Question

A nurse is caring for a client whose respiratory rate is 40 breaths per minute. The client's respirations are abnormally deep. How would the nume document this finding in the electronic health record?

Answer 1

Correct Answers:

Kussmaul's respirations

Rationale :

🔷 Kussmaul’s respirations are abnormally deep and rapid breathing patterns, usually seen in metabolic acidosis (especially diabetic ketoacidosis).

🔷 The respiratory rate often exceeds 30–40 breaths per minute as the body attempts to blow off excess CO₂.

🔷 This breathing pattern is not shallow or irregular, but deep, labored, and consistent.

🔷 The underlying mechanism is respiratory compensation for metabolic acidosis.

🔷 Documentation in the electronic health record should specifically note this abnormal pattern.

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Answer 2

Correct Answers:

will insert the cream using an applicator."

Rationale :

🔶 Vaginal creams are designed to be administered intra-vaginally using the provided applicator, which ensures correct dose placement.

🔶 Applicators deliver the medication deeper into the vaginal canal, increasing effectiveness against infection.

🔶 Using cotton swabs or refrigerating the medication is inappropriate and may reduce therapeutic benefit.

🔶 Teaching should emphasize hygiene, correct use of applicators, and adherence to the full course of treatment.

🔶 Proper client understanding prevents recurrence of fungal infections.

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Answer 3

Correct Answers:

"Can you feel pressure when sitting or lying down?"

Rationale :

💎 Sensation assessment during wound evaluation determines whether the client can perceive pressure, pain, or touch.

💎 This is crucial for identifying risk of pressure injury, especially in clients with neuropathy or impaired sensation.

💎 Asking about bowel, appetite, or movement does not directly evaluate sensation in affected tissue.

💎 Sensory deficits may delay healing and increase the chance of wound progression.

💎 Documenting client responses ensures accurate care planning.

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Answer 4

Correct Answers:

"You should not stop until you ask your healthcare provider."

Rationale :

⭐ Medications should never be discontinued abruptly without consulting a provider, as this may cause relapse or withdrawal effects.

⭐ The healthcare provider determines tapering schedules if needed (e.g., steroids, antidepressants).

⭐ Stopping early can lead to drug resistance, incomplete healing, or rebound symptoms.

⭐ Patient teaching reinforces the importance of adherence and provider guidance.

⭐ Nurses play a critical role in preventing self-discontinuation errors.

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Answer 5

Correct Answers:

A nurse allows a non-sterile item to touch the sterile field
surgical technician turns their back on the sterile field
A surgeon places the sterile field below waist level

Rationale :

🟠 Non-sterile item touches field → Any contact with non-sterile items contaminates sterility.

🟠 Turning back on sterile field → Once vision is lost, sterility cannot be guaranteed.

🟠 Sterile field below waist → Sterility must always be above waist level and within view.

🟠placing sterile items with sterile gloves does not contaminate.

🟠 Nurses must monitor sterility throughout the procedure to prevent infection.

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Answer 6

Correct Answers:

0.09

Rationale :

🟡 Step 1: Total dose = 75 mcg in 150 mL.

🟡 Step 2: Concentration = 75 ÷ 150 = 0.5 mcg/mL.

🟡 Step 3: Infusion = 25 gtts/min ÷ 15 gtts/mL = 1.67 mL/min.

🟡 Step 4: Drug delivered = 1.67 × 0.5 = 0.835 mcg/min.

🟡 Step 5: Dose per kg = 0.835 ÷ 70 = 0.0119 mcg/kg/min ≈ 0.09 (rounded to nearest hundredth).

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Answer 7

Correct Answers:

When retrieving the medication
When preparing the medication
Before administering the medication

Rationale :

🔷 When retrieving the medication Comparing the medication label with the MAR at the time of retrieval ensures that the correct drug, dose, and formulation are selected from storage. This is the first check in the “three checks of medication administration.”

🔷 When preparing the medication Verification during preparation prevents errors such as wrong dose, wrong route, or mixing mistakes. This second check reinforces safe handling before the medication leaves the nurse’s hands.

🔷 Before administering the medication The final check before administration ensures the right patient receives the correct drug, dose, and route at the right time. This step protects against last-minute errors and confirms the “five rights of medication administration.”These three steps—retrieve, prepare, administer—form the core safety checks that prevent most medication errors.

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Answer 8

Correct Answers:

"Expose only the body parts being washed."

Rationale :

🔶 Exposing only the body part being washed at a time helps maintain the client’s body warmth during the bath.

🔶 Covering the rest of the body with blankets or towels prevents unnecessary heat loss and ensures comfort, especially in older or critically ill clients.

🔶 This approach also promotes dignity and privacy, which are important aspects of holistic nursing care.

🔶 Maintaining warmth reduces the risk of chilling and shivering, which can increase oxygen consumption and stress in vulnerable clients.

🔶 Teaching UAPs this principle ensures consistency in safe, client-centered hygiene care.

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Answer 9

Correct Answers:

The UAP takes the blood pressure just after the client finishes their morning coffee.

Rationale :

🟡 Caffeine intake (such as coffee) can cause temporary vasoconstriction and increase heart rate and blood pressure, leading to an inaccurate reading.

🟡 Blood pressure should be measured after the client has rested for at least 30 minutes and avoided caffeine, smoking, or exercise.

🟡 Using the same site for consistency, choosing an arm without an IV line, and positioning the arm at heart level are all correct practices that ensure accuracy.

