NR 226 EXAM 1 2024 ACTUAL EXAM AND STUDY GUIDE 400 QUESTIONS WITH DETAILED VERIFIED ANSWERS (100% CORRECT) AND RATIONALES /A+ GRADE ASSURED

NR 226 EXAM 1 2024 ACTUAL EXAM
AND STUDY GUIDE 400 QUESTIONS
WITH DETAILED VERIFIED ANSWERS
(100% CORRECT) AND RATIONALES
A+ GRADE ASSURED
A patient had hip surgery 16 hours ago. During the previous
shift the patient had 40 mL of drainage in the surgical
drainage collection device for an 8-hour period. The nurse
refers to the written plan of care, noting that the health care
provider is to be notified when drainage in the device exceeds
100 mL for the day. On entering the room, the nurse looks at
the device and carefully notes the amount of drainage
currently in it. This is an example of:
A. Planning.
B. Evaluation.
C. Intervention.
D. Diagnosis. - ...ANSWER...B. Evaluation
RATIONALE -The patient's baseline for wound drainage
was 40 mL, representing the initial assessment of the patient's
wound condition. In this example the nurse is evaluating to
determine if there is a change in the amount of drainage,
which indicates the progress of wound healing.
In which of the following examples is the nurse not applying
critical thinking skills in practice?
A. The nurse considers personnel experience in performing
intravenous (IV) line insertion and ways to improve
performance.
B. The nurse uses a fall risk inventory scale to determine a
patient's fall risk.
C. The nurse observes a change in a patient's behavior and
considers which problem is likely developing.
D. The nurse explains the procedure for giving a tube feeding
to a second nurse who has floated to the unit to assist with
care. - ...ANSWER...D. The nurse explains the procedure for
giving a tube feeding to a second nurse who has floated to the
unit to assist with care.
RATIONALE-The nurse is explaining how to provide care
on the basis of knowledge. Considering personal experience is
self-regulation through reflection. Determining a patient's fall
risk is evaluation, using a criteria-based screening scale.
Observing a change in the patient's behavior and considering
likely developments is inference, in which the nurse looks for
a relationship in findings.
A nurse assesses a patient who comes to the pulmonary clinic.
"I see that it's been over 6 months since you've been in, but
your appointment was for every 2 months. Tell me about that.
Also I see from your last visit that the doctor recommended
routine exercise. Can you tell me how successful you have
been following his plan?" The nurse's assessment covers
which of Gordon's functional health patterns?
A. Value-belief pattern
B. Cognitive-perceptual pattern
C. Coping-stress-tolerance pattern
D. Health perception-health management pattern -
...ANSWER...D. Health perception-health management
pattern
RATIONALE-The nurse is attempting to learn about the
patient's self-report of health practices, clinic appointments,
and exercise plan designed to improve his health.
The nurse asks a patient, "Describe for me your typical diet
over a 24-hour day. What foods do you prefer? Have you
noticed a change in your weight recently?" This series of
questions would likely occur during which phase of a patientcentered interview?
A. Setting the stage
B. Gathering information about the patient's chief concerns
C. Collecting the assessment
D. Termination - ...ANSWER...C. Collecting the assessment
RATIONALE-The nurse is focusing on the patient's
nutritional status and asking specific questions to assess his
diet history.
What type of interview techniques does the nurse use when
asking these questions, "Do you have pain or cramping?"
"Does the pain get worse when you walk?" (Select all that
apply.)
A. Active listening
B. Open-ended questioning
C. Closed-ended questioning
D. Problem-oriented questioning - ...ANSWER...C & D
RATIONALE-The nurse's technique is to ask a closed-ended
question using a problem oriented approach. The patient gives
a specific answer to broaden the nurse's knowledge about the
character of his pain.
What technique(s) best encourage(s) a patient to tell his or her
full story? (Select all that apply.)
A. Active listening
B. Back channeling
C. Validating
D. Use of open-ended questions
E. Use of closed-ended questions - ...ANSWER...A, B, & D
RATIONALE-Active listening allows the patient to speak
and shows the nurse's respect for what he or she has to say.
Back channeling reinforces interest in what the patient has to
say and shows the nurse's desire to hear the full story. Using
open-ended questions encourages the patient to tell his or her
story and actively describe his or her health status. Validation
simply confirms accuracy of data collected. Closed-ended
questions do not encourage storytelling.
A nurse gathers the following assessment data. Which of the
following cues form(s) a pattern suggesting a problem?
(Select all that apply.)
A. The skin around the wound is tender to touch.
B. Fluid intake for 8 hours is 800 mL.
C. Patient has a heart rate of 78 and regular.
D. Patient has drainage from surgical wound.
E. Body temperature is 101° F (38.3° C).
F. Patient asks, "I'm worried that I won't return to work when
I planned." - ...ANSWER...A, D, & E
RATIONALE-These form a pattern of a problem with wound
healing. Fluid intake of 800 mL in 8 hours and having a heart
rate of 78 are normal findings. The patient indicating some
worry about not returning to work when planned may suggest
a problem, but more cues are needed to see a pattern that
would allow the nurse to clearly identify the problem.