Font size
WorksheetsNUR 265 Exam 3 Review
Total questions: 58
Worksheet time: 5hrs 50mins
A NURSE IS PLANNING CARE FOR A CLIENT WHO HAS SEPSIS. WHICH OF THE FOLLOWING ACTIONS IS A
PRIORITY FOR THE NURSE TO TAKE?
MAINTAIN ADEQUATE FLUID VOLUME WITH IV INFUSIONS.
ADMINISTER ANTIBIOTIC THERAPY.
MONITOR HEMODYNAMIC STATUS
ADMINISTER VASOPRESSOR MEDICATION
A CHILD UNDERGOES SURGICAL REMOVAL OF A BRAIN TUMOR. DURING THE
POSTOPERATIVE PERIOD, THE NURSE NOTES THAT THE CHILD IS RESTLESS,
THE PULSE RATE IS ELEVATED, AND THE BLOOD PRESSURE HAS DECREASED
SIGNIFICANTLY FROM THE BASELINE VALUE. THE NURSE SUSPECTS THAT THE
CHILD IS IN SHOCK. WHICH OF THE FOLLOWING NURSING ACTIONS WOULD BE
APPROPRIATE?
PLACE THE CHILD IN A SUPINE POSITION FEET UP
NOTIFY THE HEALTH CARE PROVIDER (HCP)
PLACE THE CHILD IN TRENDELENBURG'S POSITION.
INCREASE THE FLOW RATE OF THE INTRAVENOUS FLUIDS.
THE NURSE WORKING IN THE EMERGENCY DEPARTMENT (ED) IS CARING FOR A CLIENT WITH A 65% TOTAL
BODY SURFACE AREA (TBSA) BURN INJURY. AFTER ASSESSING FOR PATENCY OF THE CLIENT’S AIRWAY, WHICH OF THE FOLLOWING ACTIONS WOULD BE THE PRIORITY?
PERFORM A FULL NEUROLOGICAL ASSESSMENT
PREPARE TO TRANSFER THE CLIENT TO THE NEAREST BURN UNIT.
INSERT AN INDWELLING URETHRAL CATHETER
INITIATE PRESCRIBED INTRAVENOUS (IV) FLUIDS.
AN OLDER CLIENT IS HOSPITALIZED WITH GUILLAIN-BARR SYNDROME. A FAMILY MEMBER TELLS THE NURSE THE CLIENT IS RESTLESS AND SEEMS CONFUSED. WHAT ACTION BY THE NURSE IS BEST?
PLACE THE CLIENT ON A BED ALARM
CHECK THE MEDICATION LIST FOR INTERACTIONS
ASSESS THE CLIENT’S OXYGEN SATURATION
PUT THE CLIENT ON SAFETY PRECAUTIONS
THE NURSE IS REVIEWING THE LABORATORY TEST RESULTS FOR A CLIENT ADMITTED
TO THE BURN UNIT 3 HOURS AFTER AN EXPLOSION THAT OCCURRED AT A WORKSITE.
THE CLIENT HAS A SEVERE BURN INJURY THAT COVERS 35% OF THE TOTAL BODY
SURFACE AREA (TBSA). THE NURSE IS MOST LIKELY TO NOTE WHICH FINDING ON THE
LABORATORY REPORT?
HEMATOCRIT 60% (0.60)
SERUM ALBUMIN 4.8 G/DL (48 G/L)
SERUM SODIUM 144 MEQ/L (144 MMOL/L)
WHITE BLOOD CELL (WBC) COUNT 9000 MM3 (9 × 109/L)
A NURSE IS CARING FOR FOUR CLIENTS IN THE NEUROLOGIC INTENSIVE CARE UNIT.
AFTER RECEIVING THE HAND-OFF REPORT, WHICH CLIENT SHOULD THE NURSE SEE
FIRST?
