Question

A nurse is planning care for a client who is to receive a competitive neuromuscular blocking agent. Which of the following items should the nurse plan to have at the client's bedside?

Answer 1

Correct Answers:

Bag-valve-mask device

Rationale :

💎 Neuromuscular blockers paralyze skeletal muscles, including respiratory muscles.

💎 Bag-valve-mask provides immediate ventilation support in case of apnea.

💎 Central venous or urinary catheter trays are not immediate life-saving necessities.

💎 Temporary pacemaker is not indicated unless patient has cardiac conduction issues.

💎 Having this device at bedside ensures patient safety and rapid emergency intervention.

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Answer 2

Correct Answers:

Frequent skin assessments
Inspect the sacrum for blanching
Frequent turning and positioning
Optimizing nutrition

Rationale :

💎 Frequent skin assessments identify early tissue damage.

💎 Checking for blanching detects pressure areas before ulcer formation.

💎 Regular turning and positioning relieves prolonged pressure on bony prominences.

💎 Proper nutrition supports tissue integrity and wound healing.

💎 Maintaining head of bed at 45° may increase sacral pressure, so it is not always protective.

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Answer 3

Correct Answers:

Wash hands with soap and water

Rationale :

💎 C. difficile spores are resistant to alcohol-based sanitizers.

💎 Soap and water mechanically remove spores from hands.

💎 Bleach wipes clean surfaces but do not replace proper hand hygiene.

💎 Donning new gloves without handwashing risks self-contamination.

💎 Correct hand hygiene prevents nosocomial transmission to other patients and staff.

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Answer 4

Correct Answers:

Chest x-ray
Collect specimen x3 mornings for acid-fast bacilli
Admit to a negative pressure room

Rationale :

💎 Chest x-ray detects lung infiltrates suggestive of active TB.

💎 Collecting multiple AFB sputum samples confirms diagnosis microbiologically.

💎 Negative pressre isolation prevents airborne transmission.

💎 Vital signs and lab panels may be useful but do not confirm TB.

💎 Heart-healthy diet is supportive but not diagnostic or infection control related.

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Answer 5

Correct Answers

Blank 1 Correct Option: patent
Blank 2 Correct Option: obstruction
Blank 3 Correct Option: dosing

Rationale :

💎 The nurse must ensure the IV line is patent to guarantee medication reaches the circulation.

💎 An obstruction in the IV line can prevent the full dose from being delivered.

💎 If the IV is obstructed, dosing of analgesics like morphine or ketorolac is compromised.

💎 Proper IV assessment ensures effective pain management and patient safety.

💎 Checking patency also prevents delays in relief and potential complications from missed doses.

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Answer 6

Correct Answers:

Headache, nausea, vomiting, and anorexia are known side effects of these medications.
We will measure the effectiveness of ART by measuring CD4+T cell counts
These medications should keep the viral load suppressed

Rationale :

💎 Dolutegravir and Lamivudine can cause mild side effects including headache, nausea, vomiting, and anorexia.

💎 CD4+ T cell counts are monitored to evaluate immune system recovery and ART effectiveness.

💎 ART aims to suppress viral replication, keeping viral load low and preventing disease progression.

💎 Taking ART with antacids or doubling missed doses can interfere with absorption and efficacy.

💎 Educating patients ensures adherence, monitoring for side effects, and understanding treatment goals.

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Answer 7

Correct Answers:

Inability to pass stools
Decreased urinary output
Rigid abdomen

Rationale :

💎 Peritonitis causes paralytic ileus, resulting in inability to pass stools or flatus.

💎 Inflammation and third-spacing can lead to decreased urinary output due to hypovolemia.

💎 Abdominal rigidity is a classic sign of peritoneal irritation.

💎 Frequent bowel movements and hyperactive bowel sounds are not expected; bowel activity is typically diminished.

💎 Recognizing these signs ensures prompt diagnosis and initiation of treatment, including fluids and antibiotics.

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Answer 8

Correct Answers:

Urine output

Rationale :

💎 Urine output is the most reliable indicator of effective fluid resuscitation in burn patients.

💎 Adequate renal perfusion indicates restoration of intravascular volume.

💎 Weight, heart rate, and blood pressure can be influenced by other factors and are less precise indicators.

💎 Monitoring urine output helps prevent under- or over-resuscitation, reducing risk of complications.

💎 Typical goal: 0.5–1 mL/kg/hr for adults during acute burn fluid management.

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Answer 9

Correct Answers:

Chocolate
Grapefruit
French fries

Rationale :

💎 Chocolate, citrus (grapefruit), and fatty foods (French fries) relax the lower esophageal sphincter, worsening reflux.

💎 High-fat and acidic foods increase gastric acid production and heartburn symptoms.

💎 Oatmeal and chicken are low-fat, non-acidic foods suitable for GERD diets.

💎 Dietary modification reduces symptoms and prevents esophagitis.

💎 Patient education on trigger foods improves quality of life.

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Answer 10

Correct Answers:

Aplastic anemia

Rationale :

💎 Zidovudine can suppress bone marrow, leading to aplastic anemia.

💎 Cardiac dysrhythmia, renal failure, and metabolic alkalosis are not typical adverse effects.

