Question

Nurse B receives report from Nurse A (see notes above). Which nursing action by Nurse B exhibits a critical

Answer 1

Correct Answers:

Nurse B approaches the client with an open mind, as if they are not aware of any behavioral issues.

Rationale :

🔷Approaching the client with an unbiased assessment reflects critical thinking and therapeutic communication, preventing premature labeling that can damage rapport.

🔷An open mind reduces confirmation bias, allowing Nurse B to identify underlying causes of agitation (e.g., pain, anxiety, delirium, unmet needs) and tailor care appropriately.

🔷This stance promotes a patient-centered, nonjudgmental environment that de-escalates tension and invites collaboration in care.

🔷It enables the nurse to use active listening, validate feelings, and engage in shared problem-solving, which improves adherence and safety.

🔷Starting with curiosity rather than confrontation preserves the therapeutic relationship and supports safe, trauma-informed practice.

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Answer 2

Correct Answers:

Axillary nerve damage

Rationale :

🩼Improper crutch use—especially bearing weight in the axilla or crutches that are too long—can compress the brachial plexus/axillary nerve, leading to neuropathy.

🩼Resulting deficits may include numbness, paresthesias, weakness, and difficulty with shoulder abduction or arm elevation.

🩼Safe technique places body weight through the hands on the handgrips, keeping 2–3 fingerbreadths of space between the axilla and crutch top.

🩼Proper height adjustment and gait training (e.g., 3-point gait post–lower-extremity injury) reduce nerve compression risk.

🩼Ongoing assessment for neurovascular changes in the upper extremities helps identify early nerve injury and triggers prompt correction.

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Answer 3

Correct Answers:

Encourage the client to participate as much as possible.

Rationale :

🛁Encouraging maximal participation preserves dignity, autonomy, and mobility, which are central to patient-centered care.

🛁Even small tasks (washing face/hands, holding the towel) promote range of motion, reduce deconditioning, and support skin assessment.

🛁Shared involvement improves therapeutic rapport and can decrease agitation by giving the patient control over care.

🛁It enables real-time education on hygiene and pressure-injury prevention strategies.

🛁Tailoring assistance based on tolerance and fatigue keeps the activity safe and restorative.

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Answer 4

Correct Answers:

"l will look up medication times if the healthcare provider asks for it."

Rationale :

📞Effective consultations require having pertinent data ready (vitals, labs, med times/doses, assessments) before calling.

📞Stating you’ll “look it up if asked” shows lack of preparation and risks delays or incomplete recommendations.

📞A structured SBAR (Situation-Background-Assessment-Recommendation) improves clarity and clinical decision-making.

📞Preparation conveys credibility and facilitates timely orders or care changes.

📞Thorough ready-to-report data reduce communication errors and enhance patient safety.

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Answer 5

Correct Answers:

"Can you tell me what level your pain is at now?"

Rationale :

💊Pain reassessment must use a standardized scale (e.g., 0–10) to compare pre- and post-intervention levels objectively.

💊This aligns with the pain management cycle: assess → intervene → reassess → document → adjust.

💊Numeric ratings guide whether to continue, escalate, or switch therapies (e.g., multimodal analgesia).

💊Objective reassessment supports safe dosing and mitigates breakthrough pain.

💊Clear documentation of response and timing meets quality and regulatory expectations.

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Answer 6

Correct Answers:

need for the restraint.
behavioral status.
neurovascular status.
skin integrity.

Rationale :

Need for the restraint

🔷 Continuous re-evaluation ensures restraints remain clinically justified and are used for the shortest possible time.

🔷 Confirm that less-restrictive alternatives (reorientation, sitter, de-escalation, concealment of lines) were attempted and ineffective.

🔷 Document clear behavioral/safety indications and the provider order with time limits per policy (e.g., reassess at set intervals).

🔷 Prompt removal once criteria are no longer met prevents harm, supports autonomy, and aligns with regulatory standards.

🔷 Communicate with the team and family so everyone understands goals, risks, and exit criteria for restraint use.

Behavioral status

🔷 Assess level of consciousness, agitation, orientation, and triggers to tailor non-pharmacologic strategies and reduce restraint time.

🔷 Track patterns (e.g., sundowning, pain, hypoxia, urinary retention) that may be driving behaviors amenable to treatment.

