NUR2101 Exam 4 Review

NUR 2101 Exam 4 Review

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Question 1

Question 1 - Rationale

Correct Answer

A nurse is caring for a client who was transferred to the surgical unit by the stretcher from the post-anesthesia care unit (PACU). Which of the following actions should the nurse perform immediately following the transfer?

• Check the client’s vital signs
• The greatest risk to this client is an injury from unstable vital signs (ex. Hypotension or respiratory depression) after receiving anesthesia and medication. Therefore, the first action the nurse should take is to check the client’s vital signs and compare them with the readings during the PACU stay.

Question 1 - Rationale

Incorrect Answers

• Administer pain medication
• The nurse should assess the client’s pain and administer medication to relieve pain and promote comfort as needed. However, the nurse should take another action first.
• Instruct the client to use the incentive spirometer every hour
• The nurse should instruct the client about using the incentive spirometer to prevent development of atelectasis. However, there is another action the nurse should take first.
• Provide ice chips as per provider order
• The nurse should provide ice chips to the client as per provider order to promote comfort. However, there is another action the nurse should take first.

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Question 2

Question 2 - Rationale

Correct Answer

A nurse is providing teaching to a client about a surgical procedure that is scheduled for later in the day. The client states that no one has spoken to her about the procedure before.

• Stop the teaching and check with the surgeon about informed consent.
• The client’s statement indicates that she has not given informed consent; therefore, the nurse should interrupt the teaching and notify the surgeon.

Question 2 - Rationale

Incorrect Answers

• Continue the teaching but check afterward with the surgeon about informed consent.
• The client’s statement indicates that she has not given informed consent; therefore, the nurse should interrupt the teaching.
• Stop the teaching and ask the client to sign an informed consent form.
• It is not within the nurse’s scope of practice to obtain informed consent from the client.
• Continue the teaching and check the client’s medical record afterward for a signed consent form.
• The client’s statement indicates that she has not given informed consent; therefore, the nurse should interrupt the teaching.

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Question 3

Question 3 - Rationale

Correct Answers

A nurse is demonstrating postoperative deep breathing and coughing exercises to a client who is scheduled for an emergency surgery.

• The client reports severe pain.
• A client who is experiencing sever pain is not able to concentrate and is not ready to learn a new activity.

Question 3 - Rationale

Incorrect Answers

• The client asks the nurse to repeat the instructions before attempting the exercises.
• By asking the nurse to repeat the instructions, the client is demonstrating a readiness to learn the activity, even though he might not understand the mechanics of performing the activity.
• The client asks the nurse how often deep breathing should be done after surgery.
• Asking about the frequency of the activity indicates a readiness to learn, as the client is motivated to perform the exercises and wants to know how often to do them.
• The client tells the nurse that this exercise will probably be painful after surgery.

• This indicates a readiness to learn because the client is able to think about the possible effects of exercise following surgery.

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Question 4

Question 4 - Rationale

Correct Answer

A nurse is called away for an emergency while talking with a client who is concerned about his medical diagnosis. The nurse returns to the client promptly, as promised.

• Fidelity
• The nurse is demonstrating the ethical principle of fidelity by keeping a promise that was made.

Question 4 - Rationale

Incorrect Answers

A nurse is called away for an emergency while talking with a client who is concerned about his medical diagnosis. The nurse returns to the client promptly, as promised.

• Autonomy
• The ethical principle of autonomy involves ensuring the client has the right to make personal decisions.
• Nonmaleficence
• The ethical principle of nonmaleficence involves doing no harm and preventing harm to the client.
• Justice
• The ethical principle of justice involves treating everyone fairly.

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Question 5

Question 5 - Rationale

Correct Answer

A RN witnessed a car accident and assists the victim, who has a life-threatening injury. Which should the nurse do to meet an essential standard of care when acting as a Good Samaritan at the scene of an accident.

• Stay at the scene until another qualified person takes over responsibility.
• When a nurse renders emergency care, the nurse has an ethical responsibility not to abandon the injured person. The nurse should not leave the scene until the injured person leaves or another qualified person assumes responsibility.

Question 5 - Rationale

Incorrect Answers

• Seek consent from the injured party before rendering assistance.
• Depending on the injured person’s physical and emotional status, the person may or may not be able to provide consent for care.
• Implement every critical care intervention necessary to sustain life.
• When a nurse helps in an emergency, the nurse is required to render care that is consistent with care that any reasonably prudent nurse would provide under similar circumstances. The nurse should not attempt interventions that are beyond the scope of nursing practice.
• Insist on helping because a nurse is the best qualified person to provide care.
• A nurse should offer assistance, not insist on assisting, at the scene of an emergency.

Question 6

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Question 6 - Rationale

Correct Answer

The primary role of the State Board of Nursing is to protect the public.

• Ensure nurses are licensed to practice within the state.
• State boards are tasked with protecting the public and ensure nurses maintain required licensing standards.

