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MS2 |! Exam |! 1 |! with |! precise |! detailed |!
solutions
Which |! statements |! by |! a |! nursing |! student |! indicate |! a |! need |! for |! further |! teaching |! by |! the |! nurse |! regarding |! infection |! control |! measures |! needed |! to |! care |! for |! a |! client |! who |! has |! possible |! TB? a. |! I'll |! wear |! an |! isolation |! gown |! when |! providing |! direct |! care b. |! I'll |! wear |! gloves |! when |! emptying |! the |! bed |! pain c. |! I'll |! wear |! a |! mask |! each |! time |! I |! enter |! the |! client's |! room d. |! I'll |! use |! a |! hand |! sanitizer |! when |! I |! can't |! wash |! my |! hands e. |! I'll |! wear |! goggles |! to |! protect |! my |! eyes |! - |! Correct |! answer |! ✔a. |! I'll |! wear |! an |! isolation |! gown |! when |! providing |! direct |! care e. |! I'll |! wear |! goggles |! to |! protect |! my |! eyes A |! client |! is |! diagnosed |! with |! a |! foot |! ulcer |! infected |! with |! MRSA |! infection. |! Which |! PPE |! is |! appropriate |! when |! providing |! direct |! care? a. |! mask b. |! gloves c. |! shoe |! covers d. |! goggles e. |! gown |! - |! Correct |! answer |! ✔b. |! gloves e. |! gown
While |! performing |! skin |! assessment |! on |! an |! elderly |! client, |! the |! nurse |! observes |! an |! isolated |! brownish-purple |! lesion |! with |! irregular |! boarders |! on |! the |! anterior |! chest |! wall. |! The |! lesion |! feels |! slightly |! raised |! on |! palpation, |! and |! crusted |! blood |! is |! visible |! at |! the |! lower |! edge. |! Which |! is |! the |! appropriate |! nursing |! intervention? a. |! wash |! the |! lesion |! gently |! with |! warm |! water |! to |! remove |! the |! crusts |! and |! teach |! not |! to |! pick b. |! document |! lesion's |! location, |! size, |! and |! characteristics |! and |! request |! dermatology |! consult c. |! reassure |! that |! the |! lesion |! is |! a |! common |! occurrence |! with |! aging, |! especially |! in |! sun-exposed |! areas d. |! ask |! the |! patient |! about |! exposure |! to |! new |! lotions |! or |! perfumes |! that |! could |! cause |! an |! allergic |! reaction |! - |! Correct |! answer |! ✔b. |! document |! lesion's |! location, |! size, |! and |! characteristics |! and |! request |! dermatology |! consult What |! is |! the |! appropriate |! nursing |! response |! when |! a |! client |! asks, |! "What |! is |! a |! punch |! biopsy?" a. |! the |! health |! care |! provider |! will |! use |! a |! scalpel |! to |! remove |! a |! portion |! of |! the |! skin b. |! a |! circular |! cutting |! instrument |! will |! be |! used |! to |! remove |! a |! small |! plug |! of |! tissue c. |! a |! deep |! specimen |! of |! the |! skin |! will |! be |! take, |! and |! then |! the |! health |! care |! provider |! will |! suture |! this |! area |! closed d. |! a |! local |! anesthetic |! will |! be |! injected |! before |! a |! razor |! blade |! is |! moved |! parallel |! to |! the |! skin's |! surface |! to |! obtain |! a |! sample |! - |! Correct |! answer |! ✔b. |! a |! circular |! cutting |! instrument |! will |! be |! used |! to |! remove |! a |! small |! plug |! of |! tissue