🔷 Use therapeutic communication and calming strategies (quiet environment, glasses/hearing aids, family presence) to improve cooperation.

🔷 Frequent behavioral checks (per policy) support early de-escalation and safer care.

🔷 Accurate, objective documentation (what was observed and what worked) guides the next interventions.

Neurovascular status

🔷 Check CMS—circulation, motion, sensation—for early signs of ischemia or nerve compression (coolness, pallor, numbness, tingling).

🔷 Verify capillary refill, pulses, range of motion, and ensure two-finger space under the restraint to prevent injury.

🔷 Reassess frequently and loosen/adjust if any compromise is detected; escalate promptly if deficits persist.

🔷 Position to avoid joint pressure and perform ROM exercises at ordered intervals to maintain function.

🔷 Early detection prevents neuropathy, pressure injury, and tissue damage.

Skin integrity

🔷 Inspect skin under and around the restraint for redness, moisture, abrasions, or breakdown at each check.

🔷 Use padding and keep skin clean and dry to reduce friction, shear, and maceration.

🔷 Provide routine hygiene, repositioning, and release intervals per policy to promote perfusion and comfort.

🔷 Document findings and interventions (barrier creams, padding changes) to track trends and effectiveness.

🔷 Vigilant skin care prevents pressure injuries and supports a safe, patient-centered restraint plan.

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Answer 7

Correct Answers:

need for the restraint.
behavioral status.
neurovascular status.
skin integrity.

Rationale :

Need for the restraint

🔷 Continuous re-evaluation ensures restraints remain clinically justified and are used for the shortest possible time.

🔷 Confirm that less-restrictive alternatives (reorientation, sitter, de-escalation, concealment of lines) were attempted and ineffective.

🔷 Document clear behavioral/safety indications and the provider order with time limits per policy (e.g., reassess at set intervals).

🔷 Prompt removal once criteria are no longer met prevents harm, supports autonomy, and aligns with regulatory standards.

🔷 Communicate with the team and family so everyone understands goals, risks, and exit criteria for restraint use.

Behavioral status

🔷 Assess level of consciousness, agitation, orientation, and triggers to tailor non-pharmacologic strategies and reduce restraint time.

🔷 Track patterns (e.g., sundowning, pain, hypoxia, urinary retention) that may be driving behaviors amenable to treatment.

🔷 Use therapeutic communication and calming strategies (quiet environment, glasses/hearing aids, family presence) to improve cooperation.

🔷 Frequent behavioral checks (per policy) support early de-escalation and safer care.

🔷 Accurate, objective documentation (what was observed and what worked) guides the next interventions.

Neurovascular status

🔷 Check CMS—circulation, motion, sensation—for early signs of ischemia or nerve compression (coolness, pallor, numbness, tingling).

🔷 Verify capillary refill, pulses, range of motion, and ensure two-finger space under the restraint to prevent injury.

🔷 Reassess frequently and loosen/adjust if any compromise is detected; escalate promptly if deficits persist.

🔷 Position to avoid joint pressure and perform ROM exercises at ordered intervals to maintain function.

🔷 Early detection prevents neuropathy, pressure injury, and tissue damage.

Skin integrity

🔷 Inspect skin under and around the restraint for redness, moisture, abrasions, or breakdown at each check.

🔷 Use padding and keep skin clean and dry to reduce friction, shear, and maceration.

🔷 Provide routine hygiene, repositioning, and release intervals per policy to promote perfusion and comfort.

🔷 Document findings and interventions (barrier creams, padding changes) to track trends and effectiveness.

🔷 Vigilant skin care prevents pressure injuries and supports a safe, patient-centered restraint plan.

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Answer 8

Correct Answers:

Spills sterile water onto the sterile field

Rationale :

🧪 Fluid on a porous drape can cause strike-through contamination, rendering the field unsterile.

🧪 Once the barrier is wet, microorganisms can wick from nonsterile to sterile areas.

🧪 The correct response is to stop and re-establish a new sterile field.

🧪 Maintaining the field dry, above the waist, and in view preserves sterility.

🧪 Meticulous pouring technique (at the edge, without splashing) prevents contamination.

