Title RECALLS 13 - NP4 - KEY ✅

A. Improve circulation in the lower extremities. B. Keep the client comfortable. C. Prevent occurrence of pressure sores. D. Prevent flexion contractures in the lower extremities. 14. Nurse Em recognizes that an early major problem of the client with paraplegia is: A. Client education. B. Bladder control. C. Use of mechanical aids for ambulation. D. Quadriceps setting 15. Nurse Em is aware that a complication the client with paraplegia may experience is formation of urinary calculi. The factor that contributes to this condition is: A. High fluid intake B. Increases loss of calcium for the skeletal system. C. Inadequate kidney functioning. D. Increased calcium intake. 16-20. Situation. A 63-year-old male arrives at the Out-Patient Department complaining of numbness and tingling sensation of the lower extremities and pain in the legs upon exercising. The nurse suspects the client may have Peripheral Arterial Disease (PAD). 16. The nurse asks the client the following questions. Which of the questions would determine the risk factors of PAD? 1. “Do you smoke cigarettes?” 2. “Are you diabetic?” 3. “Are you hypertensive?” 4. “Do you exercise?” 5. “Do you drink alcohol?” A. 2, 3, & 4 B. 1, 2, 3, 4, & 5 C. 1, 4, & 5 D. 1, 2, & 3 17. The client asks the nurse what the doctor meant when he heard him say that the client has intermittent claudication. The nurses’ BEST response is, Intermittent claudication is_______ A. Pain that can occur in the body with exercise B. Pain in the leg when exercising C. Pain in the leg that occurs when at rest D. A tingling feeling of sensation in the hands 18. The nurse writes a nursing diagnosis of Ineffective Tissue Perfusion for the client. Which of the following interventions is MOST appropriate for this nursing diagnosis? A. Keep his legs in dependent position B. Elevate his legs C. Take hot bath D. Limit his daily activities. 19. The nurse writes another nursing diagnosis of Risk for Impaired Skin Integrity related to decreased peripheral circulation. Which of the following interventions is MOST appropriate for the nurse to instruct the client? A. Monitor the extremities for color, motion and sensation, and pulses. B. Maintain an appropriate level of activity to promote circulation. C. Avoid risk factors that may increase problems with Peripheral Arterial Disease. D. Protect the legs from injury because the tissues are fragile. 20. Which of the following outcomes indicate that there is increased arterial blood supply to the extremity of the client with peripheral arterial disease? A. Reduced sensation to touch B. Reduced muscle pain C. Increased rubor D. Decreased hair on the extremity 21-25. Situation. Nurse Rose is a newly registered nurse. She is assigned to the surgical unit of X hospital. She is aware of the legal responsibilities when performing patient care. The following are situations she encountered in the surgical unit with legal significance. 21. A patient is scheduled for abdominal surgery. Which of the following statements is a responsibility of Nurse Rose in obtaining a consent form? 1. Ensure that the consent form has been signed and is attached to the chart of the patient before the operation. 2. Witness the signing of the consent before the operation is performed. 3. Provide a detailed description of the operation before asking the patient to sign the consent form 4. Answer questions that the patient may ask before the patient signs the consent form. A. 3 & 4 B. 1, 2 & 3 C. 1, 2 & 4 D. 1 & 3 22. Which of the following health care professionals is legally responsible for obtaining informed consent for an invasive procedure? The ____ A. Surgeon B. Nurse Supervisor of the unit C. Medical director D. Registered nurse on duty 23. Nurse Rose documents her observation on a patient for abdominal surgery. Which of the following statements is legally appropriate notation? A. “The charge nurse spoke with the patient about the surgery” B. “The surgeon committed an error in the medication dose to be given” 2 | Page
C. “Patient says he will sue the surgeon and the hospital if the operation turns out to be a failure.” D. “Patient says he feels sharp and stabbing pain in the abdominal area.” 24. The attending physician writes an order of Do Not Resuscitate (DNR) on a patient who is seriously ill. Which of the following is a responsibility of Nurse Rose? Nurse Rose should ________ 1) Carry out the order in the event the patient experiences sudden need for CPR 2) Determine if there is a living will on the medical record of the patient 3) Consult the policies and procedures of the Institution if she feels such DNR order is contrary to the patient’s or family’s wishes. 4) Refer to the Ethics Committee of the Institution the DNR order to determine appropriateness of the order. A. 2 & 3 B. 1 & 3 C. 3 & 4 D. 1 & 2 25. The physician orders a dose of medication to be given to a patient before undergoing surgery. Nurse Rose is aware that the dose is too high for the patient. She tries to locate the physician to check the order but the physician is not available. Which of the following is the MOST appropriate action Nurse Rose will take to ensure the safety of the patient? A. Notify the nurse supervisor immediately B. Administer half of the dose of the medication ordered. C. Administer the medication as ordered. D. Withhold the medication. 26-30. Situation. The charge nurse in the Emergency Department calls for a crisis meeting to review principles in mass casualty to enhance preparedness and improve emergency quality care. 26. Which of the following statements is NOT TRUE about emergency preparedness? A. Hospitals should have an emergency preparedness plan that is tested through drills or actual participation. B. Generally, hospital employees participate seriously in emergency drills. C. Emergency preparedness training and drills are standard functions of emergency departments of hospitals. D. Drills must involve the participation and collaboration of the community. 27. The charge nurse explains that mass casualty incidents are due to events such as the following EXCEPT: A. Earthquakes B. Severe weather phenomena. C. Lightning strikes. D. Transportation disasters. 28. The charge nurse reiterates the importance of using a disaster triage tag system. Clients that have been “green-tagged” are those ________. A. With injuries of closed fracture, sprains, contusions and abrasions. B. Who are expected to die or are dead already. C. With major injuries such as open fractures and large wounds. D. Experiencing hemorrhagic shock that requires immediate treatment. 29. The term NBC means nuclear, biological and chemical weapons of mass destruction. Which of the following is an example of biologic terrorism agents? A. Vaccine B. Nerve agent antidotes C. Anthrax D. Neoplastic agents 30. The charge nurse emphasizes the overall goal in a disaster situation which is ___. A. Saving as many lives as possible B. Using a disaster triage system that categorizes triage priority by color and number. C. Calling all emergency medical service providers from the hospital to attend the needs of the victims. D. Doing the greatest good for the greatest number of people. 31-35. Situation. The nurse in the emergency department performs initial assessment on clients brought to the department. The following questions pertain to assessment and nursing interventions. 31. The nurse assesses a trauma client in pain who refuses pain medication. Which of the following alternative methods to manage pain can the nurse use or recommend? 1) Positioning/Splinting 2) Application of heat and cold 3) Non-therapeutic touch 4) Guided imagery 5) Humor A. 1, 2, 3 & 5 B. 2, 4 & 5 C. 1, 2, 3, 4 & 5 D. 1, 2 & 5 32. The nurse assesses circulation of an adult trauma victim by palpating a central pulse. Which of the arteries will the nurse palpate? A. Apical artery B. Brachial artery C. Femoral artery D. Popliteal artery 33. The nurse performs complete spinal immobilization. The procedure includes the following actions EXCEPT _____. A. Placing the client on the backboard B. Placing a small pillow on the head. C. Application of a rigid cervical collar. D. Immobilization of the head and neck. 34. In inspecting a client’s airway, the nurse should observe the following, EXCEPT: A. Tongue obstructing the airway B. Foreign objects that may have been lodged. 3 | Page