NUR 3316 Practice Questions: Weeks 1-3

NUR 3316 Practice Questions: Weeks 1-3

By Breanne Wilburn, DNP, RN, CMSRN

​UNFOLDING CASE STUDIES

• recognize cues

• analyze cues

• prioritize hypotheses

• generate solutions

• take action

• evaluate outcomes.

​UNFOLDING CASE STUDIES

• Post-Op Atelectasis: https://umaryland.az1.qualtrics.com/jfe/form/SV_1RAIcNZ0SmsBAlE

• Pressure Injury: https://umaryland.az1.qualtrics.com/jfe/form/SV_aYtAlNRXHHP82dE

​G. P., a 49-yr-old woman, is seen in the primary care clinic for chronic fatigue and disturbed sleep. She is postmenopausal based on self-report. In the past year, since the end of her periods, she has had daily hot flashes and sleep problems. She denies any other health problems. On a usual workday she drinks 2 cups of hot tea in the morning and a can of diet cola in the late afternoon. Currently she is taking OTC diphenhydramine for sleep. Her partner, who has accompanied her to the clinic, states that her snoring has gotten worse, and it is interfering with his sleep.

Subjective Data

• Reports hot flashes and nighttime sweating

• Reports daytime tiredness and fatigue

• States she has trouble getting to sleep and staying asleep

Use the dropdown menu for each nursing action listed below that are Indicated (appropriate or necessary), Contraindicated (could be harmful), or Non-Essential (makes no difference or not necessary) for the patient’s care at this time.

Instruct the patient to take multiple short naps each day: INDICATED/CONTRAINDICATED/NON-ESSENTIAL

Educate the patient to avoid reading in bed: I/C/N

Suggest the patient decrease her caffeine intake: I/C/N 

Teach the patient how to implement relaxation techniques throughout the day: I/C/N

​G. P., a 49-yr-old woman, is seen in the primary care clinic for chronic fatigue and disturbed sleep. She is postmenopausal based on self-report. In the past year, since the end of her periods, she has had daily hot flashes and sleep problems. She denies any other health problems. On a usual workday she drinks 2 cups of hot tea in the morning and a can of diet cola in the late afternoon. Currently she is taking OTC diphenhydramine for sleep. Her partner, who has accompanied her to the clinic, states that her snoring has gotten worse, and it is interfering with his sleep.

Subjective Data

• Reports hot flashes and nighttime sweating

• Reports daytime tiredness and fatigue

• States she has trouble getting to sleep and staying asleep

Use the dropdown menu for each nursing action listed below that are Indicated (appropriate or necessary), Contraindicated (could be harmful), or Non-Essential (makes no difference or not necessary) for the patient’s care at this time.

Instruct the patient to take multiple short naps each day: INDICATED/CONTRAINDICATED/NON-ESSENTIAL

Educate the patient to avoid reading in bed: I/C/N

Suggest the patient decrease her caffeine intake: I/C/N 

Teach the patient how to implement relaxation techniques throughout the day: I/C/N

Multiple Select

The nurse would delegate which nursing intervention to the licensed practical/vocational nurse (LPN/VN)? Select all that apply. One, some, or all responses may be correct.

• Administration of oral medications

• Assisting a stable patient with ambulation

• Assessment of a newly admitted patient

• Reassessing a patient with a blood pressure of 190/104

• Dressing change for a patient with an abdominal wound

RATIONALE

The administration of oral medications and a dressing change for a patient with an abdominal wound are the most appropriate skills to delegate to the LPN/LVN because these are within the scope and standards of practice as defined by the state nursing practice act. The RN can delegate these skills to the LPN/LVN. Assisting a stable patient with ambulation can also be delegated to the LPN/LVN or to a UAP. Nursing interventions that require independent nursing knowledge, skill, or judgement, such as assessment, patient teaching, and planning or evaluation of care cannot be delegated. The assessment of a newly admitted patient is the responsibility of the RN. Reassessment of a patient with a BP of 190/104mmHg requires assessment and evaluation of care and is the responsibility of the RN (Harding et al., (2023)

Multiple Select

Which tasks, if delegated by the registered nurse (RN), are beyond the subordinate’s scope of practice? Select all that apply.