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Answer 9

Correct Answers:

700

Rationale :

✍️1 gram = 1,000,000 micrograms (mcg).

✍️0.007 g × 1,000,000

↦7000 mcg.

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Answer 10

Correct Answers:

Have a designated blood pressure cuff in the client's room.

Rationale :

🧰Varicella requires airborne + contact precautions; using dedicated equipment prevents fomite transmission to other patients.

🧰A room-specific BP cuff/thermometer/stethoscope limits cross-contamination during frequent vital-sign checks.

🧰Combine with appropriate PPE (e.g., N95 respirator in room, gloves, gown) and limit transport unless necessary.

🧰If transport is unavoidable, mask the patient and cover lesions to reduce environmental spread.

🧰Environmental cleaning should use an EPA-approved disinfectant, not just warm soapy water.

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NUR104 July 2025 Exam 1

No.

1 :
Nurse B receives report from Nurse A (see notes above). Which nursing action by Nurse B exhibits a critical

2 :
One of the complications associated with the improper use of crutches is:

3 :
The nurse prepares to bathe a bedridden client. Which nursing intervention is most appropriate

4 :
The nurse prepares to make a phone consultation with the healthcare provider. Which statement by the nurse indicates they are not prepared for the consultation?

5 :
The nurse cares for a client who reports leg pain at the level of 10/10. The nurse administers pain medication to the client as ordered. What will the nurse ask the client, to determine if this intervention has been effective?

6 :
The nurse is caring for a 72 year old patient in bilateral soft wrist restraints. The nurse should assess the client’s? Select all that apply.

7 :
The nurse is caring for a 72 year old patient in bilateral soft wrist restraints. The nurse should assess the client’s? Select all that apply.

8 :
The nurse is observing the surgical aseptic technique of a nursing student. Which observation by the nurse requires follow-up

9 :
Convert 0.007 g to mcg. Round to the nearest whole number.

10 :
The nurse is caring for a child admitted with varicella. Which of the following actions should the nurse take

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NUR104 July 2025 Exam 1

No.

1 : Nurse B receives report from Nurse A (see notes above). Which nursing action by Nurse B exhibits a critical

2 : One of the complications associated with the improper use of crutches is:

3 : The nurse prepares to bathe a bedridden client. Which nursing intervention is most appropriate

4 : The nurse prepares to make a phone consultation with the healthcare provider. Which statement by the nurse indicates they are not prepared for the consultation?

5 : The nurse cares for a client who reports leg pain at the level of 10/10. The nurse administers pain medication to the client as ordered. What will the nurse ask the client, to determine if this intervention has been effective?

6 : The nurse is caring for a 72 year old patient in bilateral soft wrist restraints. The nurse should assess the client’s? Select all that apply.

7 : The nurse is caring for a 72 year old patient in bilateral soft wrist restraints. The nurse should assess the client’s? Select all that apply.

8 : The nurse is observing the surgical aseptic technique of a nursing student. Which observation by the nurse requires follow-up

9 : Convert 0.007 g to mcg. Round to the nearest whole number.

10 : The nurse is caring for a child admitted with varicella. Which of the following actions should the nurse take

1 :
Nurse B receives report from Nurse A (see notes above). Which nursing action by Nurse B exhibits a critical

2 :
One of the complications associated with the improper use of crutches is:

3 :
The nurse prepares to bathe a bedridden client. Which nursing intervention is most appropriate

4 :
The nurse prepares to make a phone consultation with the healthcare provider. Which statement by the nurse indicates they are not prepared for the consultation?

5 :
The nurse cares for a client who reports leg pain at the level of 10/10. The nurse administers pain medication to the client as ordered. What will the nurse ask the client, to determine if this intervention has been effective?

6 :
The nurse is caring for a 72 year old patient in bilateral soft wrist restraints. The nurse should assess the client’s? Select all that apply.

7 :
The nurse is caring for a 72 year old patient in bilateral soft wrist restraints. The nurse should assess the client’s? Select all that apply.

8 :
The nurse is observing the surgical aseptic technique of a nursing student. Which observation by the nurse requires follow-up

9 :
Convert 0.007 g to mcg. Round to the nearest whole number.

10 :
The nurse is caring for a child admitted with varicella. Which of the following actions should the nurse take