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WorksheetsNUR 111 Final Exam Review A
Total questions: 15
Worksheet time: 11mins
Negative pressure wound therapy (wound vac) is being used to treat a non-healing, chronic wound. What should be included in this client's nursing care plan?
Change the dressing daily.
Empty the canister on the machine once per day.
Measure and record the amount of drainage every shift as output.
Disconnect the wound vac each night between 2200 and 0700.
What intervention should be included in a plan of care to prevent pressure injury development in health care settings?
Do not turn; use pressure-relieving support surface.
Implement a turning schedule every 2 hours.
Change position at least once each shift.
Use donut cushions for heels and elbows.
A nurse is caring for a client who has a right femur fracture that is currently in traction. When the nurse is completing her head to toe assessment on the client, which nursing assessment findings should be reported to the health care provider? Select all that apply.
Numbness and tingling to the right leg
Dorsalis pedis pulses +2 bilaterally
Capillary refill of 4 seconds on the right foot
Edema and coolness to the right calf
Pink color and warmth to the right leg
A nurse is caring for a client who has a surgical incision at the midline abdominal region. After removal of the dressing, the nurse notes drainage from the incision. Which description of wound drainage is indicative of a possible infection?
Purulent
Serous
Sanguinous
Serosanguinous
When a nurse self-reports making a medication error, which professional value is demonstrated?
Human Dignity
Social Justice
Advocacy
Integrity
Which of the following body systems can a nurse assess by the use of palpation?
Heart sounds, lung sounds, blood pressure
Tissue density, gait, reflexes
Vision, hearing, cranial nerves
Temperature, turgor, moisture
The nurse is evaluating client outcomes and discovers there has been no progress toward meeting any of the outcomes for mobility. How should the nurse best respond to this situation?
Replace the client's individualized plan of care with a clinical pathway.
Continue the current plan of care with the hope that the client will achieve the outcomes.
Modify the plan of care to better reflect the client's current functional ability.
Terminate the plan of care since it does not now accurately reflect the client's abilities.
What pertinent information should be shared in a change-of-shift report among nurses?
Medical insurance coverage
Abnormal assessment findings
Preferred religion
Previous nurse's complaints
A father runs into the emergency room with his infant son in his arms. The father screams, "Help, he is not breathing!" The nursing diagnosis of impaired gas exchange is what level of priority diagnosis?
No priority
Low priority
Medium priority
High priority
The nurse pinches the skin under the clavicle and it tents longer than 3 seconds. What conclusion should the nurse determine from this assessment?
The skin has normal turgor.
The skin is less elastic with aging.
The client is dehydrated.
The client is overhydrated.
An adult client has requested a “Do Not Resuscitate” (DNR) order in light of his recent diagnosis with late stage IV lung cancer. The client's son and daughter-in-law are strongly opposed to the client's request. What is the primary responsibility of the nurse in this situation?
Contact a social worker to intervene.
Honor the wishes and requests of the client.
Perform a "slow code" until a decision is made.
Temporarily withhold nursing care.
The nurse is caring for a hospice client with terminal cancer. The client tells the nurse there are unresolved issues of guilt involving a sibling. What is the most therapeutic response by the nurse?
"Don't worry about that. Siblings eventually get over it and leave it in the past."
"I can contact your sister and see if I can convince her that you are sorry."
"That's an easy fix! Just call her up and apologize. Problem solved!"
"You are concerned with an issue with your younger sibling. Tell me more about that."
The nurse noted that a client just received bad news, was crying, and did not want to speak to anyone. What is the correct term for this response to this news?
Defense mechanism
Adaptation
Homeostasis
Coping mechanism
A nurse is cleaning the wound of a client with a gunshot injury. Based upon the nurse's understanding of how to cleanse wounds, which is priority to follow?
Use clean technique when cleansing the gunshot wound.
Clean the wound in a circular pattern, beginning 1 inch from the wound.
Clean wound from top to bottom and from the center of the entry point outward.
After cleaning the wound, pat the wound bed dry using an absorbent bath cloth.
The home health nurse has made a home visit for an 89-year-old client who lives alone. The client is complaining of frequent loose stools. As the nurse documents the data the client reports, what priority nursing diagnosis should be chosen for the care plan?
Imbalanced nutrition: less than body requirements
Pain related to abdominal cramping
Deficient knowledge related to medications
Deficient fluid volume related to elimination alteration
