NUR 105 quiz 7 | QUESTIONS AND ANSWERS 2020/2021

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NUR 105 quiz 7. • Question 1 0 out of 5 points Which assessment finding should the RN report to the health care provider? • Question 2 0 out of 5 points The new RN is assessing balance for a... 75-year-old client. Asking the client to perform which technique indicates additional teaching is necessary? • Question 3 5 out of 5 points Which intervention would the RN perform to decrease the respiratory effects of decreased mobility? • Question 4 5 out of 5 points Which of the following nursing diagnoses would be appropriate for the RN to select for a patient who describes dyspnea, weakness, and an excessive increase in their respiratory rate with activity? • Question 5 5 out of 5 points The RN is developing a plan of care for an 80-year-old patient admitted with spinal stenosis. The patient rates pain at 7 on the 0-10 Numeric Rating Scale during ambulation and requires assistance with ambulation and transfer. What nursing diagnoses would be appropriate for this patient? Select all that apply. • Question 6 0 out of 5 points The RN is reviewing the exercise program for a patient being discharged after left knee replacement surgery. Which patient statement indicates that further teaching is necessary? • Question 7 5 out of 5 points The Registered Nurse is teaching the staff principles of body mechanics. Which instructions are appropriate? Select all that apply. • Question 8 0 out of 5 points Which statement by the nurse manager indicates additional teaching is necessary to implement and sustain a safe patient handling and mobility (SPHM) program? • Question 9 0 out of 5 points Which activity can the RN delegate to the nursing assistive personnel (NAP)? • Question 10 0 out of 5 points The RN delegates mobility activities to the unlicensed assistive personel (UAP). Which statement by the UAP indicates the need for additional education? • Question 11 5 out of 5 points According to principles in the Handle with Care Program, which action can have the most impact in reducing the RN’s risk for injury? • Question 12 0 out of 5 points After cast removal from a fracture of the arm, performing repetitions of which exercise described below would help the patient follow the provider’s order for isometric exercises for strength? • Question 13 0 out of 5 points A patient was diagnosed with a right hip fracture and has been placed on bed rest pending possible surgery. Which nursing diagnosis is appropriate for this patient? • Question 14 5 out of 5 points The RN is collaborating with physical therapy to evaluate client’s readiness for discharge. Which finding indicates the the client needs further evaluation? • Question 15 5 out of 5 points Which intervention would the RN perform to decrease the musculoskeletal effects of decreased mobility? • Question 16 5 out of 5 points The provider order reads acetaminophen (Tylenol) 640 mg orally. The pharmacy label reads acetaminophen (Tylenol) 160 mg/5mL. How many mL per dose will the nurse administer? Record your answer as a number using decimals if necessary (for example write 0.5 instead of ½). Do not include words or abbreviations in your answer. [x] mL • Question 17 5 out of 5 points Which statement is true according to the American Nurses Association (ANA) Handle With Care Fact Sheet? • Question 18 0 out of 5 points A 15-year-old male was admitted two days ago after being involved in a motor vehicle accident. His activity level is ambulating with the assist of one person to and from the nurses’ station. The RN has selected Impaired physical mobility as a primary nursing diagnosis. Which of the following is an expected outcome for this nursing diagnosis? • Question 19 5 out of 5 points A 70-year-old patient is one day post-operative following a total knee replacement and requires the assist of one person and a walker to ambulate. During ambulation the patient reports pain and shortness of breath. The RN developed a plan of care for this patient and included a nursing diagnosis of Activity Intolerance with an expected outcome of “Patient will report no shortness of breath with ambulation.” What intervention should the RN perform? • Question 20 5 out of 5 points A patient on bedrest for several days reports being bloated and uncomfortable, and has not had a bowel movement in four (4) days, when she normally passes one daily. The RN chooses Constipation as a nursing diagnosis. What is the most likely related factor in the diagnostic statement? Wednesday, December 13, 2017 5:43:55 PM EST Rational Reference: : Treas ch 9, p 171, 174, 176, Rationale: A three year old should be able to climb stairs alternating feet, it is a delay if the 5 year old can not. All other answers are normal developmental milestones Reference: : Treas ch 10 208, Rationale: heel to toe walking, deep knee bends and the Romberg test all assess balance. Flexion and extension of the knee assesses joint mobility, not balance Reference: : Treas ch 33, 1154-1168, Rationale:a change in systolic blood pressure indicates postural hypotension, and requires additional followup and care. Reference: American Nurses Association (2013). Safe patient handling and mobility: Interprofessional national standards. Silver Spring, MD: ANA (section on interprofessional standards of safe patient handling and mobility) Rationale: Staff members should not be encouraged to use workarounds instead of using the mechanical lift equipment Establish a culture of safety Reference: Treas ch 33, pg 1153-1167 Rationale: the NAP can assist with delegation if the patient condition is stable, inform of any special considerations. Reference: Treas ch 33, pg 1128 Rationale: Isometric exercise involves muscle contraction without motion, and is used for developing strength. This type of exercise is appropriate when a cast is removed because muscle atrophy would be an issue. If patient is on best rest tissue perfusion is not the best nursing diagnosis impaired bed mobility would be the best choice. If activity is a focus for a patient then the nursing diagnosis would to iincrease ambulation tolerance not focus on ambulation without SOB as this was not asked. [Show More]

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