• RN to LPN: administering IV medication to a patient actively seizing

• RN to LPN: administering PO medication to a patient with hypertension

• RN to LPN: initiating a blood transfusion to an elderly patient with chronic anemia

• RN to UAP: reinforcing a draining abdominal dressing following a surgical procedure

• RN to UAP: obtaining and recording VS on a patient on the medical-surgical floor

​RATIONALE

The LPN is only permitted to initiate IV catheters, administer IV piggyback antibiotics, and maintain fluid administration. The LPN is not permitted to administer IV drugs. It is within the LPN scope of practice to administer PO medications to a stable patient with hypertension. The UAP is permitted to obtain and record VS on stable patients. It is not within the LPN scope of practice to initiate blood transfusion. The LPN may obtain VS at the request of the RN, but he or she cannot assess the patient’s toleration of blood products. The UAP should not be directed to reinforce a draining wound, as it is the RN responsibility to assess the outcome. (Harding et al., 2020, p. 9).

​OSA - Extended SATA

A 60-year-old obese male with a history of type 2 diabetes is being seen by the primary health provider to follow up on the results of a polysomnography, which showed that he has obstructive sleep apnea. He is accompanied by his wife who says that her husband snores, stops breathing for several seconds, and then gasps and snorts several times throughout the night. The patient states that he is extremely tired during the day and does not feel rested when he wakes up in the morning. Which patient assessment findings will the nurse expect to assess to support the patient’s diagnosis?

____ A. Patient reports decreased concentration

____ B. Weight loss of 2-3 pounds per week

____ C. Decreased oxygen saturation during the day

____ D. Impotence

____ E. Morning headache

____ F. Wife reports that patient has increased limb movement during sleep

____ G. Loss of skeletal muscle tone during the day

​OSA - Extended SATA

A 60-year-old obese male with a history of type 2 diabetes is being seen by the primary health provider to follow up on the results of a polysomnography, which showed that he has obstructive sleep apnea. He is accompanied by his wife who says that her husband snores, stops breathing for several seconds, and then gasps and snorts several times throughout the night. The patient states that he is extremely tired during the day and does not feel rested when he wakes up in the morning. Which patient assessment findings will the nurse expect to assess to support the patient’s diagnosis?

____ A. Patient reports decreased concentration

____ B. Weight loss of 2-3 pounds per week

____ C. Decreased oxygen saturation during the day

____ D. Impotence

____ E. Morning headache

____ F. Wife reports that patient has increased limb movement during sleep

____ G. Loss of skeletal muscle tone during the day

​RATIONALE

Partial or complete upper airway obstruction during sleep in which there are multiple periods of apnea that last longer than 10 seconds each are characteristics of obstructive sleep apnea (OSA). Loud snoring, followed with a period of apnea that causes hypoxemia and hypercapnia, which then trigger gasping and partial arousal are characteristics of OSA, and can occur hundreds of times each night. Decreased concentration occurs during the day in patients with OSA due to chronic sleep loss. Morning headaches are common in patients with OSA and are due to hypercapnia that occurs during apneic episodes throughout the night. Impotence is another clinical manifestation of OSA. OSA may cause testosterone levels to drop along with the oxygen, both of which can affect the ability to have an erection.

Involuntary limb movement during sleep is a sign of another sleeping disorder: periodic limb movement disorder and is not related to obstructive sleep apnea. Although obesity is a risk factor for OSA there is no relationship between OSA and weight loss. Loss of skeletal muscle tone is a sign of cataplexy, which is a type of narcolepsy (another sleep disorder) in which strong emotions can trigger partial to complete postural collapse and falling. Although oxygen saturation is decreased during apneic episodes while sleeping, oxygen saturation should be within normal limits when the patient is awake unless he has respiratory or cardiac insufficiency.