💎 Regular CBC monitoring is required to detect early marrow suppression.

💎 Early detection prevents life-threatening complications like pancytopenia.

💎 Patient education includes reporting unusual fatigue, bruising, or infections.

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Custom NUR213 Midpoint Assessment FA 1 2025_Assessment 1

No.

1 :
A nurse is planning care for a client who is to receive a competitive neuromuscular blocking agent. Which of the following items should the nurse plan to have at the client's bedside?

2 :
Pressure injuries can occur to the skin and underlying tissues due to pressure. shear or friction. Which of the following can reduce the incidence of pressure injuries in hospitalized clients? (Select All that Apply.)

3 :
A nurse is caring for a client with the diagnosis of clostridium difficile. While providing care to the client, the nurse's glove tears. After removing the soiled gloves, what is the priority action by the the nurse?

4 :
You are caring for a patient with a positive TB skin test (15mm), productive cough for two months, and unintentional weight loss. Which of the following orders will assist with the diagnosis of active tuberculosis? (Select All that Apply.)

5 :
The nurse is assigned a post-operative total hip replacement patient reporting incisional pain that is not managed with current pain medications.

Correct Answers

6 :
A patient tests positive for HIV.

Answer Options

7 :
The nurse is assessing a patient with peritonitis. What findings should they expect? (Select All that Apply.)

8 :
A nurse is monitoring a client who was admitted with a severe burn injury and is receiving IV fluid resuscitation therapy. The nurse should identify a decrease in which of the following findings as an indication of adequate fluid replacement?

9 :
The nurse is caring for a patient with a new diagnosis of gastroesophageal reflux disease. The patient asks what types of food they should avoid. The nurse tells the patient to avoid which of the following foods? (Select All that Apply.)

10 :
A nurse is caring for a client who has HIV-I infection and is prescribed zidovudine as part of antiretroviral therapy. The nurse should monitor the client for which of the following adverse effects of this medication?

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Custom NUR213 Midpoint Assessment FA 1 2025_Assessment 1

No.

1 : A nurse is planning care for a client who is to receive a competitive neuromuscular blocking agent. Which of the following items should the nurse plan to have at the client's bedside?

2 : Pressure injuries can occur to the skin and underlying tissues due to pressure. shear or friction. Which of the following can reduce the incidence of pressure injuries in hospitalized clients? (Select All that Apply.)

3 : A nurse is caring for a client with the diagnosis of clostridium difficile. While providing care to the client, the nurse's glove tears. After removing the soiled gloves, what is the priority action by the the nurse?

4 : You are caring for a patient with a positive TB skin test (15mm), productive cough for two months, and unintentional weight loss. Which of the following orders will assist with the diagnosis of active tuberculosis? (Select All that Apply.)

5 : The nurse is assigned a post-operative total hip replacement patient reporting incisional pain that is not managed with current pain medications.

Correct Answers

6 : A patient tests positive for HIV.

Answer Options

7 : The nurse is assessing a patient with peritonitis. What findings should they expect? (Select All that Apply.)

8 : A nurse is monitoring a client who was admitted with a severe burn injury and is receiving IV fluid resuscitation therapy. The nurse should identify a decrease in which of the following findings as an indication of adequate fluid replacement?

9 : The nurse is caring for a patient with a new diagnosis of gastroesophageal reflux disease. The patient asks what types of food they should avoid. The nurse tells the patient to avoid which of the following foods? (Select All that Apply.)

10 : A nurse is caring for a client who has HIV-I infection and is prescribed zidovudine as part of antiretroviral therapy. The nurse should monitor the client for which of the following adverse effects of this medication?

1 :
A nurse is planning care for a client who is to receive a competitive neuromuscular blocking agent. Which of the following items should the nurse plan to have at the client's bedside?

2 :
Pressure injuries can occur to the skin and underlying tissues due to pressure. shear or friction. Which of the following can reduce the incidence of pressure injuries in hospitalized clients? (Select All that Apply.)

3 :
A nurse is caring for a client with the diagnosis of clostridium difficile. While providing care to the client, the nurse's glove tears. After removing the soiled gloves, what is the priority action by the the nurse?

4 :
You are caring for a patient with a positive TB skin test (15mm), productive cough for two months, and unintentional weight loss. Which of the following orders will assist with the diagnosis of active tuberculosis? (Select All that Apply.)

5 :
The nurse is assigned a post-operative total hip replacement patient reporting incisional pain that is not managed with current pain medications.

6 :
A patient tests positive for HIV.

7 :
The nurse is assessing a patient with peritonitis. What findings should they expect? (Select All that Apply.)

8 :
A nurse is monitoring a client who was admitted with a severe burn injury and is receiving IV fluid resuscitation therapy. The nurse should identify a decrease in which of the following findings as an indication of adequate fluid replacement?

9 :
The nurse is caring for a patient with a new diagnosis of gastroesophageal reflux disease. The patient asks what types of food they should avoid. The nurse tells the patient to avoid which of the following foods? (Select All that Apply.)

10 :
A nurse is caring for a client who has HIV-I infection and is prescribed zidovudine as part of antiretroviral therapy. The nurse should monitor the client for which of the following adverse effects of this medication?