
Place heel protective pads and float heels | Indicated |
Place a pressure relief mattress | Indicated |
Massage reddened pressure points on the heel | Contraindicated |
Request an analgesics order | Indicated |
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.Clean the wound with normal saline
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Keep off sacrum with a donut ring
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Reposition the client at least every 2 hours side to side
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Place the client in a high-Fowler's position
-
Place heel protective pads and float heels
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Place a pressure relief mattress
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Massage reddened pressure points on the heel
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Request an analgesics order
Explanation
Correct Answers: 1. Indicated, 2. Contraindicated, 3. Indicated, 4. Contraindicated, 5. Indicated, 6. Indicated, 7. Contraindicated, 8. Indicated
Cleaning the wound with normal saline is indicated because it gently removes debris without damaging healthy tissue. Repositioning the client at least every 2 hours side to side is indicated to relieve pressure and prevent further tissue breakdown. Placing heel protective pads and floating heels is indicated to eliminate pressure on the vulnerable heel area entirely. A pressure relief mattress is indicated as it redistributes body weight and reduces pressure on bony prominences. Requesting an analgesic order is indicated since the client rates 6/10 pain, and adequate pain control supports mobility and overall care.
Why the other options are incorrect:
Keep off sacrum with a donut ring Donut-shaped cushions are contraindicated because they actually concentrate pressure around the rim of the device, restricting circulation and increasing the risk of further tissue damage rather than relieving it.
Place the client in a high-Fowler's position This position is contraindicated because it increases shearing force and pressure on the sacrum as the client slides downward in bed, worsening the existing sacral pressure injury.
Massage reddened pressure points on the heel Massaging reddened areas is contraindicated because it can cause further tissue damage and breakdown in skin that is already compromised or at risk, rather than promoting healing.
The nurse assesses the following clients for risk of infection. Which of the following client's is at greatest risk of infection and takes priority:
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44 year old client with chest pain
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87 year old male with skin ulcer
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66 year old client that smokes
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16 year female with a fracture
Explanation
Correct Answer: (B) 87 year old male with skin ulcer
The 87-year-old male with a skin ulcer is at greatest risk for infection because he has two major risk factors: advanced age, which is associated with a weakened immune system, and a break in skin integrity from the ulcer, which serves as a direct entry point for pathogens. This combination places him at the highest priority for infection risk among the clients listed.
Why Other Options are Incorrect:
A. 44 year old client with chest pain Chest pain alone does not indicate a break in skin integrity or immune compromise, making infection risk lower compared to a client with an open skin ulcer.
C. 66 year old client that smokes While smoking can impair respiratory defenses and increase infection risk over time, it does not present the same immediate, direct risk as an open wound in an elderly client.
D. 16 year female with a fracture A fracture without an open wound does not create a direct portal of entry for pathogens, and a younger client typically has a more robust immune response than an elderly client.
The nurse is caring for an obese, immobile client with a Stage 2 sacral pressure ulcer. Which would be considered the highest priority nursing diagnosis?
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Risk for falls related to age and debilitated condition
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Imbalanced nutrition: More than Body Requirements related to immobility
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Knowledge Deficit related to care of skin
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Impaired skin integrity related to presence of Stage 2 pressure ulcer
Explanation
Correct Answer: (D) Impaired skin integrity related to presence of Stage 2 pressure ulcer
Impaired skin integrity is the highest priority because the client already has an existing, actual problem — a Stage 2 pressure ulcer — that requires immediate intervention to prevent further breakdown, infection, and progression to a more severe stage. Actual problems take priority over risk or potential problems.
Why the other options are incorrect:
A. Risk for falls related to age and debilitated condition This is a potential (risk) diagnosis rather than an actual current problem, so it takes lower priority than the existing pressure ulcer.
B. Imbalanced nutrition: More than Body Requirements related to immobility While obesity and nutrition are relevant considerations, they are not the most urgent issue compared to the actual skin breakdown already present.
C. Knowledge Deficit related to care of skin This is an educational need rather than a physiological priority, making it less urgent than the existing impaired skin integrity.
Nurses' Notes
1200: Mrs. Jackson is a 78-year-old female who lives in a senior apartment with her cat. She has been recovering from stroke with mild right-sided weakness. She is independent with the use of a walker. Mrs. Jackson is receiving home care services. The home care nurse visits Mrs. Jackson today and notices that she is sitting in a recliner and reluctant to ambulate. When asked why she does not want to walk, Mrs. Jackson said she feels sad lately, and she has a lot of pain around her buttocks and right heel. According to Mrs. Jackson, she has decreased appetite over the past week, and she rarely finishes her meals.