PREOP - EXTENDED SATA

A client is scheduled for abdominal surgery and has a history of latex allergy. What are priority nursing interventions for this client? Select all that apply

1. Anticipate that the client may have a type II allergic reaction, if exposed to latex.

2. Assess for typical reactions, which include skin redness, urticaria, and rhinitis.

3. Notify the operating room of the client’s latex allergy.

4. Have surgery schedule the client as the last case of the day.

5. Wash hands with mild soap after removing gloves.

6. Verify that the client has a medic alert bracelet.

7. Use nonlatex gloves for all procedures.

8. Anticipate that blood pressure cuffs, stethoscopes, and tourniquets rarely cause a latex allergy.

9. Use an intravenous line without latex ports, preferably use stopcocks, if available.

PREOP - EXTENDED SATA

A client is scheduled for abdominal surgery and has a history of latex allergy. What are priority nursing interventions for this client? Select all that apply

1. Anticipate that the client may have a type II allergic reaction, if exposed to latex.

2. Assess for typical reactions, which include skin redness, urticaria, and rhinitis.

3. Notify the operating room of the client’s latex allergy.

4. Have surgery schedule the client as the last case of the day.

5. Wash hands with mild soap after removing gloves.

6. Verify that the client has a medic alert bracelet.

7. Use nonlatex gloves for all procedures.

8. Anticipate that blood pressure cuffs, stethoscopes, and tourniquets rarely cause a latex allergy.

9. Use an intravenous line without latex ports, preferably use stopcocks, if available.

​RATIONALE

The nurse should notify the operating room that the client has a latex allergy so that preparation for a latex-free environment can be initiated. It is important for the nurse to recognize symptoms of latex allergy—skin rash, hives, flushing, and itching; nasal, eye, and sinus symptoms; asthma; and (rarely) anaphylaxis. The nurse should also be aware of latex-containing products—gloves, blood pressure cuffs, stethoscopes, tourniquets, IV tubing, syringes, electrode pads, oxygen masks, tracheal tubes, colostomy and ileostomy tubes, urinary catheters, anesthetic masks, and adhesive tape. The use of nonlatex gloves and powder-free gloves, along with the elimination of oil-based hand creams or lotions when wearing gloves, can reduce exposure. Always wash hands after removing gloves. Individuals with latex allergy should wear a medic alert bracelet if latex sensitive. The more frequent and prolonged the exposure to latex, the greater the likelihood of developing latex allergy. Use an IV line without latex ports, preferably use stopcocks, if available. If unable to obtain IV tubing without latex ports, cover the port with tape, and note that no medications or fluids should be administered through the port. There are two types of latex allergy: type IV allergic contact dermatitis (delayed reaction) and type I allergy reaction (immediate response). The client should be scheduled as the first case in the morning.

​

(Potter et al., 2021, p.1344-1345)​

Multiple Select

Which strategies would the nurse teach a patient with a history of substance abuse about eliminating the risk of human immunodeficiency virus (HIV) transmission? Select all that apply.

• Always use sterile equipment to inject drugs

• Wear gloves when self-injecting because of potential blood exposure

• You may share thoroughly cleaned equipment to prepare the drugs

• Do not participate in sexual intercourse while under the influence of drugs

• Seek out needle exchange programs to reduce infection risk

​RATIONALE

The major risk for HIV related to using drugs involves sharing equipment or having unsafe sexual experiences while under the influence of drugs. Basic risk reduction rules include not using drugs, not sharing equipment if you do use drugs, and not having sexual intercourse when under the influence of any drug or alcohol that impairs decision-making. The risk of HIV for these individuals can be eliminated if they do not share equipment, even when thoroughly cleaned. Injecting equipment includes needles, syringes, cookers, cotton, and rinse water. Equipment used to snort or smoke drugs can also be contaminated with blood and should not be shared. Access to sterile equipment is an important risk-elimination tactic. Some communities have needle and syringe exchange programs (NSEPs) that provide sterile equipment in exchange for used equipment. Cleaning equipment before use can also reduce risk by decreasing the chance of blood contact. (Harding et al., 2020, p. 224-225)

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Multiple Choice

Which nursing assessment question would be asked to help determine the client's risk for developing malignant hyperthermia in the perioperative period?

• "Have you ever had heat exhaustion or heat stroke?"

• "What is the normal range for your body temperature?"

• "Do you or any of your family member have frequent infections?"

• "Do you or any of your family members have problems with general anesthesia?"

