Nursing 392-900 Summer Capps Quiz 2 - Adelphi University
Access The Exact Questions for Nursing 392-900 Summer Capps Quiz 2 - Adelphi University
💯 100% Pass Rate guaranteed
🗓️ Unlock for 1 Month
Rated 4.8/5 from over 1000+ reviews
- Unlimited Exact Practice Test Questions
- Trusted By 200 Million Students and Professors
What’s Included:
- Unlock Actual Exam Questions and Answers for Nursing 392-900 Summer Capps Quiz 2 - Adelphi University on monthly basis
- Well-structured questions covering all topics, accompanied by organized images.
- Learn from mistakes with detailed answer explanations.
- Easy To understand explanations for all students.
Ace Your Test with Nursing 392-900 Summer Capps Quiz 2 - Adelphi University Actual Questions and Solutions - Full Set
Free Nursing 392-900 Summer Capps Quiz 2 - Adelphi University Questions
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.
-
Amount
-
Consistency
-
Odor
-
Color
-
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.
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?
-
Infection
-
Fluid overload
-
Pressure Ulcer
-
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.
The nurse is developing a plan of care for a client on bed rest. To promote venous return, the nurse performs which of the following?
-
Encourage active and passive range of motion exercises to lower extremities
-
Apply oxygen via nasal cannula
-
Contact the provider for discontinuation of IV fluids.
-
Position client on his left side
Explanation
Correct Answer: (A) Encourage active and passive range of motion exercises to lower extremities
Active and passive range of motion exercises promote venous return by activating the calf muscle pump, which helps propel blood back toward the heart and prevents venous stasis in clients who are immobile or on bed rest. This intervention reduces the risk of complications such as deep vein thrombosis.
Why the other options are incorrect:
B. Apply oxygen via nasal cannula This addresses oxygenation, not venous return, and is unrelated to promoting circulation in the lower extremities.
C. Contact the provider for discontinuation of IV fluids. Discontinuing IV fluids has no direct effect on promoting venous return in the lower extremities.
D. Position client on his left side Left side positioning is typically used for other purposes, such as during pregnancy to relieve vena cava compression, not specifically to promote venous return in a general bed rest client.
The nurse is caring for a 32 year old male client on the surgical trauma unit who has suffered injuries from a motor vehicle accident. The patient's hemoglobin and hematocrit was drawn, and resulted at 6.8 g/dL & 20.3% respectively (Normal Range for Hemoglobin-14-16.5 g/dL and Normal Range for Hematocrit-42%-52%). Baseline vital signs were within normal limits prior to the transfusion.
Following 1L of intravenous fluid infusion, the provider has ordered 1 unit of Packed Red Blood Cells to be transfused. The nurse initiated the transfusion 15 minutes prior, and now the patient is complaining of itching. The client states, "I can't stop scratching my arms!"
Vital signs are as follows presently: HR 103 bpm, BP 102/68, RR 16, SpO2 100% on room air, Temp 36.7 C (98F). Upon assessment, the client is breathing comfortably, and lungs are clear to auscultation bilaterally. The nurse notes small red hives on the chest and upper arms, and the skin is warm to touch. Skin turgor is within normal limits and capillary refill is < 2 seconds.
Complete the following sentence by choosing from the list of options.
The nurse determines the client is experiencing 1. [Select answer choice] as evidenced by 2. [Select answer choice].
Select answer choice:
- Circulatory overload
- Allergic transfusion reaction
- Hemolytic transfusion reaction
- Bacterial infection
Select answer choice:
- Red hives on chest and upper arms
- Temperature 36.7 C
- Respiratory assessment findings
- Hgb 6.8 g/dL and Hct 20.3%
-
Circulatory overload
-
Allergic transfusion reaction
-
Hemolytic transfusion reaction
-
Bacterial infection
-
Red hives on chest and upper arms
-
Temperature 36.7 C
-
Respiratory assessment findings
-
Hgb 6.8 g/dL and Hct 20.3%
Explanation
Correct Answers: 1. (Allergic transfusion reaction) 2. (Red hives on chest and upper arms)
The client is experiencing an allergic transfusion reaction, as evidenced by the sudden onset of itching and small red hives on the chest and upper arms shortly after the transfusion began. Allergic reactions to blood products are typically mild and present with urticaria (hives) and pruritus (itching), while the client otherwise remains hemodynamically stable — breathing comfortably, lungs clear bilaterally, normal oxygen saturation, and a near-normal temperature.
Why the other options are incorrect:
Circulatory overload This would present with signs of fluid overload such as dyspnea, crackles, or elevated blood pressure, none of which are present; the client's respiratory assessment is clear and unlabored.
Hemolytic transfusion reaction This is a serious reaction typically presenting with fever, chills, back pain, and hemodynamic instability, none of which match this client's stable vital signs and localized hives.
Bacterial infection This would typically present with fever and signs of sepsis, but the client's temperature is normal (36.7 C) and there are no systemic infection signs.
Temperature 36.7 C This is a normal temperature and does not support any transfusion reaction, ruling it out as supporting evidence.
Respiratory assessment findings The client's lungs are clear and breathing is comfortable, so this finding does not support any reaction requiring intervention.
Hgb 6.8 g/dL and Hct 20.3% These are the client's baseline pre-transfusion lab values indicating anemia (the reason for transfusion), not evidence of a transfusion reaction.
A peripherally inserted central catheter (PICC) is being inserted. To prevent a central line associated bacteremia (CLABS), which solution should be used to prep the skin?