Client with Glasgow Coma Scale that was 10 and is now 8
CLIENT WITH A GLASGOW COMA SCALE SCORE THAT WAS 9 AND IS NOW IS 12
CLIENT WITH A MODERATE BRAIN INJURY WHO IS AMNESIC FOR THE EVENT
CLIENT WHO IS REQUESTING PAIN MEDICATION FOR A HEADACHE
THE NURSE WORKING IN THE EMERGENCY DEPARTMENT (ED) IS CARING FOR MULTIPLE CLIENTS WHO
WERE RESCUED FROM AN APARTMENT FIRE. IT WOULD BE NECESSARY FOR THE NURSE TO INITIALLY
ASSESS THE CLIENT WHO IS
10-YEARS OLD WITH SUPERFICIAL BURNS TO BOTH ARMS, A HISTORY OF SEIZURES, AND AN OXYGEN
SATURATION OF 95% ON 2 LITERS OF NASAL CANNULA OXYGEN
23-YEARS OLD WITH SUPERFICIAL PARTIAL-THICKNESS BURNS TO BOTH HANDS, A HISTORY OF
HYPERTHYROIDISM, AND SWELLING OF THE FINGERS
60-YEARS OLD WITH FULL THICKNESS BURNS TO FEET, A HISTORY OF BLADDER CANCER, AND IS
SCHEDULED FOR SURGICAL WOUND DEBRIDEMENT IN FOUR HOURS
65-YEARS OLD WITH DEEP PARTIAL--THICKNESS BURNS TO THE CHEST, A HISTORY OF
CARDIOMYOPATHY, AND AUDIBLE WHEEZES..
THE NURSE IS CARING FOR FOUR CLIENTS WITH TRAUMATIC BRAIN INJURIES.
WHICH CLIENT SHOULD THE NURSE ASSESS FIRST?
CLIENT WITH INCREASED INTRACRANIAL PRESSURE OF 12 MM HG
CLIENT WHO HAS A GLASGOW COMA SCALE SCORE OF 12
CLIENT WITH A PACO2 OF 36 MM HG WHO IS ON A VENTILATOR
CLIENTLIENT WHO HAS A TEMPERATURE OF 102 F (38.9 C)
AFTER A CRANIOTOMY, THE NURSE ASSESSES THE CLIENT AND FINDS DRY, STICKY
MUCOUS MEMBRANES AND RESTLESSNESS. THE CLIENT HAS IV FLUIDS RUNNING AT 75
ML/HR. WHAT ACTION BY THE NURSE IS BEST?
ASSESS THE CLIENT’S MAGNESIUM LEVEL.
ASSESS THE CLIENT’S SODIUM LEVEL.
INCREASE THE RATE OF THE IV INFUSION
PROVIDE ORAL CARE EVERY HOUR
THE PATIENT IS ADMITTED WITH INJURIES THAT WERE SUSTAINED IN A FALL. DURING THE
NURSE'S FIRST ASSESSMENT UPON ADMISSION, THE FINDINGS ARE: BLOOD PRESSURE 90/60
(AS COMPARED TO 136/66 IN THE EMERGENCY DEPARTMENT), FLACCID PARALYSIS OF
LOWER EXTREMITIES, ABSENT BOWEL SOUNDS, ZERO URINE OUTPUT, AND PALPATION OF A
DISTENDED BLADDER. THESE SIGNS ARE CONSISTENT WITH WHICH OF THE FOLLOWING?
PARALYSIS
SPINAL SHOCK
HIGH CERVICAL INJURY
TEMPORARY HYPOVOLEMIA
THE NURSE RECOGNIZES THAT WHICH PATIENT WOULD BE MOST LIKELY TO
DEVELOP HYPOVOLEMIC SHOCK? A PATIENT WITH:
DECREASED CARDIAC OUTPUT
SEVERE CONSTIPATION
ASCITES
SYNDROME OF INAPPROPRIATE ADH (SIADH)
A NURSE IS CARING FOR FOUR CLIENTS IN THE NEUROLOGIC/NEUROSURGICAL INTENSIVE CARE UNIT.
WHICH CLIENT SHOULD THE NURSE ASSESS FIRST?
A CLIENT WHO HAS BEEN DIAGNOSED WITH MENINGITIS WITH A FEVER OF 101 F (38.3 C)
A CLIENT WHO HAD A TRANSIENT ISCHEMIC ATTACK AND IS WAITING FOR TEACHING ON CLOPIDOGREL
(PLAVIX).