​RATIONALE

​Malignant hyperthermia is a dominantly inherited disorder in which a combination of anesthetic agents (the muscle relaxant succinylcholine and inhalation agents such as halothanes) triggers uncontrolled skeletal muscle contractions that can quickly lead to a potentially fatal hyperthermia. Questioning the client about the family history of general anesthesia problems may revel this as a risk for the client. Options 1, 2, and 3 are unrelated to this surgical complication.

Multiple Select

The registered nurse (RN) collaborates with a licensed practical nurse (LPN) to create a plan of care for a patient with a wound on the bottom of a heel. The RN assigns which functions to the LPN? Select all that apply.

• Create a diet plan to support wound healing.

• Perform sterile dressing changes on the wound.

• Teach the patient about care of the wound at home.

• Develop a plan of care to accelerate wound healing.

• Collect and record data about the wound’s appearance.

​RATIONALE

The role of the LPN is to perform sterile dressing changes and collect and record data about the appearance of the wound. Making a diet plan, developing a plan of care, and teaching the patient require advanced nursing judgement and should be performed by the RN. (Harding et al., 2020, p. 168).

Multiple Choice

A patient is admitted to the postanesthesia care unit (PACU) after bowel surgery and tells the nurse that he or she is going to "throw up." Which statement by the nurse reflects a priority nursing intervention?

• "I need to check your vital signs."

• "Let me help you turn to your side."

• "Here is a sip of ginger ale for you."

• "I can give you some anti-nausea medicine."

​RATIONALE

If the patient is nauseated and may vomit, place the patient in a lateral recovery position to keep the airway open and reduce the risk of aspiration if vomiting occurs. Checking vital signs does not address the nausea. It may not be appropriate to give the patient oral fluids immediately following bowel surgery. Administering an antiemetic may be appropriate after turning the patient to the side. (Harding et al., 2020, p. 340)

Multiple Choice

The nurse assesses a pressure ulcer on a patient’s trochanter. The moist and pink ulcer indicates a partial-thickness loss of skin, and there is no adipose tissue present. Which pressure injury stage will the nurse document in the patient’s medical record?

• Stage I

• Stage II

• Stage III

• Stage IV

​RATIONALE

• Table 11.12 (Harding et al., 2020)

• Lesson 3.1 (Canvas)

  • "Pressure Ulcer NCLEX Questions" (link)

​

Subject | Subject

Some text here about the topic of discussion

Multiple Select

Which educational information would the nurse provide a patient to alleviate urticaria? Select all that apply.

• Practice relaxation techniques

• Plan a stress management program

• Undergo immunotherapy to become symptom-free

• Undergo skin testing, which will help to identify the allergens

• Undergo a six-month drug therapy program to become free of symptoms

​RATIONALE

Urticaria may be aggravated by fatigue and emotional stress. It is therefore necessary for the patient to practice relaxation and create a stress management program. Undergoing a skin test will help to detect the antigen so that one's lifestyle can be planned accordingly. The patient should be informed that immunotherpay or drug therapy will not result in total desensitization. Hence, the patient should initiate preventative measures to control allergies (Harding et al., 2020, p. 196)​

Multiple Choice

Which intervention would the nurse implement first for a patient who develops severe symptoms of an anaphylactic reaction during intradermal skin testing?

• Elevate the legs of the patient.

• Move the patient to a supine position.

• Notify the health care provider.

• Apply a tourniquet above the site of the test.

​RATIONALE

An intradermal skin test is performed on a patient’s arm, so a tourniquet is applied immediately to stop the spread of the allergen from the site and to decrease the severity of the anaphylactic reaction. Elevating the patient’s legs will reduce the risk of hypotension, but it is not the priority intervention to reduce allergy symptoms. A supine position will help keep the airway open if the patient loses consciousness, but placing the patient in supine position is not the priority intervention to reduce severity of allergic reaction. The nurse should notify the health care provider in case of a severe allergic reaction, but only after applying a tourniquet. (Harding et al., 2020, p. 198).

Multiple Choice

A patient is admitted to a health care facility with a respiratory infection suspected to be caused by tuberculosis (TB). Which infection precaution does the nurse initiate?

