Chapter 10 NCLEX RN Review3 - Prentice Hall Reviews&...

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Unformatted text preview: 3/21/2011 Prentice Hall Reviews & Rationales: Nursing Fundamentals, 2/e Mary Ann Hogan RN, MSN, Mary Jean Ricci, Carl Ross Chapter 10: NCLEX RN Review PostTest You got 0 out of 10 questions correct 1. A client has been on bed rest with cervical traction for 2 weeks. The traction is discontinued and the client is to ambulate. Prior to getting the client out of bed, it is important for the nurse to take which of the following initial actions? Select all that apply. You answered incorrectly: The correct answers were: Raise the head of the bed slowly; Take the client's blood pressure prior to ambulation Rationale: Orthostatic intolerance or hypotension may occur if the client has been on bed rest. To decrease the problem, gradually elevate the head of the bed to assist the client to a sitting position. Also check the client's blood pressure to ensure that it is stable. Assessing the strength of the leg muscles is not something that would be done directly before getting a client up to ambulate. A cane may or may not be ordered, and there is no information in the question to support the need for a neck brace. Cognitive Level: Application Client Need: Safe, Effective Care Environment: Safety and Infection Control Integrated Process: Nursing Process: Implementation Content Area: Fundamentals Strategy: The critical phrases are bed rest in cervical traction for 2 weeks and ambulate. Recall the major complications of immobility and related nursing actions and use the process of elimination to determine the options that will reduce the client's risk and increase client safety when getting out of bed after prolonged bed rest. Reference: Kozier, B., Erb, G., Berman, A., & Snyder, S. J. (2004). Fundamentals of nursing: Concepts, process, and practice (7th ed.). Upper Saddle River, NJ: Pearson Education, p. 1068. 2. A 76-year-old client is admitted to the hospital. In planning for client teaching, the nurse would assess for which of the following conditions that is often associated with aging and that might interfere with the client's ability to participate in education activities? Select all that apply. You answered incorrectly: The correct answers were: Presbyopia; Presbycusis Rationale: Presbyopia is the inability to focus on close objects; this condition normally accompanies aging. Presbycusis is the hearing loss associated with aging. A conductive hearing loss involves an obstruction in the ear canal. Tinnitus is ringing in the ears. Cognitive Level: Application Client Need: Health Promotion and Maintenance Integrated Process: Nursing Process: Assessment and Analysis Content Area: Fundamentals Strategy: The critical phrase is aging process. Recall sensory deficits that occur with advancing age and use the process of elimination to make a selection. Reference: Kozier, B., Erb, G., Berman, A., & Snyder, S. J. (2004). Fundamentals of nursing: Concepts, process, and practice (7th ed.). Upper Saddle River, NJ: Pearson Education, p. 403. 3. A client who visits the optometrist for an eye exam is told that he has myopia. The client asks the nurse what the treatment will be. The nurse's reply would include information about which of the following standard treatments? You answered incorrectly: The correct answer was: Glasses or contact lenses Rationale: Myopia or nearsightedness is a condition in which light rays come into focus in front of the retina. It is treated with eyeglasses or contact lenses. The statement in option 1, surgical removal, is incorrect because there is no "removal," although the condition could be treated surgically. Eye medication and oral antibiotics are of no use in improving the vision of the client with myopia. Cognitive Level: Application Client Need: Health Promotion and Maintenance Integrated Process: Teaching and Learning Content Area: Fundamentals Strategy: The critical term is myopia. Recall information about common refractory errors to discriminate among the options and make a correct selection. Reference: Kozier, B., Erb, G., Berman, A., & Snyder, S. J. (2004). Fundamentals of nursing: Concepts, process and practice (7th ed.). Upper Saddle River, NJ: Pearson Education, p. 546. 4. The nurse is performing wound care on a pressure ulcer. The doctor orders a wet-to-damp dressing. A family member asks why the dressing is put on wet. The nurse explains that the purpose of this type of dressing is to: You answered incorrectly: The correct answer was: Debride the wound. Rationale: A wet-to-damp dressing debrides the wound. As the dressing partially dries, necrotic debris will adhere to the dressing. When the dressing is removed, dead tissue will be removed also. Although it provides some protection of the wound, that is not its main purpose. A wet-to-wet dressing, not wet-to-damp, would dilute a thickened or viscous exudate. Cognitive Level: Application Client Need: Physiological Integrity: Reduction of Risk Potential Integrated Process: Teaching and Learning Content Area: Fundamentals Strategy: The critical term is wet-to-damp dressing. Recall the uses this type of dressing to select the option that provides accurate information to the client and family. Reference: Kozier, B., Erb, G., Berman, A., & Snyder, S. J. (2004). Fundamentals of nursing: Concepts, process, and practice (7th ed.). Upper Saddle River, NJ: Pearson Education, p. 882. 5. The nurse assesses a wound of a client and finds that a scab has formed. The nurse concludes that this wound is at what point in the phases wound healing? You answered incorrectly: The correct answer was: End of the inflammatory phase Rationale: Near the end of the inflammatory phase of wound healing, protein dries out at the top of the wound, forming a scab. This scab provides safety for the wound because the first line of defense, the skin, is again covered. Options 2 and 4 are later phases of wound healing. Option 3 is not a current term associated with phases of wound healing. Cognitive Level: Application Client Need: Physiological Integrity: Basic Care and Comfort Integrated Process: Nursing Process: Analysis Content Area: Fundamentals Strategy: The critical word in the question is scab. Recall the phases of wound healing and visualize what the wound will look like in each phase to make the correct selection. Reference: Kozier, B., Erb, G., Berman, A., & Snyder, S. J. (2004). Fundamentals of nursing: Concepts, process, and practice (7th ed.). Upper Saddle River, NJ: Pearson Education, p. 860. 