Question 6 - Rationale

Incorrect Answers

• Enforce a state’s medical care practice act.
• State boards of nursing enforce their nurse practice acts, not a medical care act, by regulating those who fall under the purview of each state’s act.
• Publish nurse discipline cases for the public to view.
• State boards of nursing have rules and regulations on disciplinary cases that must work in conjunction with the state’s nurse practice act. Disciplinary actions are considered public information, but publishing this information is not essential to protect the public.
• Develop exemptions for non-licensed nurses to practice in the state.
• Nurses must be licensed to practice within their state of practice. Some states grant temporary licensing for new graduate nurses and have procedures in place for emergency credentialing if they need to license nurses quickly. The Nurse Licensure Compact permits nurses to practice in multiple states.

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Question 7

Question 7 - Rationale

Correct Answer

The nurse manager is informed that a large number of clients will be admitted in response to the collapse of a parking deck.

• Authoritarian
• The authoritarian leadership style is the appropriate style to use in a crisis when urgent decisions are necessary. In a crisis one person must assume the responsibility for decisions. Autocratic leaders give orders and directions and make decisions for the group.

Question 7 - Rationale

Incorrect Answers

• Collaborative
• Collaborative refers to the democratic style of leadership. Democratic leaders encourage discussion and decision making within the group, which requires collaboration, coordination, and communication among group members.
• Laissez-faire
• The laissez-faire leadership style is not the appropriate style to use in a crisis when urgent decisions are necessary. Laissez-faire leaders are non-directive and permissive, which allows for self-regulation, creativity, and autonomy but limits fast-acting efficiency.
• Democratic
• The democratic leadership style is not the appropriate style to use in a crisis when urgent decisions are necessary. Democratic leaders encourage discussion and decision making within the group which takes time.

Question 8

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Question 8 - Rationale

Correct Answer

According to Kubler-Ross, a person who is overwhelmingly lonely or sad and withdraws from interaction with others is in which stage of grieving?

• Depression
• A person realizes the full significance of the loss during the depression stage. When depressed, the person feels overwhelmingly lonely or sad and withdraws from interaction with others.

Question 8 - Rationale

Incorrect Answers

According to Kubler-Ross, a person who is overwhelmingly lonely or sad and withdraws from interaction with others is in which stage of grieving?

• Denial
• Individuals in the denial stage act as though nothing has changed. They cannot believe or understand that a loss has occurred.
• Acceptance
• During the stage of acceptance, the individual begins to accept the reality and inevitability of loss and looks to the future.
• Bargaining
• During bargaining the individual postpones awareness of the loss and tries to prevent it from happening by making deals or promises.

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Question 9

Question 9 - Rationale

Correct Answers

What type of grief occurs when an individual can’t openly acknowledge a loss or receive support from others?

• Disenfranchised
• Disenfranchised grief occurs when an individual can’t openly acknowledge a loss or receive social support from others. This type of grieving is difficult for others to understand or can be viewed as insignificant or invalid (ex. early miscarriage)

Question 9 - Rationale

Incorrect Answers

• Normal or uncomplicated
• Consists of commonly expected emotional and behavioral reactions to loss. (resentment, sorrow, anger, crying, loneliness, and temporary withdrawal from activities). Caused by the death of a loved one, through death or ending a relationship.
• Anticipatory
• The process of “letting go” before an actual loss or death has occurred. Defines as grief that is experienced before the loss of someone or something. This kind of grief arises when a loss is expected.
• Complicated (prolonged grief disorder)
• Grief that lasts longer than 6 months and can be so significant that it affects the client’s ability to function. A person has difficulty progressing through the loss experience and may feel strain in relationships and finds it hard to go forward in life.

Question 10

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Question 10 - Rationale

Correct Answers

A nurse is caring for a group of clients in a long-term care facility. The nurse should understand that which of the following clients is eligible for hospice services at this time?

• A client who has end-stage cirrhosis.
• A client who has end-stage cirrhosis likely has a life expectancy of less than 6 months. Therefore, this client is eligible for hospice services.

Question 10 - Rationale

Incorrect Answers

• A client who has multiple sclerosis and uses a wheelchair.
• Although multiple sclerosis is a chronic debilitating disease, the client is not likely to be eligible for hospice service.
• A client who has hemiplegia due to a stroke.
• A client who has hemiplegia due to a stroke might recover partially or fully. Therefore, this client is not likely to be eligible for hospice services.
• A client who has cancer and receives weekly chemotherapy treatments.
• This client is currently undergoing treatment for cancer. Therefore, this client is not likely to be eligible for hospice services.

Question 11

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Question 11 - Rationale

Correct Answers

A nurse is caring for a client who has a terminal illness. Which of the following findings indicates that the client’s death is imminent?

• Cold extremities
• The presence of cold extremities, first in the feet and then in the hands, is a physical change that occurs when a client’s death is imminent.

Question 11 - Rationale

Incorrect Answers

• Urinary retention
• Urinary incontinence is a physical change that occurs when a client’s death is imminent.
• Hypertension
• Hypotension is a physical change that occurs when a client’s death is imminent.
• Tachycardia
• A slow, weak pulse is a physical change that occurs when a client’s death is imminent.