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WorksheetsNUR 155 Exam 3 Review Questions
Total questions: 37
Worksheet time: 19mins
The nurse recognizes which goal to be appropriate for the patient who is postoperative day one from a hip fracture with the nursing diagnosis Impaired mobility?
Patient will interact with others.
Patient will ambulate to the bathroom with assistance.
Patient will have no skin breakdown.
Patient will have a physical therapy consult.
The nurse knows which description would be classified as a closed wound?
A puncture wound that is healing
A large bruise on the side of the face
An abrasion on the leg
A surgical incision that is sutured closed
The nurse identifies what goal to be the most appropriate goal for a patient with a stage 3 pressure injury who has a nursing diagnosis of impaired skin integrity?
Patient will ambulate twice a day.
Wound will be completely healed in 72 hours.
Wound will show signs of healing within 2 weeks.
Patient will develop no new pressure injuries.
A new nurse is delegating care of a chronic, nonsterile wound to a UAP. What action by the new nurse causes the preceptor to intervene?
The nurse asks the UAP to change the dressing.
The nurse asks the UAP to assess the wound.
The nurse asks the UAP to observe changes in dietary intake.
The nurse asks the UAP to report increased wound drainage.
The nurse recognizes which intervention is not a form of mechanical debridement?
Whirlpool baths
Wet to damp dressing
Wet to dry dressings
Enzymatic dressing
The nurse is explaining the purpose of occlusive dressings to the student nurse. Which statement by the student nurse indicates a lack of understanding?
Occlusive dressings support the most comfortable form of debridement.
Hydrocolloids are a type of occlusive dressing.
Occlusive dressings are used for autolytic debridement.
Occlusive dressings can be used on infected wounds.
The nurse understands which rationale to be appropriate for drying a wound after irrigation?
Prevent infection from irrigate solution.
Prevent skin breakdown from moisture.
Ensure the new dressing adheres to the wound.
Ensure the new dressing remains occlusive.
When discussing stage 3 pressure injuries with the student nurse, which description would the staff nurse include?
A pressure injury that involves exposure of bone and connective tissue
A pressure injury that does not extend through the fascia
A pressure injury that does not include tunneling
A partial-thick wound that involves the epidermis
The nurse identifies which skin layer that delivers the blood supply to the dermis, provides insulation, and has a cushioning effect?
Subcutaneous layer
Stratum corneum
Stratum germinativum
Epidermis
The nurse is providing discharge instructions to an older adult who is being discharged with orthostatic hypotension. Which response by the patient indicates a need for further education?
I should take my blood pressure once a day at home.
I should drink plenty of water during the day.
I should get up slowly and carefully.
I should get up quickly to avoid my blood pressure dropping.
The nurse identifies which goal to be most appropriate for the nursing diagnosis of acute confusion?
The patient will remain within the unit while in long-term care.
The patient will use the call light before getting out of bed within 48 hours.
The patient will respond appropriately to questions about place within 48 hours.
The patient will use a calendar to remember the date within 48 hours.
The nurse recognizes which goal to be appropriate for the patient with a nursing diagnosis of social isolation?
The patient will interact with other residents during activities.
The patient will remain within the unit while in long-term care.
The patient will participate in cognitive exercises.
The patient will communicate basic needs through use of photos.
The nurse is educating the family to care for a patient at home with cognitive alterations. Which statement by the family indicates a need for further education?
24-hour supervision may become necessary.
I should keep the home free of scissors.
I should minimize the number of visitors.
I should use push-button door locks.
A nurse is providing care to a patient. Which of the following statements indicates the nurse is providing appropriate care?
I should keep the noise levels low.
I should keep the room well lit.
I should allow the family to visit.
I should schedule all the care together.
The nurse is providing discharge instructions to a patient with visual alterations. Which statement by the patient indicates a need for further education?
I should make sure the passageways are wide.
I should remove all the throw rugs.
I can use a cane to feel for objects in front of me.
I should keep the lights dim.
The nurse is teaching a patient about the difference between mild anxiety and moderate anxiety. Which statement by the patient indicates a need for further education?
Moderate anxiety will increase my perception.
Mild anxiety can help me remember things.
Mild anxiety will help me be creative.
Moderate anxiety will narrow my focus.
The nurse is assessing level of stress in a patient from another culture. Which question is the most appropriate in helping the nurse understand the impact of the patient’s belief system?
Do you engage in prayer to help you during times of stress?
Do you have certain beliefs that are helpful during times of stress?
Do you go to church or other form of organized worship?
Do you want spiritual counseling while you are here?
The nurse is performing a physical assessment of patient who is undergoing a bone marrow biopsy. What finding by the nurse indicates the patient is experiencing stress?
Respiratory rate of 10 breaths/min
Blood pressure of 120/84
Heart rate of 110 beats/min
Temperature of 99.5 °F (37.5 °C)
The nurse is assessing the patient’s use of coping skills in response to stressful situations. The nurse identifies which question to be the most useful?
Have you been evaluated for stress?
How have you managed stressful situations in the past?
Do you have someone you can go to for help when you are stressed?
Does stress cause you to experience muscle tension or headaches?
The nurse knows which goal to be appropriate for the nursing diagnosis of caregiver stress?
The patient will discuss strategies for coping with relationship violence within 24 hours.
Caregiver will use respite care for the family loved one once a week for the next month.
The caregiver will attend a coping skills class on a weekly basis.
