Assess the bilateral femoral and axillary pulses

NU211/NUR2115 Section 02 Fundamentals of Professional Nursing- Online - 2017 Fall Quarter

Test Nur 2115 Exam 2

Time Elapsed 19 minutes out of 1 hour and 30 minutes

c. The organisms are growing and multiplying.

d. Early signs and symptoms of disease are present, but these are often vague and nonspecific.

b. Ineffective airway clearance ??

c. Anxiety
d. Tachypnea

c. Complete an incident report.

d. Go to employee health services.

flaring and mouth is wide open. How will the nurse document this client's response to activity?

a. Wheezing with activity.

1 out of 1 points

A home care client was recently prescribed continuous oxygen. What client statement indicates further education is needed?

A nurse working on an orthopedic unit is caring for four clients. What client is at greatest risk for skin breakdown?

1 out of 1 points

The nurse is assigned to care for a middle-ages adult woman who
recently had abreast removed due to cancer. While preparing to clean the incision, the patient tells the nurse, "I just can't look at myself like this." What is the best therapeutic response?

c. Ask the client how the interventions is working.

d. Delegate skin assessment to a licensed practical nurse.

d. Decrease susceptibility of the host.

b. Pleural friction rub.

c. Rhonchi.

b. The risk of developing pneumonia
c. The risk of developing a pressure ulcer
d. To assess the level of swallowing.

0 out of 1 points

d. While transporting cerebrospinal fluid specimen to the lab.

d. Using an electric ceiling lift to reposition client every 2 hours.

c. Use an alcohol rub when your hands are visibly soiled.

d. Use hot water to kill the most germs.

b. Client will have oximetry results in the range of 80-85% on room air.

c. Client will demonstrate non-labored breathing at 12-20 breaths per minute within 48 hours
d. Client will tolerate oxygen wearing while maintaining oxygen saturations>100%

1 out of 1 points

The nurse uses critical thinking in the evaluation phase of the nursing process. What is an appropriate nursing intervention upon finding a pressure ulcer that is larger than the previous measurement? (Select all that apply.)

A client suddenly begins to have syncope and dyspnea upon exertion (DOE). What objective data may be found when the nurse performs the focused assessment?

The client's white blood cell count (WBC) is 7,500/mm3. What
interpretation of the laboratory values by the nurse is most accurate? a. Client has a low value and is at risk for infection.

The body transfers heat to an ice pack, causing the ice pack to melt and the clients temperature to be reduced. The nurse knows the decrease in temperature is caused by which process?

a. Radiation
b. Convection
c. Evaporation
d. Conduction

a. Nursing diagnoses identify the plan
b. Nursing diagnoses link to the health care provider’s
recommendations
c. Nursing diagnoses identify actual problems and potential problems d. Nursing diagnoses gather clients’ data and analyze their health status

c. The client’s food intake will likely be decreased as a result of the illness.

d. Nutrition directly affects wound healing and infection prevention.

c. Assess the bilateral femoral and axillary pulses. d. Abdominal shape and symmetry.

0 out of 1 points

A nurse is planning care for an older adult client who is at risk for developing pressure ulcers. What intervention should the nurse use to help maintain the integrity of the client's skin?

What nursing intervention is best for patients with existing pressure ulcers on bilateral heels?

1 out of 1 points

d. Expect minor discomfort after the procedure.

0 out of 1 points

You are caring for a 20 year old client who has an abdominal incision. The surgical wound was closed with 10 sutures. This surgical wound is healing by what process?

1 out of 1 points

A nurse is caring for a client who has methicillin-resistant Staphylococcus aureus (MRSA) in an abdominal wound. The nurse prepares to enter the room to check the client's pulse. What personal protective equipment (PPE) should the nurse don?

What desired outcome is most appropriate for a client with the nursing diagnosis of impaired gas exchange?

e. Why don’t you just swallow the mucous?

 Question 50
1 out of 1 points

A nurse is planning care for an older adult client who is at risk for developing pressure ulcers. What order of intervention should the nurse use to help maintain the integrity of the client's skin after an episode of incontinence? (Choose the correct order)

d. Protective

d. Elevated heart rate.

4. What body systems is not involved in the process of normal gas exchange? a. Cardiovascular system.
b. Pulmonary system.

c. Listen to the top of the anterior chest and then the top of the posterior chest. d. Listen to the chest sounds proceeding from top to bottom and side to side.

6. A nurse is caring for a client who experienced a lacerated spleen with internal bleeding. She has been on bedrest for several days. The nurse auscultates
decreased breath sounds in the lower lobes of both lungs. The nurse should realize that this finding is most likely an indication of what condition.