b. |! increased |! pruritus c. |! cough |! with |! fever d. |! new |! plaques |! on |! leg |! - |! Correct |! answer |! ✔c. |! cough |! with |! fever Which |! statement |! made |! by |! the |! student |! nurse |! requires |! further |! teaching |! by |! the |! nurse |! preceptor? a. |! I |! will |! always |! remove |! crusts |! from |! bacterial |! lesions |! before |! applying |! topical |! antimicrobials b. |! I |! will |! avoid |! using |! adult |! briefs |! for |! my |! bedridden |! incontinent |! client |! who |! has |! a |! perineal |! yeast |! infection c. |! If |! signs |! and |! symptoms |! of |! a |! systemic |! infection |! are |! present, |! I |! will |! contact |! the |! health |! care |! provider |! to |! discuss |! ordering |! blood |! cultures d. |! I |! will |! tell |! my |! client |! that |! transmission-based |! precautions |! are |! not |! necessary |! after |! the |! first |! dose |! of |! oral |! antiviral |! therapy |! for |! herpes |! zoster |! is |! taken |! - |! Correct |! answer |! ✔d. |! I |! will |! tell |! my |! client |! that |! transmission-based |! precautions |! are |! not |! necessary |! after |! the |! first |! dose |! of |! oral |! antiviral |! therapy |! for |! herpes |! zoster |! is |! taken The |! nurse |! is |! teaching |! a |! client |! how |! to |! treat |! pediculosis |! (lice). |! Which |! teaching |! will |! the |! nurse |! include? a. |! use |! a |! fine-tooth |! comb |! to |! remove |! nits b. |! chemical |! killing |! of |! these |! parasites |! is |! required c. |! wash |! bed |! linens |! in |! cold |! water |! to |! remove |! lice |! and |! eggs d. |! lice |! do |! not |! affect |! clothing |! items |! become |! they |! jump |! off |! of |! fabric e. |! eggs |! of |! lice |! must |! be |! killed |! to |! reduce |! the |! risk |! for |! development |! of |! skin |! cancer
f. |! lice |! can |! infest |! hair |! on |! the |! head, |! in |! the |! genital |! region, |! in |! the |! axillae, |! on |! eyelashes, |! and |! on |! other |! body |! hair |! - |! Correct |! answer |! ✔a. |! use |! a |! fine-tooth |! comb |! to |! remove |! nits b. |! chemical |! killing |! of |! these |! parasites |! is |! required f. |! lice |! can |! infest |! hair |! on |! the |! head, |! in |! the |! genital |! region, |! in |! the |! axillae, |! on |! eyelashes, |! and |! on |! other |! body |! hair The |! nurse |! is |! performing |! an |! assessment |! on |! a |! female |! client |! and |! notices |! a |! large, |! irregularly |! shaped |! mole |! on |! her |! upper |! back. |! The |! client |! expresses |! concern |! about |! the |! cosmetic |! appearance |! of |! the |! lesion. |! What |! is |! the |! priority |! nursing |! intervention? a. |! refer |! to |! a |! dermatological |! health |! care |! provider b. |! ask |! if |! there |! are |! any |! other |! lesions |! that |! bother |! her c. |! perform |! a |! head |! to |! toe |! skin |! assessment |! and |! document |! the |! findings d. |! teach |! about |! the |! importance |! of |! avoiding |! excessive |! sun |! exposure |! and |! tanning |! beds |! - |! Correct |! answer |! ✔c. |! perform |! a |! head |! to |! toe |! skin |! assessment |! and |! document |! the |! findings When |! taking |! a |! history |! for |! a |! patient |! with |! GI |! problems, |! which |! daily |! client |! behaviors |! requires |! further |! nursing |! assessment? a. |! eats |! multiple |! servings |! of |! vegetables b. |! takes |! 800 |! mg |! of |! ibuprofen |! for |! arthritic |! pain c. |! walks |! 30 |! minutes d. |! chews |! tobacco e. |! takes |! senna |! to |! assist |! with |! bowel |! movements