The patient will report an ability to focus on discharge instructions.
The nurse knows that when coordination between multiple health care disciplines is needed, which role should be utilized?
Pastoral care
Dietitian
Case manager
Social worker
The nurse is providing education to a patient around anger management strategies. Which statement indicates a need for further education by the patient?
I can take a time-out.
I can use humor.
“Exercise can help me deal with the anger.”
“I can punch things.”
The nurse is educating the patient about alternative therapies. Which statement by the patient indicates a need for more information?
Alternative therapies can include relaxation techniques.
Alternative therapies can be used when patients are experiencing stress.
Some alternative therapists require certification.
Alternative therapies are used in conjunction with medical therapies.
A client is admitted to the unit with the diagnosis of Deficient Fluid Volume related to excessive fluid loss. Which action related to fluid management should be charged to a nursing assistant?
Administer intravenous (IV) fluids as prescribed by the physician.
Develop a plan for added fluid intake over 24 hours.
Provide straws and offer fluids between meals.
Educate family members to assist the client with fluid intake.
The nurse is caring for a client diagnosed with diabetic ketoacidosis. Which action should you delegate to the nursing assistant? Select all that apply.
Assess for indicators of fluid imbalance.
Review fingerstick glucose results every hour.
Measure vital signs every 15 minutes.
Document intake and output every hour.
The newly hired nurse is assigned by the charge nurse to care for a client with acute renal failure and hypernatremia. Which action can the nurse assign to the nursing assistant? Select all that apply.
Administer 0.45% saline by IV line
Assess daily weights for trends
Check for indications of dehydration
D. Render oral care every 3 to 4 hours
Which nursing action should the charge nurse delegate to an LPN for a client who has frequent watery stool admitted due to dehydration possibly caused by C. difficile?
Giving the ordered metronidazole (Flagyl) 500 mg PO to the client.
Reconsidering the client’s medical history for any risk factors for diarrhea.
Doing ongoing assessments to determine the client’s hydration status.
Explaining the purpose of ordered stool cultures to the client family.
Which of the following nursing actions can a nurse assign to an LPN/LVN for a client with a leg ulcer infected with vancomycin-resistant S. aureus (VRSA)?
Assess risk for further skin breakdown.
Collect wound cultures during dressing changes.
Create methods to improve the client’s oral protein intake.
Educate the client about home care of the leg ulcer.
Which infection control activity should the charge nurse assign to an experienced nursing assistant?
Asking clients about the use of immunosuppressant medications.
Demonstrating correct hand washing to client visitors.
Disinfecting blood pressure cuffs after clients are discharged.
Screening clients for upper respiratory tract symptoms.
Which task is most appropriate to assign to the nursing assistant when an instantaneous death transpires in the ED? Select all that apply
Assisting with postmortem care
Escorting the family to a place of privacy
Going with the organ donor specialist to talk to the family
Helping the family to collect belongings
The nurse finds the patient in cardiopulmonary arrest with no pulse or respirations. Which oxygen delivery device will the nurse use for this patient?
High-flow nasal cannula
Bag-valve-mask unit
Continuous positive airway pressure (CPAP)
Non-rebreather mask
The nurse is caring for a patient who is hospitalized for pneumonia. Which nursing diagnosis has the highest priority?
Impaired airway clearance r/t thick secretions in trachea and bronchi
Impaired nutritional intake r/t poor appetite and increased metabolic needs
Lack of knowledge r/t use of nebulizer and inhaled bronchodilators
Activity intolerance r/t generalized weakness and hypoxemia
The nurse is caring for a patient with severe COPD who is becoming increasingly confused and disoriented. What is the priority action of the nurse?
Administer a mild sedative and reorient the patient as needed.
Increase the patient’s oxygen until the pulse oximetry is greater than 98%.
Obtain an arterial blood gas to check for carbon dioxide retention.
Lower the head of the patient’s bed and insert a nasal airway.
The nurse is caring for a patient who has been prescribed warfarin (Coumadin) therapy after being diagnosed with atrial fibrillation. The patient asks the nurse what could happen if the prescription doesn’t get filled. What is the nurse’s best response?
You could go into respiratory failure.
You could develop heart failure.
You could have a stroke.
Your kidneys could fail.
The nurse identifies which patient who would benefit from postural drainage?
A patient with a heart murmur and jugular venous distention.
A patient with right-sided heart failure and pitting edema.
A patient with asthma and audible wheezing.
A patient with chronic bronchitis and congested cough.
The home care nurse is caring for a patient who has severe COPD and home oxygen therapy. The patient tells the nurse that she feels much better after increasing the oxygen flowmeter from 2 L to 5 L/min. The patient’s pulse oximetry is 98%. What is the priority action of the nurse?
Reduce the oxygen flow rate until the patient’s pulse oximetry value is more than 88%.
Inform the patient’s physician and obtain an order for oxygen at 5 L/min.
Document the intervention and findings in the patient’s medical record.
Listen to the patient’s lung fields and reinforce pursed-lip breathing techniques.
The nurse is caring for a patient with a history of left-sided congestive heart failure who is acutely short of breath. The nurse hears fine crackles throughout both lung fields and notes that the patient’s pulse oximetry is only 88% on 4 L of oxygen. What is the priority intervention of the nurse?
Have the patient use the ordered incentive spirometer.
Administer the ordered intravenous diuretic.
Prepare for insertion of a chest tube.
Suction secretions from the patient’s respiratory tract.