• Contact precautions

• Droplet precautions until the presence of TB is confirmed

• Airborne precautions

• Standard precautions only, until a diagnosis is made

Multiple Choice

The nurse is educating a patient about ways to decrease the risk of antibiotic-resistant infection. Which instructions should the nurse not include in the teaching? 

• Perform frequent handwashing

• Follow medication directions as prescribed

• Complete the full course of antibiotics

• Request antibiotics for faster resolution of the flu.

​RATIONALE

Handwashing is typically the most important way to prevent any kind of infection, and the caregivers should be encouraged to follow this practice. Antibiotics should not be stopped just because the symptoms have subsided. The antibiotics course should be completed as prescribed. Antibiotics, and all medications, should be taken as directed by the healthcare provider. Not following the instructions or skipping the doses can lead to resistance of the bacteria toward the antibiotic. Antibiotics are not effective against viruses and therefore should not be requested as treatment. (Harding et al., 2020, p. 215)

Multiple Choice

When developing a plan of care for a patient who has had an allergic reaction to a bee sting, which expected outcome would the nurse establish as the priority for this patient?

• Verbalizes comfort at bee sting site.

• Maintains a clear and patent airway.

• Remains free of infection symptomology

• Demonstrates ability to self-administration of epinephrine

​RATIONALE

This patient is at risk for development of an anaphylactic reaction. Maintaining a clear and patent airway is a priority outcome with a patient who has sustained a bee strong and has a known allergy to bees. Comfort and being free of signs and symptoms of infection are important after ensuring airway patency and breathing. Although the demonstration of self-administered epinephrine is likely valuable for the allergic patient, immediately after the bee sting is not the best time to engage in education because a delay in the administration of epinephrine could result (Harding et al., 2020, p. 195).

Multiple Choice

A patient phones the emergency department and says to the triage nurse, "I have a tick stuck to my leg. What should I do?" Which instruction does the nurse give?

• "Bathe the site with a topical lice shampoo immediately"

• "Carefully remove the tick with tweezers and inspect the site."

• "Burn the tick and apply some petroleum jelly to the bite."

• "Make an appointment with your healthcare provider in two days if the tick is still present."

​RATIONALE

As a means of preventing the various diseases caused by tick bites,​ the tick should be carefully removed immediately with tweezers. The longer the tick remains, the greater the chance it will transmit a disease such as Lyme disease or Rocky Mountain spotted fever. Bathing with lice shampoo and burning the tick then applying petroleum jelly are not effective methods of tick removal. After the tick is removed, the site should be assessed for redness, edema, or other signs of infection. If any of the manifestations are present, then the patient should be instructed to contact the healthcare provider. The patient should not wait two days to remove the tick (Harding et al., 2020, p. 1617).

Subject | Subject

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Multiple Select

Which actions will the nurse anticipate taking for a patient who has been working outside on a summer day and now is minimally responsive and has hypotension, body temperature of 106 ^oF (41 ^oC), and dry skin? Select all that apply.

• Administer 100% O2.

• Immerse in a cool bath.

• Administer cooled IV fluids.

• Cover the patient with light blankets.

• Administer an anti-pyretic.

​RATIONALE

The patient data indicate heatstroke. ​Treatment focuses first on stabilizing the patient's airway, breathing, and circulation (ABCs) and rapidly reducing the core temperature. Administration of 100% O2 compensates for the patient's hypermetabolic state. Cooling the body with IV infusions will help to rapidly lower temperature. Immersion in a cool water bath will increase conductive heat loss. The patient will be uncovered to increase heat loss. Antipyretics will not be effective because the increase in temperature is not related to infection or problems with the hypothalamic set point for temperature (Harding et al., 2020, p. 1612-1613).

Subject | Subject

Some text here about the topic of discussion

Multiple Select

Which strategies would the nurse teach a patient with a history of substance abuse about eliminating the risk of human immunodeficiency virus (HIV) transmission? Select all that apply.