e. |! double-contrast |! barium |! enema |! every |! 5 |! years f. |! take-home |! yearly |! guaiac |! fecal |! occult |! blood |! tests The |! nurse |! is |! caring |! for |! four |! clients. |! Which |! is |! the |! highest |! risk |! for |! development |! of |! oral |! cancer? a. |! a |! 32-year-old |! client |! with |! ankle |! fracture |! b. |! 41 |! y/o |! with |! HPV |! infection c. |! 60 |! y/o |! who |! quit |! smoking |! 20 |! years |! ago d. |! 83 |! y/o |! who |! lives |! in |! a |! warm |! climate |! during |! the |! winter |! - |! Correct |! answer |! ✔b. |! 41 |! y/o |! with |! HPV |! infection Adequate |! nutrition |! is |! required |! for |! healing |! after |! treatment |! for |! recurrent |! aphthous |! ulcers |! (RAU). |! Which |! client |! response |! indicates |! that |! nursing |! teaching |! has |! been |! effective? a. |! i've |! ordered |! a |! snack |! of |! milk |! and |! pretzels b. |! i'll |! try |! to |! drink |! orange |! juice |! twice |! per |! day c. |! i |! ordered |! my |! sandwich |! on |! a |! crusty |! roll d. |! i'd |! like |! scrambled |! eggs |! and |! a |! banana |! for |! breakfast |! - |! Correct |! answer |! ✔d. |! i'd |! like |! scrambled |! eggs |! and |! a |! banana |! for |! breakfast The |! nurse |! is |! caring |! for |! a |! client |! who |! is |! concerned |! about |! developing |! oral |! tumors. |! Which |! client |! statement |! requires |! immediate |! nursing |! intervention? a. |! i |! used |! to |! chew |! tobacco |! but |! quit |! 5 |! years |! ago b. |! i |! use |! sunscreen |! to |! cover |! my |! face |! and |! body |! when |! i'm |! at |! the |! beach c. |! i |! don't |! have |! dental |! insurance, |! so |! i |! can't |! get |! dental |! check |! ups
d. |! i |! only |! drink |! alcohol |! on |! special |! occasions |! like |! my |! birthday |! and |! anniversary |! - |! Correct |! answer |! ✔c. |! i |! don't |! have |! dental |! insurance, |! so |! i |! can't |! get |! dental |! check |! ups A |! client |! completing |! radiation |! treatment |! has |! developed |! dysphagia |! and |! stomatitis. |! What |! teaching |! will |! the |! nurse |! provide? a. |! brush |! teeth |! twice |! daily |! with |! chemobrush b. |! thin |! liquids |! will |! make |! it |! easier |! to |! swallow c. |! limit |! alcohol |! consumption |! to |! three |! drinks |! per |! day d. |! rinse |! mouth |! with |! mild |! saline |! and |! water |! mix |! before |! and |! after |! eating e. |! refrain |! from |! using |! liquid |! dietary |! supplements |! because |! these |! will |! irritate |! mucous |! membranes f. |! plan |! to |! eat |! soft |! foods |! such |! as |! cheese, |! well-cook |! legumes, |! peanut |! butter, |! and |! pudding |! - |! Correct |! answer |! ✔a. |! brush |! teeth |! twice |! daily |! with |! chemobrush d. |! rinse |! mouth |! with |! mild |! saline |! and |! water |! mix |! before |! and |! after |! eating f. |! plan |! to |! eat |! soft |! foods |! such |! as |! cheese, |! well-cook |! legumes, |! peanut |! butter, |! and |! pudding Which |! facial |! assessment |! finding |! in |! a |! client |! with |! a |! salivary |! gland |! tumor |! prompts |! the |! nurse |! to |! notify |! the |! health |! care |! provider? a. |! loss |! of |! sensation |! in |! tongue b. |! alternates |! smiling |! and |! grimacing c. |! wrinkles |! brows |! on |! command d. |! holds |! eyes |! shut |! as |! the |! nurse |! pulls |! gently |! on |! the |! eyebrows |! - |! Correct |! answer |! ✔a. |! loss |! of |! sensation |! in |! tongue