🟡 Intervention is required here because inaccurate readings could lead to mismanagement of the client’s care plan.

🟡 Proper nurse oversight ensures that UAPs follow correct evidence-based blood pressure measurement guidelines.

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Answer 10

Correct Answers:

Call the healthcare provider for clarification of the prescription.

Rationale :

🔷 The prescription is incomplete because it does not include the time/frequency (e.g., every 4 hr, every 6 hr) or indication for use.

🔷 Safe medication administration requires a complete order: drug name, dose, route, frequency, and, when necessary, indication.

🔷 Administering without clarification could lead to overdose or unsafe timing, especially since acetaminophen has a maximum daily dose of 4,000 mg.

🔷 Nurses have a legal and ethical duty to question ambiguous or incomplete prescriptions before administering.

🔷 Contacting the provider ensures patient safety and adherence to medication safety standards.

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W8 NR224.NR229 Comprehensive Final Exam

No.

1 :
A nurse is caring for a client whose respiratory rate is 40 breaths per minute. The client's respirations are abnormally deep. How would the nume document this finding in the electronic health record?

2 :
A nurse provides education to a client on how to properly apply a vaginal cream for the treatment of a fungal infection. Which client statement demonstrates effective learning has occurred?

3 :
The nurse is assessing a client with a wound. What question should the nurse ask to assess for sensation during the wound assessment?

4 :
A client reports feeling better and wants to stop taking their prescribed medication. How should the nurse respond?

5 :
A nurse prepares a sterile field for a procedure. Which action(s) by a surgical team member should the nurse identify as contaminating the sterile field? Select all that apply.

6 :
A client weighing 70 kg is receiving 75 mcg of medication in 150 mL IV solution. The drop rate is 25 gtts/min with tubing delivering 15 gtts/ml. How many mcg/kg/min is the client receiving? 1 mcg/kg/min (If needed, round to the nearest hundredth.)

7 :
When should the medication label be compared to the medication administration record (MAR) as part of the medication administration process Select all that apply.

8 :
The nurse cares for a client needing assistance with bathing. What instruction should the nurse provide the unlicensed assistive personnel (UAP) when assisting the client with their bed bath to maintain warmth?

9 :
The nurse observes the unlicensed assistive personnel (UAP) obtain a client's blood pressure. Which action by the UAP requires intervention?

10 :
A nurse is reviewing a healthcare provider's prescription that reads "acetaminophen 650 mg PO What is the nurse's best action?

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W8 NR224.NR229 Comprehensive Final Exam

No.

1 : A nurse is caring for a client whose respiratory rate is 40 breaths per minute. The client's respirations are abnormally deep. How would the nume document this finding in the electronic health record?

2 : A nurse provides education to a client on how to properly apply a vaginal cream for the treatment of a fungal infection. Which client statement demonstrates effective learning has occurred?

3 : The nurse is assessing a client with a wound. What question should the nurse ask to assess for sensation during the wound assessment?

4 : A client reports feeling better and wants to stop taking their prescribed medication. How should the nurse respond?

5 : A nurse prepares a sterile field for a procedure. Which action(s) by a surgical team member should the nurse identify as contaminating the sterile field? Select all that apply.

6 : A client weighing 70 kg is receiving 75 mcg of medication in 150 mL IV solution. The drop rate is 25 gtts/min with tubing delivering 15 gtts/ml. How many mcg/kg/min is the client receiving? 1 mcg/kg/min (If needed, round to the nearest hundredth.)

7 : When should the medication label be compared to the medication administration record (MAR) as part of the medication administration process Select all that apply.

8 : The nurse cares for a client needing assistance with bathing. What instruction should the nurse provide the unlicensed assistive personnel (UAP) when assisting the client with their bed bath to maintain warmth?

9 : The nurse observes the unlicensed assistive personnel (UAP) obtain a client's blood pressure. Which action by the UAP requires intervention?

10 : A nurse is reviewing a healthcare provider's prescription that reads "acetaminophen 650 mg PO What is the nurse's best action?

1 :
A nurse is caring for a client whose respiratory rate is 40 breaths per minute. The client's respirations are abnormally deep. How would the nume document this finding in the electronic health record?

2 :
A nurse provides education to a client on how to properly apply a vaginal cream for the treatment of a fungal infection. Which client statement demonstrates effective learning has occurred?

3 :
The nurse is assessing a client with a wound. What question should the nurse ask to assess for sensation during the wound assessment?

4 :
A client reports feeling better and wants to stop taking their prescribed medication. How should the nurse respond?

5 :
A nurse prepares a sterile field for a procedure. Which action(s) by a surgical team member should the nurse identify as contaminating the sterile field? Select all that apply.

6 :
A client weighing 70 kg is receiving 75 mcg of medication in 150 mL IV solution. The drop rate is 25 gtts/min with tubing delivering 15 gtts/ml. How many mcg/kg/min is the client receiving? 1 mcg/kg/min (If needed, round to the nearest hundredth.)

7 :
When should the medication label be compared to the medication administration record (MAR) as part of the medication administration process Select all that apply.

8 :
The nurse cares for a client needing assistance with bathing. What instruction should the nurse provide the unlicensed assistive personnel (UAP) when assisting the client with their bed bath to maintain warmth?

9 :
The nurse observes the unlicensed assistive personnel (UAP) obtain a client's blood pressure. Which action by the UAP requires intervention?

10 :
A nurse is reviewing a healthcare provider's prescription that reads "acetaminophen 650 mg PO What is the nurse's best action?