-
Chlorhexidine
-
Betadine
-
Dakin's Solution
-
Alcohol
Explanation
Correct Answer: (A) Chlorhexidine
Chlorhexidine is the preferred skin antiseptic for central line insertion because it provides broad-spectrum, rapid, and long-lasting antimicrobial activity, significantly reducing the risk of central line-associated bloodstream infections (CLABSI) compared to other antiseptic solutions.
Why the other options are incorrect:
B. Betadine While betadine (povidone-iodine) is an effective antiseptic, it has a slower onset of action and shorter residual antimicrobial effect compared to chlorhexidine, making it a less preferred choice for central line insertion.
C. Dakin's Solution Dakin's solution is primarily used for wound irrigation and debridement, not for skin antisepsis prior to central line insertion.
D. Alcohol Alcohol evaporates quickly and lacks the sustained antimicrobial residual effect needed to prevent CLABSI during central line insertion.
The nurse is conducting the initial assessment on a newly admitted client. Which of the following statements best describes the purpose of the initial assessment?
-
Establish a baseline database
-
Identify an emergency
-
Establish priorities for care
-
Gathers data about a specific problem
Explanation
The purpose of the initial assessment is to establish a comprehensive baseline database of the client's health status upon admission. This baseline serves as a reference point for evaluating the client's progress and detecting future changes in condition throughout their care.
Why the other options are incorrect:
B. Identify an emergency This describes the purpose of an emergency assessment, which is focused on rapidly identifying life-threatening conditions, not a comprehensive initial assessment.
C. Establish priorities for care This describes the purpose of a problem-focused or ongoing assessment, which builds on the baseline data to prioritize specific client needs.
D. Gathers data about a specific problem This describes a focused assessment, which targets a particular issue rather than establishing an overall baseline of the client's health.
The nurse is caring for a patient who will be receiving parenteral nutrition. Which of the following actions should the nurse take to reduce the risk of developing sepsis?
-
Wears clean gloves when changing the central line dressing.
-
Takes down a running bag of TPN after 36 hours.
-
Wears a surgical mask when changing the central line dressing.
-
Runs the lipids for no longer than 24 hours.
Explanation
Correct Answer: (D) Runs the lipids for no longer than 24 hours
Lipid emulsions support rapid bacterial and fungal growth, so infusion should be limited to no longer than 24 hours to reduce the risk of catheter-related bloodstream infection and sepsis. Adhering to this time limit is a key infection control measure specific to parenteral nutrition administration.
Why the other options are incorrect:
A. Wears clean gloves when changing the central line dressing. Central line dressing changes require sterile technique, not clean gloves, to prevent introducing pathogens into the bloodstream through the catheter site.
B. Takes down a running bag of TPN after 36 hours. TPN bags should be changed every 24 hours, not 36 hours, since prolonged hang time increases the risk of microbial contamination and growth.
C. Wears a surgical mask when changing the central line dressing. While a mask may be used, sterile technique with sterile gloves is the critical infection control measure for central line dressing changes, not simply wearing a mask.
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?
-
Therapeutic effect
-
Toxic effect
-
Idiosyncratic effect
-
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.
A nurse is caring for a client with the following provider's order: Acetaminophen 650 mg orally, prn temperature greater than 101 F (38.3C) The client's temperature at 1600 is 100.2F (37.8) orally. Acetaminophen comes in 325 mg each tablet. At 1600, how many tablets will the nurse administer?
-
None
-
One tablet
-
One and one half tablet
-
Two tablets
Explanation
The provider's order specifies that acetaminophen should only be administered if the client's temperature exceeds 101°F (38.3°C). Since the client's current temperature is 100.2°F (37.8°C), which is below the threshold specified in the order, the nurse should not administer the medication at this time.
Why Other Options are Incorrect:
B. One tablet This would provide 325 mg, but medication administration is not indicated at all since the temperature does not meet the criteria for administration.
C. One and one half tablet This dose is not applicable since the medication should not be given based on the current temperature.
D. Two tablets This would provide the full 650 mg ordered dose, but again, administration is not warranted since the temperature criterion has not been met.
The nurse is caring for a client with a nursing diagnosis of Fluid Volume Excess. Which of the following assessments is most accurate to assess fluid balance?
-
Pain level
-
Daily weights
-
Skin assessment
-
Functional status
Explanation
Correct Answer: (B) Daily weights
Daily weights are the most accurate and reliable indicator of fluid balance in a client with Fluid Volume Excess. Body weight changes correlate directly with fluid gains or losses, since 1 kilogram (2.2 lbs) of weight change equals approximately 1 liter of fluid. Weights should be taken at the same time each day, using the same scale, and with the client wearing similar clothing to ensure accuracy.
Why Other Options are Incorrect:
A. Pain level Pain is not a reliable or direct indicator of fluid status and is more relevant to other nursing diagnoses unrelated to fluid balance.
C. Skin assessment While skin turgor and edema can suggest fluid imbalance, these findings are subjective and less precise than measurable daily weights, making them a supportive rather than primary assessment.
D. Functional status Functional status reflects a client's ability to perform activities of daily living and does not provide direct or quantifiable data about fluid volume changes.
How to Order
Select Your Exam
Click on your desired exam to open its dedicated page with resources like practice questions, flashcards, and study guides.Choose what to focus on, Your selected exam is saved for quick access Once you log in.
Subscribe
Hit the Subscribe button on the platform. With your subscription, you will enjoy unlimited access to all practice questions and resources for a full 1-month period. After the month has elapsed, you can choose to resubscribe to continue benefiting from our comprehensive exam preparation tools and resources.
Pay and unlock the practice Questions
Once your payment is processed, you’ll immediately unlock access to all practice questions tailored to your selected exam for 1 month .