NUR 3737C EXAM 2 LATEST VERSION

pg. 1

NUR 3737C EXAM 2 LATEST VERSION

QUESTIONS AND CORRECT VERIFIED

ANSWERS ALREADY GRADED A+/ NUR

3737C EXAM 2

A nurse is caring for an elderly client who has nearly fallen twice while getting out of bed to go to the bathroom. The nurse has instructed the client not to get up without assistance. The client tells the nurse about feeling a need to get to the bathroom when the urge to void occurs and feeling a need to rush. Which strategy should the nurse utilize to minimize the client's risk of falling?

a) Obtain an order for an indwelling catheter

b) Require that a family member stay with the client

c) Check on the client every 2 hours and offer toileting assistance

d) Obtain an order for restraints to prevent injury - ANSWER-c) Check on the

client every 2 hours and offer toileting assistance

A nurse working the evening shift has five patients and is teamed up with an assistive personnel. One of the assigned patients has just returned from surgery, one is newly admied, and one has requested a pain medication. The patient who has returned from surgery just minutes ago has a large abdominal dressing, is still on oxygen by nasal cannula, and has an intravenous line. One of the other patients has just called out for assistance in seeing up a meal tray. Another patient is stable and resting comfortably. Which patient is the nurse's current greatest priority?

• Patient in pain
• Patient newly admitted 1 / 4

pg. 2

• Patient who returned from surgery
• Patient requesting assistance with meal tray - ANSWER-3. Patient who returned

from surgery

The nurse administers a tube feeding via a patient's nasogastric tube. This is an example of which of the following?

• Physical care technique
• Activity of daily living
• Indirect care measure
• Lifesaving measure - ANSWER-1. Physical care technique

Which principle is most important for a nurse to follow when using a clinical practice guideline for an assigned patient?

• Knowing the source of the guideline
• Reviewing the evidence used to develop the guideline
• Individualizing how to apply the clinical guideline for a patient
• Explaining to a patient the purpose of the guideline - ANSWER-3.

Individualizing how to apply the clinical guideline for a patient

A nurse is visiting a patient who lives alone at home. The nurse is assessing the patient's adherence to medications. While talking with the family caregiver, the nurse learns that the patient has been missing doses. The nurse wants to perform interventions to improve the patient's adherence. Which of the following will affect how this nurse will make clinical decisions about how to implement care for this patient? (Select all that apply.)

• / 4

pg. 3

• Reviewing the family caregiver's availability during medication administration

times

• Determining the value the patient places on taking medications
• Reviewing the number of medications and time each is to be taken
• Determining all consequences associated with the patient missing specific

medicines

• Reviewing the therapeutic actions of the medications - ANSWER-2.

Determining the value the patient places on taking medications

• Determining all consequences associated with the patient missing specific

medicines

The nurse enters a patient's room and finds that the patient was incontinent of liquid stool. Because the patient has recurrent redness in the perineal area, the nurse worries about the risk of the patient developing a pressure injury. The nurse cleanses the patient, inspects the skin, and applies a skin barrier ointment to the perineal area. The nurse consults the ostomy and wound care nurse specialist for recommended skin care measures.Which of the following correctly describe the nurse's actions? (Select all that apply.)

• The application of the skin barrier is a dependent care measure.
• The call to the ostomy and wound care specialist is an indirect care measure.
• The cleansing of the skin is a direct care measure.
• The application of the skin barrier is an instrumental activity of daily living.
• Inspecting the skin is a direct care activity. - ANSWER-2. The call to the

ostomy and wound care specialist is an indirect care measure.

• The cleansing of the skin is a direct care measure.
• / 4

pg. 4 In general, most children are not developmentally or physiologically ready for

toilet training until which age:

1-2 2-3 3-4

4-5 - ANSWER-2-3

The nurse would use which of the following scales to help clients identify the characteristics of their bowel movements?

Morse Fall Scale Norton Scale Braden Scale Bristol Stool Scale - ANSWER-Bristol Stool Scale

A nurse is working with a client who experiences constipation. The nurse recognizes that additional education is needed when the client states the following:

• "I should plan for routine physical activity to help improve my bowel habits."
• "I plan to drink at least 1,500ml of fluids per day to help promote a regular

bowel movement."

• "Fiber is a really important aspect of my diet that I should plan to incorporate

more often."

• "I plan to take my stimulant laxative every day for at least the next 6 months to

make sure it's working." - ANSWER-d) "I plan to take my stimulant laxative every day for at least the next 6 months to make sure it's working."

• / 4