The |! nurse |! is |! caring |! for |! a |! client |! who |! has |! been |! diagnosed |! with |! esophageal |! cancer. |! The |! client |! appears |! anxious |! and |! asks |! the |! nurse, |! "does |! this |! mean |! i'm |! going |! to |! die?" |! which |! nursing |! responses |! are |! appropriate? |! a. |! no, |! surgery |! can |! cure |! you b. |! it |! sounds |! like |! death |! frightens |! you c. |! lets |! me |! call |! the |! hospital |! chaplain |! to |! talk |! with |! you d. |! you |! can |! beat |! this |! disease |! if |! you |! just |! put |! your |! mind |! to |! it e. |! let |! me |! sit |! with |! you |! for |! a |! while |! and |! we |! can |! discuss |! how |! you're |! feeling |! about |! this |! - |! Correct |! answer |! ✔b. |! it |! sounds |! like |! death |! frightens |! you e. |! let |! me |! sit |! with |! you |! for |! a |! while |! and |! we |! can |! discuss |! how |! you're |! feeling |! about |! this The |! nurse |! is |! performing |! medication |! reconcilation |! for |! a |! newly |! admitted |! client. |! The |! nurse |! recognizes |! which |! drugs |! contribute |! to |! signs |! and |! symptoms |! of |! gastritis? a. |! aspirin, |! taken |! once |! daily |! to |! prevent |! cardiac |! concerns b. |! Naproxen, |! taken |! once |! daily |! for |! joint |! pain |! associated |! with |! arthritis c. |! Amoxicillin, |! taken |! over |! a |! 10-day |! period |! for |! an |! acute |! sinus |! infection d. |! Bacitracin |! ointment |! (OTC), |! applied |! to |! minor |! scrapes |! on |! arms |! and |! legs e. |! Prednisone, |! tapered |! over |! a |! 14-day |! period |! to |! decrease |! inflammation |! associated |! with |! an |! acute |! sinus |! infection |! - |! Correct |! answer |! ✔a. |! aspirin, |! taken |! once |! daily |! to |! prevent |! cardiac |! concerns b. |! Naproxen, |! taken |! once |! daily |! for |! joint |! pain |! associated |! with |! arthritis e. |! Prednisone, |! tapered |! over |! a |! 14-day |! period |! to |! decrease |! inflammation |! associated |! with |! an |! acute |! sinus |! infection
When |! caring |! for |! a |! patient |! who |! has |! just |! has |! an |! upper |! GI |! endoscopy, |! the |! nurse |! assesses |! that |! the |! client |! has |! developed |! a |! temperature |! of |! 101.8F. |! What |! is |! the |! appropriate |! nursing |! intervention? a. |! promptly |! assess |! the |! client |! for |! a |! potential |! perforation b. |! ask |! the |! nursing |! assistant |! to |! bathe |! the |! client |! with |! tepid |! water c. |! administer |! Tylenol |! to |! lower |! the |! temp d. |! delegate |! to |! a |! UAP |! to |! retake |! the |! temperature |! - |! Correct |! answer |! ✔a. |! promptly |! assess |! the |! client |! for |! a |! potential |! perforation The |! nurse |! is |! caring |! for |! a |! client |! with |! a |! bleeding |! duodenal |! ulcer |! who |! was |! admitted |! to |! the |! hospital |! after |! vomiting |! bright, |! red |! blood. |! Which |! condition |! does |! the |! nurse |! anticipate |! when |! the |! client |! develops |! a |! sudden, |! sharp |! pain |! in |! the |! mid-epigastric |! region |! and |! a |! rigid, |! board-like |! abdomen? a. |! pancreatitis b. |! ulcer |! perforation c. |! small |! bowel |! obstruction d. |! development |! of |! additional |! ulcers |! - |! Correct |! answer |! ✔b. |! ulcer |! perforation Which |! client |! statement |! regarding |! treatment |! for |! gastric |! cancer |! requires |! the |! nurse |! to |! intervene |! immediately? a. |! i |! understand |! my |! treatment |! regimen b. |! my |! prognosis |! is |! fighting |! to |! me |! and |! my |! partner c. |! life |! just |! doesn't |! seem |! to |! be |! worth |! living |! anymore d. |! there |! is |! a |! list |! of |! community |! resources |! stored |! in |! my |! computer |! for |! when |! i |! need |! them |! - |! Correct |! answer |! ✔c. |! life |! just |! doesn't |! seem |! to |! be |! worth |! living |! anymore