On assessment, the client is dehydrated and emaciated. There is a strong smell of urine. Pressure injuries are noted on the sacrum and right heel. The client rates 6/10 pain on the sacrum and right heel. The home care nurse transfers her to the emergency department. Mrs. Jackson is admitted to the medical unit for further management of pressure injuries.
Past medical history: Peripheral vascular disease (reduced circulation of blood due to narrowing in the blood vessel)
When observing drainage of a wound, the nurse should assess which of the following? Select all that apply.
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Amount
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Consistency
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Odor
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Color
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Pain
Explanation
Correct Answers: (A) Amount, (B) Consistency, (C) Odor, (D) Color
When assessing wound drainage, the nurse evaluates the amount (scant, moderate, or large), consistency (thin/watery or thick), odor (presence and character of any smell), and color (such as serous, sanguineous, serosanguineous, or purulent). These four characteristics together help the nurse determine the type of drainage and identify signs of infection or healing progress.
Why Other Options are Incorrect:
E. Pain While pain is an important assessment finding related to the wound overall, it is not a characteristic of the drainage itself and is assessed as a separate component of the wound evaluation.
Which two of the following are not representative of the Eleven Rights of Medication Administration.
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Color
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Time
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Documentation
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Dose
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Client
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Route
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Provider
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Medication
Explanation
The Eleven Rights of Medication Administration expand on the traditional rights to include: right client, medication, dose, route, time, documentation, reason, response, to refuse, education, and assessment. Color and Provider are not part of this recognized framework and are not safety checks used in medication administration.
Why Other Options are Incorrect:
B. Time, C. Documentation, D. Dose, E. Client, F. Route, H. Medication These are all core components of the Eleven Rights of Medication Administration and are correctly recognized as part of this safety framework.
A client who is taking an oral opioid for pain relief tells the nurse he is constipated. This common response to opioid is called which of the following?
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Therapeutic effect
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Toxic effect
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Idiosyncratic effect
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Side effect
Explanation
Constipation is a well-known, common, and expected side effect of opioid medications, occurring because opioids slow gastrointestinal motility. It is a predictable, non-therapeutic effect that happens alongside the drug's intended pain-relieving action.
Why the other options are incorrect:
A. Therapeutic effect This refers to the intended, desired effect of a medication, which for an opioid is pain relief, not constipation.
B. Toxic effect A toxic effect results from excessive drug levels in the body and is typically more severe or dangerous, such as respiratory depression, not a common expected symptom like constipation.
C. Idiosyncratic effect This refers to an unusual, unpredictable, and rare reaction to a medication, whereas constipation with opioid use is common and expected.
The nurse educator is teaching students about the use of Nursing Diagnoses. Which of the following reasons for using nursing diagnoses is most appropriate for the nurse to tell the students?
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Nursing diagnoses describes evidence based medical diagnoses
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Nursing diagnoses is not legally accepted as a part of the client's medical record
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Nursing diagnoses provide a common language for nurses to communicate
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Nursing diagnoses helps define the nursing curriculum
Explanation
Correct Answer: (C) Nursing diagnoses provide a common language for nurses to communicate
Nursing diagnoses provide standardized terminology that allows nurses to communicate a client's health status consistently across care settings and among healthcare team members. This common language supports clear documentation, continuity of care, and appropriate care planning based on client responses to health conditions.
Why Other Options are Incorrect:
A. Nursing diagnoses describes evidence based medical diagnoses Nursing diagnoses focus on a client's response to actual or potential health problems, not on medical diagnoses, which identify specific diseases or pathological conditions.
B. Nursing diagnoses is not legally accepted as a part of the client's medical record Nursing diagnoses are, in fact, a legally recognized and required component of the client's medical record and care plan.
D. Nursing diagnoses helps define the nursing curriculum While nursing diagnoses may be taught within nursing curricula, their primary purpose is clinical, not to shape the structure of nursing education programs.
A patient has intravenous fluid running at 250 mL/hr. The patient complains of burning at the IV insertion site. Upon assessment, the nurse finds the IV site is cool, pale and swollen. The nurse suspects which of the following clinical conditions?
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Infection
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Fluid overload
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Pressure Ulcer
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Infiltration
Explanation
Correct Answer: (D) Infiltration
Infiltration occurs when IV fluid leaks into the surrounding tissue instead of the vein, causing the classic signs of coolness, pallor, swelling, and burning or discomfort at the insertion site. This happens when the catheter dislodges from the vein or the vein wall is compromised.
Why the other options are incorrect:
A. Infection Infection at an IV site typically presents with warmth, redness, and purulent drainage, not coolness and pallor.
B. Fluid overload Fluid overload is a systemic condition presenting with symptoms like dyspnea, crackles, and edema, not localized coolness and swelling at the IV site.
C. Pressure Ulcer A pressure ulcer results from prolonged pressure on skin and tissue, which is unrelated to IV fluid administration or the symptoms described.
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