Nursing 392-900 Summer Capps Quiz 2 - Adelphi University
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Free Nursing 392-900 Summer Capps Quiz 2 - Adelphi University Questions
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?
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Establish a baseline database
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Identify an emergency
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Establish priorities for care
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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.
Which of the following are represent the Six 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
Correct Answers: (B) Time, (C) Documentation, (D) Dose, (E) Client, (F) Route, (H) Medication
The Six Rights of Medication Administration are a set of safety checks nurses use before giving any medication: right client, right medication, right dose, right time, right route, and right documentation. These six checks help prevent medication errors and ensure client safety throughout the medication administration process.
Why the other options are incorrect:
A. Color Color is not part of the Six Rights framework and is not a safety check used in medication administration.
G. Provider While confirming the prescriber may be relevant to verifying an order, "right provider" is not one of the recognized Six Rights of Medication Administration.
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?
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Encourage active and passive range of motion exercises to lower extremities
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Apply oxygen via nasal cannula
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Contact the provider for discontinuation of IV fluids.
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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.
Nurses' Notes
0900: Mrs. Frost is a 75-year-old female who enjoys living alone in a senior apartment. The home care nurse has been visiting Mrs. Frost once a week since she was discharged from a rehabilitation facility three weeks ago after she had her total right hip replacement. Mrs. Frost is seen by her physical therapist at home twice a week. Her rehabilitation is progressing slowly as she still has pain when walking.
During this visit, the home care nurse notices that Mrs. Frost is confused and drowsy. She cannot recognize the nurse and the time of the day. Her house is cluttered with dirty dishes everywhere. When asked about her pain lately, Mrs. Frost states that the pain is worse when she needs to move around, so that she has been taking more pain medications than what she has been asked to. She also feels short of breath and lightheaded over the past 2 days.
Assessment findings: BP 100/50 mmHg lying and 75/40 mmHg standing with reported dizziness, Pulse 98 bpm, regular, RR 10 breaths/min, shallow and labored, Pulse oximetry reading is 89% on room air, Temp 99.4 F (37.4 C). Skin is warm to touch. The incision on her right hip is almost healed.
Past medical history: Osteoarthritis, Chronic back pain, Congestive Heart Failure (CHF)
Medication history: Furosemide (diuretic) 40 mg PO daily for CHF; Oxycodone Hydrochloride extended release (opioid narcotic analgesic for moderate to severe pain) 10mg PO 1 tablet every 12 hours for pain PRN
The home care nurse identifies that which of the following risk factors may cause the client to fall. Select all that apply.
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Blood pressure
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Types of foods Mrs. Frost eats
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Cluttered house
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Advanced age
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Presence of stairs in the apartment
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Pain medication
Explanation
Correct Answers: (A) Blood pressure, (C) Cluttered house, (D) Advanced age, (F) Pain medication
Mrs. Frost demonstrates a significant orthostatic drop in blood pressure (100/50 lying to 75/40 standing) accompanied by dizziness, placing her at high risk for falls upon standing. Her cluttered house with dirty dishes creates physical obstacles and tripping hazards in her living environment. As a 75-year-old, advanced age is an independent risk factor for falls due to normal physiologic changes affecting balance, vision, and reaction time. Additionally, she has been taking more pain medication (Oxycodone, an opioid) than prescribed, which can cause sedation, confusion, and drowsiness, all of which impair balance and judgment and increase fall risk.
Why Other Options are Incorrect:
B. Types of foods Mrs. Frost eats There is no evidence in the scenario linking her diet to fall risk; nutrition is not identified as a contributing factor here.
E. Presence of stairs in the apartment The scenario does not mention any stairs in Mrs. Frost's senior apartment, so this cannot be identified as a risk factor based on the data given.
The nurse is teaching a newly hired nurse about mixing 2 different insulins in the same syringe. Which of the following statements by the newly hired nurse requires further discussion with the nurse?
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"I can mix a long acting insulin like Glargine with a short acting Regular insulin".
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"A short acting regular insulin and an intermediate insulin like NPH can be mixed in one syringe".
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"Injection sites must be rotated".
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"Draw up the clear insulin before the cloudy insulin".
Explanation
This statement requires further discussion because Glargine (a long-acting insulin) must never be mixed with any other type of insulin in the same syringe. Mixing alters the pH-dependent formulation of Glargine, disrupting its extended release properties and reducing its effectiveness.
Why the other options are incorrect:
B. "A short acting regular insulin and an intermediate insulin like NPH can be mixed in one syringe". This is an accurate statement, as Regular and NPH insulin can safely be mixed in the same syringe.
C. "Injection sites must be rotated". This is a correct and important principle of insulin administration to prevent lipodystrophy and ensure consistent absorption.
D. "Draw up the clear insulin before the cloudy insulin". This is the correct technique when mixing insulins, as it prevents contamination of the clear (short-acting) insulin vial with the cloudy (intermediate-acting) insulin.
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.
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.
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 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?
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None
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One tablet
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One and one half tablet
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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.
A nurse is preparing to assess the client. Which of the following guidelines regarding assessment of clients is most accurate?
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All clients with unstable vital signs need to be assessed hourly, or every two hours if vitals are stable.
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Assessment data needs only to be collected after receiving beginning report and again before giving end of shift report.
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Assessment data need be collected only before provider rounding.
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Assessment data should be collected continuously.
Explanation
Nursing assessment is an ongoing, continuous process throughout the entire course of client care, not limited to specific time points or fixed intervals. Continuous assessment allows the nurse to detect changes in the client's condition promptly and respond appropriately.
Why the other options are incorrect:
A. All clients with unstable vital signs need to be assessed hourly, or every two hours if vitals are stable. This imposes rigid, fixed intervals rather than reflecting the continuous nature of assessment, which should be individualized to client condition.
B. Assessment data needs only to be collected after receiving beginning report and again before giving end of shift report. This limits assessment to only two points in a shift, which is insufficient for safe, ongoing client monitoring.
C. Assessment data need be collected only before provider rounding. This restricts assessment to a single event tied to provider rounding, rather than reflecting the continuous, ongoing nature of nursing assessment.
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