6. A client has a large pressure ulcer on his lower extremity. The nurse instructs the client about nutrients needed for healing, especially vitamin C and protein. While evaluating intake, the nurse determines that the instruction was successful after noting that the client is eating which of the following breakfasts? You answered incorrectly: The correct answer was: Milk, scrambled eggs, and cantaloupe Rationale: To promote healing, the client should eat a diet high in protein and vitamin C. The food options in option 2 are highest in these nutrients, with milk and scrambled eggs being higher in protein and cantaloupe having vitamin C. The menus in the other options tend to be higher in fat (foods such as bacon and butter) or low in vitamin C (an absence of any fruit or vegetables). Cognitive Level: Analysis Client Need: Physiological Integrity: Basic Care and Comfort Integrated Process: Nursing Process: Evaluation Content Area: Fundamentals Strategy: The core issue of the question is knowledge of foods that are high in vitamin C and protein for wound healing. Use information related to nutrition and the process of elimination to make a selection. Reference: Kozier, B., Erb, G., Berman, A., & Snyder, S. J. (2004). Fundamentals of nursing: Concepts, process, and practice (7th ed.). Upper Saddle River, NJ: Pearson Education, p. 862. 7. The nurse is using the Braden scale to assess a client's risk for developing a pressure ulcer and calculates a score of 7. The nurse should interpret that this client has which level of risk for development of pressure ulcers? You answered incorrectly: The correct answer was: High risk Rationale: The Braden scale evaluates 6 factors: sensory perception, moisture, activity, mobility, nutrition, and friction/shear. Each factor can receive a score from 1 to 4 except friction/shear, which is scored 1 to 3. Low numbers indicate factors that are likely to contribute to the development of an ulcer. Overall scores above 19 indicate that the client has a low risk of pressure ulcer development. Cognitive Level: Analysis Client Need: Physiological Integrity: Reduction of Risk Potential Integrated Process: Nursing Process: Analysis Content Area: Fundamentals Strategy: The critical words in the question are Braden scale and score of 7. To answer this question correctly, it is necessary to be familiar with common pressure ulcer risk assessment scales (such as the Braden or Norton scales) and recall that lower numbers rather than higher ones place the client at risk. Reference: Kozier, B., Erb, G., Berman, A., & Snyder, S. J. (2004). Fundamentals of nursing: Concepts, process, and practice (7th ed.). Upper Saddle River, NJ: Pearson Education, p. 864. 8. During an exercise session with a client who had vascular surgery to the leg, the nurse dorsiflexes and then plantar flexes the foot. The client looks surprised and asks why the nurse is performing this activity. What should the nurse include in a response? You answered incorrectly: The correct answer was: "Passive range of motion will help maintain muscle tone until you can participate more actively in the exercises." Rationale: Passive range of motion is exercise conducted with the assistance of another individual (option 2), while active range of motion (option 1) is done by the client alone. Options 3 and 4 refer to exercises that involve resistance (option 3) or no resistance (option 4) and do not apply to the current client situation. Cognitive Level: Application Client Need: Physiological Integrity: Basic Care and Comfort Integrated Process: Teaching/Learning Content Area: Fundamentals Strategy: The core issue of the question is knowledge of the rationales and benefits for passive range of motion exercises. Use this knowledge and the process of elimination to make a selection. Reference: Kozier, B., Erb, G., Berman, A., & Snyder, S. J. (2004). Fundamentals of nursing: Concepts, process, and practice (7th ed.). Upper Saddle River, NJ: Pearson Education, p. 1096. 9. Which assessment of the immobilized client would prompt the nurse to take further action? You answered incorrectly: The correct answer was: Absence of bowel sounds Rationale: Absence of bowel sounds is a complication of immobility. It could be followed by constipation and other gastrointestinal problems. Fatigue (option 1) is a complaint that any client may experience in the hospital. Urinary output is within normal range as well as the white blood count (options 2 and 3, respectively). Cognitive Level: Analysis Client Need: Physiological Integrity: Reduction of Risk Potential Integrated Process: Nursing Process: Analysis Content Area: Fundamentals Strategy: The critical words are immobilized client and further action. Recall the major complications of immobility and use the process of elimination to make a selection. Reference: Kozier, B., Erb, G., Berman, A., & Snyder, S. J. (2004). Fundamentals of nursing: Concepts, process, and practice (7th ed.). Upper Saddle River, NJ: Pearson Education, pp. 1070-1071. 10. The nurse is assessing several clients with different types of injuries. The nurse would conclude that the client who is least likely to develop a wound infection would be the client with which of the following? You answered incorrectly: The correct answer was: A contusion Rationale: A contusion is a crushing of the tissues; there is no break in the skin. Therefore, this wound is less likely to become infected. A septic wound is one that has been invaded by pathogenic microorganisms (option 3). Purulent exudate also is an indicator of infection (option 4). A wound healing by second intention is a wound in which there is extensive injury and the edges of the wound are not well approximated. Because of this factor, this type of wound has a risk of infection. Cognitive Level: Analysis Client Need: Physiological Integrity: Reduction of Risk Potential Integrated Process: Nursing Process: Analysis Content Area: Fundamentals Strategy: The critical words in the question are least likely. This tells you that the correct option is one that has the data that is the nearest to normal of the options presented. Use nursing knowledge and the process of elimination to make a selection. Reference: Kozier, B., Erb, G., Berman, A., & Snyder, S. J. (2004). Fundamentals of nursing: Concepts, process, and practice (7th ed.). Upper Saddle River, NJ: Pearson Education, p. 856. ...
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This note was uploaded on 10/03/2011 for the course NURSING nursing taught by Professor Marcus during the Spring '11 term at New York Institute of Technology-Westbury.

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