e. |! serosanguineous |! fluid |! draining |! from |! two |! Jackson-Pratt |! drains |! - |! Correct |! answer |! ✔b. |! gas |! inside |! the |! pouch c. |! pain |! controlled |! with |! analgesics e. |! serosanguineous |! fluid |! draining |! from |! two |! Jackson-Pratt |! drains The |! emergency |! department |! nurse |! is |! assessing |! a |! client |! with |! a |! known |! inguinal |! hernia. |! Which |! assessment |! findings |! indicate |! that |! the |! hernia |! may |! have |! strangulated? a. |! fever b. |! tachycardia c. |! ABD |! distension d. |! mild |! ABD |! pain e. |! N/V |! - |! Correct |! answer |! ✔a. |! fever b. |! tachycardia c. |! ABD |! distension e. |! N/V A |! client |! who |! recently |! has |! laparoscopic |! surgery |! to |! treat |! a |! ruptured |! appendix |! has |! developed |! subsequent |! peritonitis. |! The |! client |! currently |! has |! two |! JP |! drains |! placed |! in |! the |! ABD. |! Which |! findings, |! would |! the |! nurse |! report |! immediately? a. |! serosanguineous |! drainage b. |! fever c. |! cloudy |! drainage d. |! painful |! ADB |! distension
e. |! pain |! level |! 3 |! - |! Correct |! answer |! ✔b. |! fever c. |! cloudy |! drainage d. |! painful |! ADB |! distension The |! nurse |! is |! caring |! for |! an |! older |! adult |! client |! who |! experiences |! an |! exacerbation |! of |! ulcerative |! colitis |! with |! severe |! diarrhea |! that |! have |! lasted |! a |! week. |! For |! which |! complications |! with |! the |! nurse |! assess? a. |! dehydration b. |! hypokalemia c. |! skin |! breakdown d. |! DVT e. |! hyperkalemia |! - |! Correct |! answer |! ✔a. |! dehydration b. |! hypokalemia c. |! skin |! breakdown The |! nurse |! is |! caring |! for |! a |! client |! who |! has |! just |! been |! prescribed |! a |! glucocorticoid |! to |! treat |! an |! exacerbation |! of |! ulcerative |! colitis. |! What |! teaching |! will |! the |! nurse |! provide? a. |! decrease |! the |! drug |! dose |! during |! the |! next |! exacerbation b. |! report |! fever |! to |! the |! PHCP |! immediately c. |! determine |! if |! the |! client's |! insurance |! covers |! payment |! for |! this |! medication d. |! this |! drug |! will |! act |! as |! an |! antidiarrheal |! - |! Correct |! answer |! ✔b. |! report |! fever |! to |! the |! PHCP |! immediately
The |! nurse |! is |! caring |! for |! a |! client |! who |! had |! paracentesis |! performed. |! Which |! nursing |! intervention |! is |! appropriate? a. |! keep |! head |! of |! bed |! flat b. |! measure, |! describe, |! and |! record |! drainage c. |! ambulate |! 30 |! minutes |! post |! procedure d. |! weigh |! client e. |! label |! fluid |! container |! and |! send |! to |! lab |! - |! Correct |! answer |! ✔b. |! measure, |! describe, |! and |! record |! drainage d. |! weigh |! client e. |! label |! fluid |! container |! and |! send |! to |! lab The |! nurse |! is |! caring |! for |! four |! clients. |! Which |! client |! is |! at |! the |! highest |! risk |! for |! hepatitis |! B |! infection? a. |! 24 |! y/o |! with |! ABD |! pain |! who |! just |! returned |! from |! Central |! America b. |! 40 |! y/o |! who |! is |! 2 |! days |! PP |! and |! is |! breastfeeding c. |! 65 |! y/o |! who |! reports |! using |! street |! drugs |! ten |! years |! ago |! when |! homeless d. |! 