A CLIENT RECEIVING TISSUE PLASMINOGEN ACTIVATOR (TPA) WHO HAS A CHANGE IN RESPIRATORY PATTERN AND RATE.
A CLIENT WHO IS WAITING FOR SUBARACHNOID BOLT INSERTION WITH THE CONSENT FORM ALREADY
SIGNED.
A PATIENT WITH CARDIOGENIC SHOCK IS COOL AND CLAMMY AND
HEMODYNAMIC MONITORING INDICATES A HIGH SYSTEMIC VASCULAR
RESISTANCE (SVR). WHICH ACTION WILL THE NURSE ANTICIPATE TAKING?
INCREASE THE RATE FOR THE PRESCRIBED DOPAMINE (INTROPIN) INFUSION
DECREASE THE RATE FOR THE PRESCRIBED NITROGLYCERIN (TRIDIL)
INFUSION.
DECREASE THE RATE FOR THE PRESCRIBED 5% DEXTROSE IN WATER
(D5W) INFUSION.
INCREASE THE RATE FOR THE PRESCRIBED SODIUM NITROPRUSSIDE
(NIPRIDE)) INFUSION..
A PATIENT WITH CARDIOGENIC SHOCK HAS THE FOLLOWING VITAL SIGNS: BP 86/50, PULSE
126, RESPIRATIONS 30. THE CVP AND CARDIAC OUTPUT IS LOW. THE NURSE WILL
ANTICIPATE
INFUSION OF 5% HUMAN ALBUMIN..
ADMINISTRATION OF FUROSEMIDE (LASIX) IV.
TITRATION OF AN EPINEPHRINE (ADRENALIN) DRIP.
INFUSION OF NORMAL SALINE AT 150 MLS/HR
A PATIENT WITH SEPTIC SHOCK HAS A URINE OUTPUT OF 20 ML/HR FOR THE
PAST 3 HOURS. THE PULSE RATE IS 120 AND THE CENTRAL VENOUS PRESSURE
(CVP) ARE LOW. WHICH OF THESE ORDERS BY THE HEALTH CARE PROVIDER
WILL THE NURSE QUESTION?
GIVE FUROSEMIDE (LASIX) 40 MG IV
INCREASE NORMAL SALINE INFUSION TO 150 ML/HR
ADMINISTER HYDROCORTISONE (SOLUCORTEF) 100 MG IV
PREPARE TO GIVE ROCEPHIN 1 GRAM DAILY FOR 4 DAYS
A CLIENT WITH MYASTHENIA GRAVIS IS HAVING DIFFICULTY WITH AIRWAY CLEARANCE AND
DIFFICULTY WITH MAINTAINING AN EFFECTIVE BREATHING PATTERN. THE NURSE SHOULD
KEEP WHICH MOST IMPORTANT ITEMS AVAILABLE AT THE CLIENT'S BEDSIDE?
OXYGEN AND METERED-DOSE INHALER
AMBU BAG AND SUCTION EQUIPMENT
PULSE OXIMETER AND CARDIAC MONITOR
INCENTIVE SPIROMETER AND COUGH PILLOW
THE NURSE HAS COMPLETED THE DISCHARGE INSTRUCTIONS FOR A
CLIENT WITH APPLICATION OF A HALO VEST DEVICE. WHICH OF THE
FOLLOWING STATEMENTS FROM THE CLIENT INDICATES A NEED FOR
FURTHER TEACHING OF THE INSTRUCTIONS?
“I WILL USE A STRAW FOR DRINKING”
“I WILL DRIVE ONLY DURING THE DAYTIME HOURS”
“I WILL BE CAREFUL BECAUSE THE DEVICE ALTERS BALANCE”.
“I WILL WASH THE SKIN DAILY UNDER THE LAMB’S WOOL LINER VEST”
HE NURSE IS CARING FOR THE CLIENT WITH INCREASED ICP. THE NURSE WOULD NOTE
WHICH OF THE FOLLOWING VITAL SIGNS IF THE ICP IS RISING?