• Always use sterile equipment to inject drugs

• Clean equipment used to inject the drugs you use

• Wear gloves when self-injecting because of potential blood exposure

• You may share thoroughly cleaned equipment to prepare the drugs

• Do not participate in sexual intercourse while under the influence of drugs

​RATIONALE

The major risk for HIV related to using drugs involves sharing equipment or having unsafe sexual experiences while under the influence of drugs. Basic risk reduction rules include not using drugs, not sharing equipment if you do use drugs, and not having sexual intercourse when under the influence of any drug or alcohol that impairs decision-making. The risk of HIV for these individuals can be eliminated if they do not share equipment, even when thoroughly cleaned. Injecting equipment includes needles, syringes, cookers, cotton, and rinse water. Equipment used to snort or smoke drugs can also be contaminated with blood and should not be shared. Access to sterile equipment is an important risk-elimination tactic. Some communities have needle and syringe exchange programs (NSEPs) that provide sterile equipment in exchange for used equipment. Cleaning equipment before use can also reduce risk by decreasing the chance of blood contact. (Harding et al., 2020, p. 224-225)

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Multiple Select

A patient is in extreme pain due to a fracture in the leg. The nurse would expect to have which increased sign or symptom as a result of physiologic stress? SELECT ALL THAT APPLY

• Heart rate

• Blood pressure

• Muscle tension

• Respiratory rate

• Skin temperature

​RATIONALE

During any acute stress, such as pain, the body responds by physiologic and psychologic arousal. The SNS gets activate, leading to an increase in parameters like the HR, BP, muscle tension, and RR. The SNS activation is characterized by a decrease in skin temperature. (Harding et al., 2020, p. 79)

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NGN - HIGHLIGHT

The client’s girlfriend states that the client cut his foot while swimming a couple of days ago. The cut went unnoticed until yesterday, when the client’s foot became too painful to walk and began oozing thick, yellowish discharge. Vital signs are temperature of 102.2°F (39°C), heart rate of 124 beats/min, respiratory rate of 26 breaths/min, blood pressure of 82/50 mm Hg. Pain noted as 8 out of 10 for the foot and described as sore and tender. Client is responsive to questions but is lethargic and complains of nausea. The client’s foot is edematous and very warm to touch. Skin is pale and diaphoretic.

Highlight which of the above assessment findings in the nurse’s notes require follow-up by the nurse.

​ANSWER

The client’s girlfriend states that the client cut his foot while swimming a couple of days ago. The cut went unnoticed until yesterday, when the client’s foot became too painful to walk and began oozing thick, yellowish discharge. Vital signs are temperature of 102.2°F (39°C), heart rate of 124 beats/min, respiratory rate of 26 breaths/min, blood pressure of 82/50 mm Hg. Pain noted as 8 out of 10 for the foot and described as sore and tender. Client is responsive to questions but is lethargic and complains of nausea. The client’s foot is edematous and very warm to touch. Skin is pale and diaphoretic.

​RATIONALE

​Sepsis is a life-threatening organ dysfunction resulting from a dysregulated host response to infection. It can begin when a

localized infection triggers a chain reaction throughout the body as infectious organisms enter the bloodstream, this is sepsis—a lifethreatening organ dysfunction resulting from a dysregulated host response to infection. Some clinical findings include temperature of more than 101°F (38.3°C) or less than 96.8°F (36°C), heart rate of more than 90 beats/min, respiratory rate of more than 20 breaths/ min, SBP ,90 mm Hg; MAP ,70 mm Hg, acute oliguria (output ,0.5 mL/kg/h for 2 hours despite adequate fluid resuscitation), abnormal WBC count (.12,000/mm3 or ,4000/mm3 ), normal WBC count with .10% bands, platelet count ,100,000/mm3 , creatinine increase .0.5 mg/dL, INR .1.5 or aPTT .60 seconds, absent bowel sounds, hyperglycemia (plasma glucose .140 mg/dL or 7.7 mmol/L) in the absence of diabetes, total bilirubin .4 mg/dL, edema, and unexplained changes in mental status. It is important for the nurse to understand that the early sepsis intervention, and prevention of severe sepsis and septic shock, are easier to achieve early in the process. If signs and symptoms are not recognized and interventions begun in early sepsis, the condition can progress to septic shock and death.