81 |! y/o |! who |! donated |! own |! blood |! before |! a |! surgical |! procedure |! - |! Correct |! answer |! ✔c. |! 65 |! y/o |! who |! reports |! using |! street |! drugs |! ten |! years |! ago |! when |! homeless The |! community |! nurse |! is |! talking |! with |! four |! clients |! who |! have |! reported |! digestive |! concerns. |! Which |! client |! does |! the |! nurse |! recognize |! as |! most |! likely |! to |! experience |! gallstone |! production? a. |! 23 |! y/o |! caucasian |! vegetarian |! who |! is |! a |! dancer b. |! 35 |! y/o |! american |! indian |! who |! works |! in |! construction
c. |! 48 |! y/o |! canadian |! who |! manages |! a |! fast-food |! restaurant d. |! 59 |! year-old |! asian |! american |! who |! is |! an |! investment |! banker e. |! 64 |! y/o |! mexican |! american |! who |! resides |! with |! grandchildren |! - |! Correct |! answer |! ✔b. |! 35 |! y/o |! american |! indian |! who |! works |! in |! construction e. |! 64 |! y/o |! mexican |! american |! who |! resides |! with |! grandchildren The |! nurse |! will |! include |! what |! postoperative |! teaching |! when |! caring |! for |! the |! client |! who |! is |! preparing |! to |! undergo |! endoscopic |! cholecystectomy? |! a. |! you'll |! have |! a |! small, |! midline |! ABD |! inscision b. |! you |! can't |! eat |! or |! drink |! for |! a |! few |! days |! after |! the |! procedure c. |! you |! won't |! be |! able |! to |! return |! to |! regular |! activity |! for |! several |! weeks d. |! this |! procedure |! has |! a |! low |! incidence |! of |! infection e. |! the |! hospital |! stay |! after |! this |! procedure |! is |! typically |! 3 |! to |! 4 |! days |! - |! Correct |! answer |! ✔a. |! you'll |! have |! a |! small, |! midline |! ABD |! inscision d. |! this |! procedure |! has |! a |! low |! incidence |! of |! infection e. |! the |! hospital |! stay |! after |! this |! procedure |! is |! typically |! 3 |! to |! 4 |! days The |! nurse |! closely |! monitors |! the |! client |! with |! acute |! pancreatitis |! for |! which |! life- threatening |! complication? a. |! jaundice b. |! type |! 1 |! DM c. |! ABD |! pain d. |! DIC |! - |! Correct |! answer |! ✔d. |! DIC
e. |! encourage |! the |! client |! to |! eat |! quickly |! to |! get |! the |! entire |! meal |! consumed f. |! provide |! food |! to |! the |! client |! only |! when |! hunger |! is |! reported |! - |! Correct |! answer |! ✔a. |! assess |! the |! client's |! level |! of |! pain |! and |! provide |! interventions |! as |! necessary b. |! remove |! objects |! from |! sight |! in |! the |! client's |! room |! such |! as |! bedpans |! or |! urinals |! at |! mealtime c. |! provide |! a |! quiet |! environment |! during |! mealtime d. |! provide |! washcloth |! and |! towel |! for |! washing |! hands |! before |! each |! meal A |! client |! with |! obesity |! tells |! the |! nurse, |! "i |! wouldn't |! be |! overweight |! if |! it |! weren't |! for |! my |! genes." |! What |! is |! the |! appropriate |! nursing |! response? a. |! genes |! are |! responsible |! for |! obesity b. |! tell |! me |! about |! your |! family |! history c. |! let's |! talk |! about |! your |! nutrition |! intake d. |! how |! do |! you |! feel |! about |! exercise? e. |! you |! should |! get |! bariatric |! surgery |! - |! Correct |! answer |! ✔b. |! tell |! me |! about |! your |! family |! history c. |! let's |! talk |! about |! your |! nutrition |! intake d. |! how |! do |! you |! feel |! about |! exercise?