INCREASING TEMP., INCREASING HR, INCREASING RESPIRATIONS, DECREASING BP
INCREASING TEMP., DECREASING HR, DECREASING RESPIRATIONS, INCREASING BP
DECREASING TEMP., DECREASING HR, INCREASING RESPIRATIONS, DECREASING BP
DECREASING TEMP., INCREASING HR, DECREASING RESPIRATIONS, INCREASING BP
A NURSE OBTAINS A FOCUSED HEALTH HISTORY FOR A CLIENT WHO IS SUSPECTED OF
HAVING BACTERIAL MENINGITIS. WHICH QUESTION SHOULD THE NURSE ASK?
DO YOU LIVE IN A CROWDED RESIDENCE??
WHEN WAS YOUR LAST TETANUS VACCINATION?
HAVE YOU HAD ANY VIRAL INFECTIONS RECENTLY?
HAVE YOU TRAVELED OUT OF THE COUNTRY IN THE LAST MONTH?
A NURSE IS ASSESSING A CLIENT WHO SUSTAINED DEEP PARTIAL‑THICKNESS AND
FULL‑THICKNESS BURNS OVER 40% OF HIS UPPER BODY 24 HR AGO. WHICH OF THE
FOLLOWING ARE FINDINGS SHOULD THE NURSE EXPECT? (SELECT ALL THAT APPLY.)
DYSPNEA
BRADYCARDIA
HYPERKALEMIA
HYPONATREMIA
DECREASED HEMATOCRIT
A NURSE IS PLANNING CARE FOR AN ADULT CLIENT WHO SUSTAINED SEVERE BURN
INJURIES. WHICH OF THE FOLLOWING INTERVENTIONS SHOULD THE NURSE INCLUDE IN
THE PLAN OF CARE? (SELECT ALL THAT APPLY.)
LIMIT VISITORS IN THE CLIENT’S ROOM
ENCOURAGE FRESH VEGETABLES IN THE DIET
INCREASE PROTEIN INTAKE
INSTRUCT THE CLIENT TO CONSUME 2,000 CALORIES/DAY
RESTRICT FRESH FLOWERS IN THE ROOM
A CLIENT WITH MYASTHENIA GRAVIS HAS THE PRIORITY CLIENT PROBLEM OF INADEQUATE
NUTRITION. WHAT ASSESSMENT FINDING INDICATES THAT THE PRIORITY GOAL FOR THIS
CLIENT PROBLEM HAS BEEN MET?
ABILITY TO CHEW AND SWALLOW WITHOUT ASPIRATION
EATING 75% OF MEALS AND BETWEEN-MEAL SNACKS
INTAKE GREATER THAN OUTPUT 3 DAYS IN A ROW
WEIGHT GAIN OF 3 POUNDS IN 1 MONTH
A NURSE ASSESSES A CLIENT WITH A SPINAL CORD INJURY AT LEVEL T5. THE CLIENTS
BLOOD PRESSURE IS 184/95 MM HG, AND THE CLIENT PRESENTS WITH A FLUSHED FACE
AND BLURRED VISION. WHICH ACTION SHOULD THE NURSE TAKE FIRST?
INITIATE OXYGEN VIA A NASAL CANNULA
PLACE THE CLIENT IN A SUPINE POSITION
PALPATE THE BLADDER FOR DISTENTION
ADMINISTER A PRESCRIBED BETA BLOCKER
AN EMERGENCY ROOM NURSE INITIATES CARE FOR A CLIENT WITH A CERVICAL SPINAL
CORD INJURY WHO ARRIVES VIA EMERGENCY MEDICAL SERVICES. WHICH ACTION SHOULD
THE NURSE TAKE FIRST?
ASSESS LEVEL OF CONSCIOUSNESS
OBTAIN VITAL SIGNS
ADMINISTER OXYGEN THERAPY
EVALUATE RESPIRATORY STATUS
THE NURSE IS CARING FOR A CLIENT WHO HAD A SEVERE TRAUMATIC BRAIN INJURY AND
IS BEING DISCHARGED HOME, WHERE THE SPOUSE WILL BE A FULL-TIME CAREGIVER.
WHAT STATEMENT BY THE SPOUSE WOULD LEAD THE NURSE TO PROVIDE FURTHER
EDUCATION ON HOME CARE?
I KNOW I CAN TAKE CARE OF ALL THESE NEEDS BY MYSELF
I NEED TO SEEK COUNSELING BECAUSE I AM VERY ANGRY
HOPEFULLY THINGS WILL IMPROVE GRADUALLY OVER TIME
WITH RESPITE CARE AND SUPPORT, I THINK I CAN DO THIS.
THE NURSE WORKING IN THE POSTANESTHESIA CARE UNIT (PACU) IS CARING FOR A CLIENT
WHO HAD AN ABDOMINAL AORTIC ANEURYSM (AAA) REPAIR. WHICH OF THE FOLLOWING
ASSESSMENT FINDINGS WOULD SUGGEST THAT THE CLIENT IS IN THE INITIAL (EARLY) STAGE
OF HYPOVOLEMIC SHOCK?
A DECREASE IN THE CLIENT’S MEAN ARTERIAL PRESSURE (MAP) OF 20 MM HG FROM
BASELINE.
AN INCREASE IN THE CLIENTS HEART RATE FROM 80 TO 107 BPM
A CHANGE IN PUPILLARY RESPONSE TO LIGHT FROM 4 TO 6 MM
A DECREASE IN RESPIRATORY RATE (RR) FROM 28 TO 14 BREATHS PER MINUTE
THE NURSE IS CARING FOR A 17-YEAR-OLD CLIENT INVOLVED IN A MOTOR VEHICLE CRASH
WHO IS IN THE REFRACTORY STAGE OF SHOCK. WHICH OF THE FOLLOWING ACTIONS
WOULD BE APPROPRIATE FOR THE NURSE TO TAKE?
RECOMMEND TO THE CASE MANAGER THAT THE CLIENT RECEIVE A REFERRAL FOR
PLACEMENT IN A LONG-TERM ACUTE CARE (LTAC) FACILITY
DETERMINE IF THE FAMILY WOULD LIKE TO SPEND TIME AT THE CLIENTS BEDSIDE
MONITOR THE CLIENT’S URINE OUTPUT ONCE EVERY 15 MINUTES
USE RINGER’S LACTATE (RL) WHEN ADMINISTERING A PRESCRIBED UNIT OF PACKED
RED BLOOD CELLS (PRBCS).
A PATIENT WITH MASSIVE TRAUMA AND POSSIBLE SPINAL CORD INJURY IS ADMITTED TO THE
EMERGENCY DEPARTMENT (ED). WHICH FINDING BY THE NURSE WILL HELP CONFIRM A
DIAGNOSIS OF NEUROGENIC SHOCK?
COOL, CLAMMY SKIN
INSPIRATORY CRACKLES
APICAL HEART RATE 48 BPM
TEMPERATURE 101.2° F (38.4° C)
During the acute phase of meningitis, which intervention is appropriate?
Limiting conversations with patient
Keeping extraneous noise to a minimum
Performing treatments quickly
Keep lights on so patient will not be confused
Which of the following would lead the nurse to suspect pneumococcal meningitis?
Bladder infection
Middle ear infection
Fractured clavicle
Septic arthritis
Which assessment would be priority when caring for a pt with Guillain-Barre syndrome?
assessing the ability to follow simple commands
evaluating bilateral muscle strength
range of motion exercises
providing a diversionary activity
Why do you assess speech for a pt with Guillain- Barre?
inflammation of the larynx and epiglottis
Increased ICP
involvement of facial and cranial nerves
pts can lose their voice
Pt’s family ask why mannitol is being given to pt. You say...
“It helps hold fluid in the vascular bed to prevent shock.”
“It aids in decreasing swelling in the brain.”
“It increases caloric intake to aid wound healing.”
“It fights off bacteria to prevent infections.”
After a craniotomy, you notice clear drainage on the dressing. You should...
change the dressing.
Elevate HOB
test the fluid for glucose
note the color and consistency in your documentation
you would decide that spinal shock is resolving if you find...
atomic urinary bladder
flaccid paralysis
hyperactive reflexes
widened pulse pressure
Pt with thoracic spinal cord injury complains of pounding headache and is sweaty. You should...
check patency of urinary cath
lower the pt’s head below his knees
place the pt flat on his back
Prepare to administer epi Sub-Q
Which of the following NSG interventions is correct for a pt with ICP of 20?
give pt a warming blanket
administer low dose barbiturates
encourage the pt to hyperventilate
restrict fluids
You administer mannitol. Which assessment should you monitor closely?
muscle relaxation
I&O’s
widening pulse pressure
pupil dilation
Which position should you place a pt with increased ICP?
HOB elevated 30-45 degrees
trendelenburg’s
Left Simm’s
the head elevated with 2 pillows
Which activity should the pt avoid when the pt is at risk for increased ICP?
deep breathing
turning
coughing
passive ROM
Priority nursing DX for pt during the emergent phase of a burn?
Excess Fluid Volume
imbalance nutrition: less than body requirements
risk for injury
risk for infection
you would anticipate that burn pt will be susceptible to which during the early phase?
hypernatremia
hypocalcemia
metabolic alkalosis
hyperkalemia
which burn victim would require intubation?
electrical burns on hands and arms causing dysthymia
thermal burns to head and face
chemical burns to chest and abdomen
second-hand smoke inhalation
after the initial phase of a burn, the focus of the plan of care will be...
helping the pt maintain a positive self-concept
promoting hygiene
preventing infection
educating the pt about care of skin grafts.
which complication must the nurse be alert for when caring for a burn pt?
CKD
gastric distention
hiatal hernia
curling’s ulcer
which patient should you see first?
partial thickness burns on legs reports continued pain
Pt arrived from ER with facial burns
pt post-op from skin grafts to the anterior chest wall
Pt with full thickness burns awaiting D/C teaching for 3hrs
Pt with full thickness burns awaiting D/C teaching for 3
Which requires the MOST immediate assessment?
pt admitted 4 days ago for facial burns crying after visitor
post op skin graft 3 hrs ago rating pain 8/10
partial thickness burn with temp of 102.6
Electrical burn with K+ of 5.1
Pt with hypovolemic shock has received a bolus of fluids. What indicates better perfusion?
right arterial pressure increases
Systolic BP increases to 85
urine output increases to 30 ml/hr
heart rate drops to 100 beats per minute
Pt had MVA with multiple injuries. VS T-98, P-130, BP-50/40, R-34. What kind of shock?
distributive
cardiogenic
neurogenic
hypovolemic
84 YO comes into ER with increased confusion and elevated temp. What kind of shock?
distributive
cardiogenic
neurogenic
hypovolemic
Pt with HX of pericarditis comes in with dyspnea and a rapid, weak pulse. What kind of shock?
distributive
cardiogenic
obstructive
hypovolemic
which of these are a compensatory method to increase cardiac output?
tachycardia
hypertension
bounding pulses
increase MAP
You caring for a PT with septic shock. Which should you give first?
steroids to decrease inflammation
antibiotics to treat underlying infection
Vasopressors to increase BP
IVF to increase volume
which of the following is a early indicator for hypovolemic shock?
diminished bowel sounds
increased urinary output
tachycardia
hypertension
when compensatory methods are established for hypovolemic shock, the nurse will find what to be normal?
intensity of pulses and body temp
peripheral pulses and heart rate
Metabolic alkalosis and O2 sat
cardiac output and blood pressure
which patient is at most risk for developing hypovolemic shock?
decreased cardiac output
pt with frequent loose stools
SIADH
DI
To evaluate effectiveness of omperazole for a pt with SIRS the nurse should
listen to bowel sounds
ask the pt about nausea
monitor stools for occult blood
check for abdominal distention
Pt is enroute to your ED following a MVA. You are prepared to do which of the following?
grab 500 ml of albumin
Grab 1000 ml of LR
Grab enough stuff for 2 large bore IVs.
get a pump for dopamine infusion
